Case Report

Use of recombinant activated factor VII in a Jehovah’s Witness patient

Managing acute hemorrhages in Jehovah’s Witnesses who refuse blood (or Blood components) transfusions has been a well-documented clinical challenge for medical professionals. This article reports the successful use of recombinant activated factor VIIa in controlling gastroin- testinal hemorrhage in a Jehovah’s Witness patient.

A 77-year-old male Jehovah’s Witness with metastatic oropharyngeal carcinoma and myelodysplastic syndrome was admitted at the Dubbo Base Hospital with anorexia, severe weight loss, bony tenderness, and constipation. His initial blood tests showed a hemoglobin level of 92 g/L, platelet count of 186 x 10⁹, international normalized ratio of

1.8 (not on oral anticoagulant, normal activated partial thromboplastin time of 27.2 sec), serum potassium level of

2.5 mmol/L, serum HCO^- level of 39.2 mmol/L, and corrected serum Ca⁺⁺ level of 4.38 mmol/L. The Clinical impression was paraneoplastic hypercalcemic syndrome complicated by dehydration and malnutrition. He was treated with intravenous fluids and potassium replacement, which brought his serum calcium level down to 3.65 mmol/L.

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On day 2 of his admission, he developed severe fresh per rectum bleeding with clots. His pulse rate increased to

108 beats per minute, and although his blood pressure remained normal he became disoriented to time and place, with his Glasgow Coma Scale score recorded at 14. He was resuscitated with intravenous Gelofusine (B. Braun Australia Pty Ltd, Bella Vista, NSW), and blood was immediately sent for group and crossmatching. The surgical team was consulted, but he was deemed unsuitable for urgent colonoscopy or surgery because of the continuing bleeding and because he was a poor candidate for anesthesia. At this point, the attending medical team was informed of an advanced directive documented in his previous admission 4 years ago that he is not to receive any blood products because of his religious belief. His wish was confirmed by the daughter. The patient and his daughter were informed that the bleeding is severe and he may bleed to death without adequate transfusion. He continued to pass fresh blood per rectum, and his hemoglobin level fell to 70 g/L. He was given vitamin K and Tranexamic acids and was transferred into the intensive care unit.

After an urgent consultation with the hematology unit at Royal Prince Alfred Hospital in Sydney, Australia, a decision

was taken to administer recombinant activated factor VIIa (NovoSeven, Novo Nordisk, Baulkham Hills, NSW, Aus- tralia). He was given 90 lg/kg of the drug (a total of 4.2 mg) at 5:35 pm, and his bleeding stopped approximately 3 hours later. Overnight, his condition remained stable with no further observed episode of per rectum bleeding. His hemoglobin level the following morning was 54 g/L. He

was returned to the general ward the same afternoon and was transferred to a palliative hospital 4 days later.

Managing acute hemorrhages in Jehovah’s Witnesses who refuse blood (or blood components) transfusions has been a well-documented clinical challenge for medical professional worldwide [1-8]. Recombinant activated factor VIIa, which could induce local hemostasis via the extrinsic pathway of the coagulation cascade and directly activate coagulation factors

IX and X, has been approved by the Food and Drug Administration to treat hemorrhages and prevent hemor- rhages during invasive procedures in patients with factor VII deficiency and in patients with hemophilia A and B [9]. Moreover, it has been demonstrated to successfully control severe hemorrhages in other settings [3,4,7,8]. With the large number of Jehovah’s Witnesses worldwide, recombinant activated factor VIIa can potentially be an important therapeutic option for the management of acute hemorrhages in Jehovah’s Witnesses without contradicting their believes.

Albert Hsieh

Royal Prince Alfred Hospital

Sydney, Australia

Izham Cheong Department of Medicine Dubbo Base Hospital NSW, Australia

Faculty of Medicine University of Sydney, Australia

E-mail address: [email protected] doi:10.1016/j.ajem.2007.03.007

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