FEIBA

[anes121508]

Are any of you guys using this in cardiac surgery? If so, when have you turned to it? How are you dosing it? What have been your experiences?

---

Members don't see this ad.

 

[Consigliere]

What is FEIBA?

 

[nimbus]

What is FEIBA?

I had to look it up. Never heard of it. SDN is awesome.

http://www.feiba.com/us/HCP/hcp_aboutus.html

 

[bigdan]

Not using in cardiac surgery. In fellowship or now in practice, the "last resort" is a baby dose of activated Factor VII.

There's a relatively recent paper that suggests that FEIBA vs aFVII has similar benefit in stopping bleeding without much difference in thrombotic complications, but I've just never used it.

 

[OB1🤙]

I've used it at one community hospital that didn't have KCentra but did have FEIBA, for a type A dissection that was on Pradaxa.

It probably works better than nonactivated PCCs for Pradaxa anyway.

Worked well and the case went fine.

 

[sleepallday]

I haven't personally used it but our cardiologists use it like water before their afib ablations if the INR is not normalized. Seems to work fine.

 

[BLADEMDA]

Why FEIBA over KCentra for bleeding issues or elevated INR? FFP still looks like the best choice for CABG patients: http://www.kcentra.com/professional/why-use-kcentra/why-use-kcentra.aspx?ref=tab

FEIBA is not indicated for the treatment of bleeding episodes resulting from coagulation factor deficiencies in the absence of inhibitors to coagulation factor VIII or coagulation factor IX.


Kcentra is contraindicated in patients with known anaphylactic or severe systemic reactions to Kcentra or any of its components (including heparin, Factors II, VII, IX, X, Proteins C and S, Antithrombin III and human albumin). Kcentra is also contraindicated in patients with disseminated intravascular coagulation. Because Kcentra contains heparin, it is contraindicated in patients with heparin-induced thrombocytopenia (HIT).

 

[ethilo]

We use it fairly regularly in our ORs. Usually when expecting a long bypass time or circ arrest. I feel like I've used it almost every case involving circ arrest we do.

How we dose it in the cardiac room is typically 20 units/kg. The Micromedex "suggested dosing" is specifically for hemophiliacs (hemophilia B) and they suggest 50-100 units/kg which is NOT for post-bypass coagulopathy.

Typical dosing strategy we use for FEIBA in the OR is to get about 1000 units (or 1 box) which is even LESS than 20 units/kg for a 70 kg patient. After you dose it, look for effect, and redose if needed.

 

[urge]

We use it fairly regularly in our ORs. Usually when expecting a long bypass time or circ arrest. I feel like I've used it almost every case involving circ arrest we do.

How we dose it in the cardiac room is typically 20 units/kg. The Micromedex "suggested dosing" is specifically for hemophiliacs (hemophilia B) and they suggest 50-100 units/kg which is NOT for post-bypass coagulopathy.

Typical dosing strategy we use for FEIBA in the OR is to get about 1000 units (or 1 box) which is even LESS than 20 units/kg for a 70 kg patient. After you dose it, look for effect, and redose if needed.

Are you also transfusing other factors such as platelets, cryo, or ffp? Or are you just giving it alone?

What about antifibrinolytics and ddavp? Are you using those too?

 

[drmwvr]

We use it fairly regularly in our ORs. Usually when expecting a long bypass time or circ arrest. I feel like I've used it almost every case involving circ arrest we do.

So, no antifibrinolytics on these cases?

 

[ethilo]

Are you also transfusing other factors such as platelets, cryo, or ffp? Or are you just giving it alone?

What about antifibrinolytics and ddavp? Are you using those too?

So, no antifibrinolytics on these cases?

Our recipe usually goes:
- Amicar 60 mg/kg bolus pre sternotomy, then 30 mg/kg/hr until chest is closed.
- We take off autologous if their HCT is >40, usually around 1200 mL if they have a normal HCT. If ~40, usually only about 600 mL.
- Post-bypass usually we give cell-saver first, then follow with autologous, then product as we go depending on need, usually FFP and platelets empirically.
- I feel like I've noticed in VAD cases and patients on plavix we lean more towards platelets.
- We routinely send coags/cbc immediately after protamine reversal.
- If clotting doesn't seem to be improving I notice we tend to move towards FEIBA if FFP/plts don't work.
- Less frequently we turn to cryo. I think I've only used cryo once in the ~ 50 cardiac cases I've done halfway through residency. And that was on someone we'd already done 2 rounds of FEIBA on. Funny, the cryo ended up doing the trick

At our place we usually reserve TXA for big spine cases or other ortho with anticipated high EBL. We don't routinely use k-centra in the cardiac room.
At our VA hospital that connects to our institution we usually do a 5g amicar bolus pre bypass and a 5g amicar bolus immediately post bypass. No infusion.

 

[drmwvr]

Our recipe usually goes:
- Amicar 60 mg/kg bolus pre sternotomy, then 30 mg/kg/hr until chest is closed.
- We take off autologous if their HCT is >40, usually around 1200 mL if they have a normal HCT. If ~40, usually only about 600 mL.
- Post-bypass usually we give cell-saver first, then follow with autologous, then product as we go depending on need, usually FFP and platelets empirically.
- I feel like I've noticed in VAD cases and patients on plavix we lean more towards platelets.
- We routinely send coags/cbc immediately after protamine reversal.
- If clotting doesn't seem to be improving I notice we tend to move towards FEIBA if FFP/plts don't work.
- Less frequently we turn to cryo. I think I've only used cryo once in the ~ 50 cardiac cases I've done halfway through residency. And that was on someone we'd already done 2 rounds of FEIBA on. Funny, the cryo ended up doing the trick

At our place we usually reserve TXA for big spine cases or other ortho with anticipated high EBL. We don't routinely use k-centra in the cardiac room.
At our VA hospital that connects to our institution we usually do a 5g amicar bolus pre bypass and a 5g amicar bolus immediately post bypass. No infusion.

Wow...that is a lot...ROTEM or it's equivalent could separate the wheat from the chaff here if it's available to you. Cryo is indicated sooner that it is given most times.

 

[urge]

Our recipe usually goes:
- Amicar 60 mg/kg bolus pre sternotomy, then 30 mg/kg/hr until chest is closed.
- We take off autologous if their HCT is >40, usually around 1200 mL if they have a normal HCT. If ~40, usually only about 600 mL.
- Post-bypass usually we give cell-saver first, then follow with autologous, then product as we go depending on need, usually FFP and platelets empirically.
- I feel like I've noticed in VAD cases and patients on plavix we lean more towards platelets.
- We routinely send coags/cbc immediately after protamine reversal.
- If clotting doesn't seem to be improving I notice we tend to move towards FEIBA if FFP/plts don't work.
- Less frequently we turn to cryo. I think I've only used cryo once in the ~ 50 cardiac cases I've done halfway through residency. And that was on someone we'd already done 2 rounds of FEIBA on. Funny, the cryo ended up doing the trick

At our place we usually reserve TXA for big spine cases or other ortho with anticipated high EBL. We don't routinely use k-centra in the cardiac room.
At our VA hospital that connects to our institution we usually do a 5g amicar bolus pre bypass and a 5g amicar bolus immediately post bypass. No infusion.

Thanks for the reply. I was hoping you were using FEIBA to avoid transfusing factors and platelets. We don't tend to transfuse much where I'm at. Any pump case less than 3 hrs will rarely get transfused platelets or factors. We do transfuse a lot of rbcs. Everyone is anemic here.

 

[ethilo]

Yeah, for the most part, we don't use that much product either. It's mainly those circ arrest cases and redo sternotomies that I refer to.

FEIBA is so expensive, quick google search shows it's about $1-2 per unit, and we're using like 1500 units at time. I guess it's no where near how much they give to hemophiliacs, though... and even less expensive than NovoSeven for hemophiliacs

http://www.bloodjournal.org/content/119/2/325?sso-checked=true

 

[ethilo]

Wow...that is a lot...ROTEM or it's equivalent could separate the wheat from the chaff here if it's available to you. Cryo is indicated sooner that it is given most times.

Our TEG is performed by a single trauma research fellow who is on call but probably won't get us a result for at least an hour at the point of considering it. The culture here is we tend to use TEG for liver transplants. Haven't seen it used yet in cardiac.

 

[AdmiralChz]

I was hoping you were using FEIBA to avoid transfusing factors and platelets.

For our institution and most of what I've seen, since FEIBA (and the more commonly-used Factor VII) is so expensive and somewhat aggressive you are typically expected to try platelets as a closer to first-line therapy.

 

[urge]

For our institution and most of what I've seen, since FEIBA (and the more commonly-used Factor VII) is so expensive and somewhat aggressive you are typically expected to try platelets as a closer to first-line therapy.

I understand, but platelets carry the stigma of a transfusion with all the negative connotations associated with it.