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Recombinant coagulation products are used to manage bleeding in hemophilia, von Willebrand’s disease, and in patients with acquired antibodies/inhibitors.

  1. Recombinant activated factor VIIa (rFVIIa) is most widely known and approved for hemophilia patients with inhibitors to treat bleeding. The incidence of thrombotic complications among patients who received rFVIIa is relatively low. rFVIIa can normalize elevated international normalized ratio (INR)/prothrombin time values without actually correcting the coagulation defect, especially in patients receiving warfarin and other vitamin K antagonists.

  2. Factor XIII (FXIII) is an important final step in clot formation that stabilizes the initial clot (reductions in FXIII during cardiopulmonary bypass and an inverse relationship between postoperative blood loss and postoperative FXIII levels).

  3. Prothrombin complex concentrates (PCCs) include factors II, VII, IX, and X in variable concentrations (indicated for prevention/control of bleeding in patients with hemophilia B).

    1. It is considered preferable to give a PCC containing all four vitamin K-dependent coagulation factors and the natural anticoagulants antithrombin and activated protein C (APC) for anticoagulation reversal.

  4. Although warfarin reversal in the United States is typically achieved with fresh frozen plasma (FFP), most other countries use PCCs. Compared with FFP, PCCs provide quicker INR correction, have a lower infusion volume, and are more readily available without crossmatching.

  5. Topical hemostatic agents are used intraoperatively to promote hemostasis at the site of vascular injury and include physical and mechanical agents, caustic agents, biologic physical agents, and physiologic agents.

    1. Absorbable agents include gelatin sponges (Gelfoam), derived from purified pork skin gelatin that increase contact activation to help create topical clot. Surgicel or Oxycel are oxidized regenerated cellulose that work like Gelfoam. Avitene is microfibrillar collagen derived from bovine skin.

    2. Collagen sponges are available in different commercial forms and are derived from bovine Achilles tendon or bovine skin. Gelatin foam should not be used near nerves or in confined spaces but can be administered topically with thrombin.

    3. Topically applied thrombin preparations are used extensively.

    4. Fibrin sealants (biologic glue or fibrin tissue adhesives) are component products that combine thrombin (mostly human) and fibrinogen.