Invited Commentary: Where to Turn When the Bleeding Won't Stop: Choosing Factor Concentrates for Significant Bleeding After Pediatric Cardiac Surgery.

Coagulopathy and bleeding following the repair of complex congenital cardiac lesions are common and an important cause of morbidity and mortality in our patients. Every cardiac surgeon, anesthesiologist, and intensivist have struggled to manage a patient following an excel-lent anatomic repair secondary to persistent coagulopathy. Signi fi cant bleeding can lead to low cardiac output and hemodynamic instability, the need for large-volume administration of blood products and esca-lation of inotropic support, and injury to the lungs, liver, kidney, and brain. Multiple risk factors for bleeding during congenital cardiac surgery have been previously described and include longer periods of cardiopulmonary bypass (CPB) and aortic cross clamping, lower temperature, the use of deep hypothermic circulatory arrest (DHCA), and lower patient weight. 1 Despite the recognition of this important problem and access to similar products for reversing coagulopathy, there is signi fi cant variability from one institution to another in regard to the management of bleeding. Such variability in practice exists in part because of a paucity of evidence to support an optimal strategy for managing coagulopathy. Although the use of concentrated coagulation factor concentrates has signi fi cantly increased over the past decade, there are few published studies comparing the use of activated recombinant factor VII (rFVIIa) and prothrombin complex concentrate (PCC) in the congenital cardiac population. The newly published study by Benson et al 2 is a retrospective single-center review over a seven-year period that compares the ef fi - cacy and safety of rFVIIa and PCC in pediatric patients undergoing cardiac surgery with CPB. The primary ef fi cacy endpoint was the time from the separation of CPB to arrival time in the pediatric inten-sive