Bleeding History in a Child Undergoing Surgery
Spero R. Cataland, MD, and Eric H. Kraut, MD
Ohio State University
VI. PROGNOSIS/CLINICAL COURSE
Laboratory testing confirmed the diagnosis of hemophilia A. With the elective tonsillectomy planned for the near future, prophylactic administration of a factor VIII product prior to surgery will be required to enable the patient to achieve normal hemostasis and healing during and after the surgical procedure.
To avoid the potential for the transmission of blood borne illnesses, recombinant factor VIII preparations are more commonly used to restore normal levels of factor VIII after trauma or in anticipation of a surgical procedure. Typically, patients with a diagnosis of hemophilia A will require factor VIII administration after trauma or spontaneous bleeds into muscles or joints. In addition, since many of these patients bleed spontaneously, severely affected patients are often treated prophylactically to prevent bleeding episodes. In the patient presented, the factor VIII level of 8% suggests that the patient has mild hemophilia A.
In a patient with mild to moderate hemophilia A, spontaneous bleeds into muscles or joints are less likely, but this patient would require prophylactic factor VIII administration prior to the planned tonsillectomy. Factor VIII should be administered prior to the procedure to achieve factor VIII levels of 100%, with additional dosing post operatively to maintain approximately 50% of normal factor VIII levels, to allow for healing from the surgical procedure. It should also be mentioned that some patients with mild to moderate hemophilia A will respond to DDAVP administration with an increase in factor VIII levels, but patients should be tested in advance to demonstrate their response before attempting to use DDAVP therapeutically. The duration of post-operative factor administration depends upon the severity of the patient’s disease but also the extent of the hemostatic challenge facing the patient. Aminocaproic acid, an anti-fibrinolytic agent, is also used as an adjunct to factor VIII in patients with hemophilia A who will undergo dental extractions and surgical procedures.
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