What types of surgeries require factor VII (FVII) transfusion based on bleeding risk and current FVII levels?

From the Guidelines

Factor VII (FVII) transfusions are primarily required for surgeries in patients with FVII deficiency, with the need based on both the patient's baseline FVII levels and the bleeding risk of the procedure. The decision to transfuse FVII depends on the type of surgery and the patient's current FVII levels, as well as their individual bleeding risk. For major surgeries with high bleeding risk, such as neurosurgery, cardiovascular procedures, major orthopedic operations, and extensive abdominal surgeries, FVII replacement is recommended when levels are below 15-20% of normal, targeting levels of 50-100% of normal using recombinant activated Factor VII (rFVIIa) at doses of 15-30 μg/kg every 2-3 hours initially, then tapering as healing progresses 1. Some key points to consider when deciding on FVII transfusion include:

• The patient's baseline FVII level
• The bleeding risk of the procedure
• The need to balance the risk of bleeding with the risk of thrombotic complications
• The use of rFVIIa as an adjunct to other treatments, such as surgery and blood products, to control bleeding. It is also important to note that the efficacy of rFVIIa in reducing morbidity and mortality is still uncertain, and its use should be carefully considered on a case-by-case basis 1. In terms of specific types of surgeries, FVII replacement is recommended for major surgeries with high bleeding risk, and may be considered for moderate-risk procedures, such as routine orthopedic surgeries and endoscopies with biopsies, when FVII levels are below 10-15%. Minor procedures, such as dental extractions and superficial surgeries, generally require replacement only when FVII levels are below 10%, aiming for levels of 15-30% 1. The short half-life of FVII (3-4 hours) necessitates frequent dosing during the perioperative period, and treatment should begin immediately before surgery and continue until adequate healing occurs, typically 1-2 weeks for major surgeries and 1-3 days for minor procedures. Overall, the decision to transfuse FVII should be made on a case-by-case basis, taking into account the individual patient's needs and risk factors, and should prioritize minimizing bleeding risk while balancing the risk of thrombotic complications.

From the Research

Types of Surgeries Requiring Factor VII Transfusion

• Orthopaedic surgeries, such as total hip replacement and arthroscopic procedures, may require factor VII (FVII) transfusion in patients with FVII deficiency 2
• Other surgeries that may require FVII transfusion include cholecystectomies, thyroidectomy procedures, exploratory laparotomies, left hemicolectomy, total proctocolectomy, inguinal hernia repairs, and excisions of varicose veins 3
• Oncological surgeries may also require FVII transfusion in patients with FVII deficiency 4

Bleeding Risk and Current FVII Levels

• The need for FVII transfusion depends on the bleeding risk and current FVII levels, with patients having FVII activity <10% of normal value requiring higher doses of recombinant activated factor VII (rFVIIa) 3
• Patients with FVII activity between 10-25% of normal value may require lower doses of rFVIIa 3
• A patient's history of increased tendency to bleed may be more important than the FVII level or increased international normalized ratio (INR) value in determining the need for preoperative substitution 5

Factor VII Transfusion Regimens

• Different factor VII transfusion regimens have been used in various studies, including administration of rFVIIa every 8-12 hours on the day of surgery and subsequent days 2, 3
• The dose of rFVIIa may range from 15-37 μg/kg body weight, depending on the type of surgery and the patient's FVII activity level 2, 3