Canterbury DHB

Haemarthroses

• Spontaneous

  If treated early, a single dose of replacement product may be sufficient. If symptoms do not settle, consider a second dose 12 to 24 hours later. Timing of the second dose will depend on whether a short or extended half-life product is being used.

  Seek specialist advice if the bleed has not settled after two doses.

  Aim: To achieve a peak factor level of 30 to 40% activity.

  Treatment regimen
  FVIII	20 u/kg
  FIX	30 u/kg

• Traumatic, Late, More Major Bleed (Excluding Knees/Hips)

  In more major bleeds, use a dosing schedule with repeated doses.

  Aim: To increase factor level to 30 to 40%. Repeat dosing schedule.

  Treatment regimen
  FVIII 20 u/kg	® 10 to 15 u/kg @ 12 hours	® 10 u/kg @ 24 hours
  FIX 30 u/kg	® 15 to 20 u/kg @ 12 hours	® 15 u/kg @ 24 hours
  If symptoms persist after 24 hours, continue with the 24-hour dose regimen until symptoms settle.

  Note: In children, the plasma half-life of factor VIII and factor IX may be reduced. In these cases it may be necessary to give treatment every 8 hours.

• Major Hip and Knee Bleeds, Severe Shoulder Bleeds

  Admit to hospital if necessary. Repeated dosing schedule.

  Aim: To increase factor level to 60 to 80%, initially with dose reduction.

  Treatment regimen
  FVIII 30 to 40 u/kg	® 20 u/kg 12-hourly for 2 to 5 days according to severity.
  FIX 50 to 60 u/kg	® 40 u/kg daily for 2 to 5 days according to severity.
  Dose reduction under Consultant supervision.

  Consider treatment with a continuous infusion (see above).

Muscle Bleeds

Consider admission to hospital for major muscle bleed.

Repeated dose schedule or continuous infusion.

Aim: To increase factor level to 80% with trough levels ³ 40% initially. Dose reduction over 7 to 10 days under Consultant supervision.

• Physical measures:
  • Immobilisation is important.
  • Use ice or a cooling pack on an acute bleed.
  • Physiotherapy is important to maintain a full range of movement. Factor replacement may be necessary before exercise.
• Follow up: After a significant muscle bleed, follow up to ensure no evidence of compression or compartment syndrome. Pseudotumours can develop from an inadequately treated muscle bleed.
• Psoas Bleed: Patients with a psoas muscle bleed may require hospital admission and prolonged replacement therapy for up to 7 to 10 days. Further treatment may be required before mobilisation and physiotherapy.

Topic Code: 5241