The Role of Human Fibrinogen Concentrate (RiaSTAP) in Decreasing Blood Loss and the Need for Component Blood Therapy in Infants Undergoing Cardiopulmonary Bypass.
Phase: PHASE4
Conditions: Hypofibrinogenemia, Afibrinogenemia, Bleeding Disorders
Sponsor: Nicklaus Children's Hospital f/k/a Miami Children's Hospital

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Christopher Tirotta, MD 
 
PROTOCOL and SAP 
 
The Role of Human Fibrinogen Concentrate 
(RiaSTAP) in Decreasing Blood Loss and the Need 
for Component Blood Therapy in Infants 
Undergoing Cardiopulmonary Bypass   
 
 
 
National Clinical Trial (NCT) Identification Number:  NCT02822599 
 
 
 
 
 
 
  December 7, 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Christopher Tirotta, MD 
Purpose of Study 
The goal of the study is to determine whether the use of Human Fibrinogen Concentrate 
(RiaSTAP) will decrease blood loss and the need for component blood therapy in neonates 
and infants undergoing cardiopulmonary bypass.  RiaSTAP will be administered after 
termination of Cardiopulmonary Bypass (CPB) at a dose of 70 mg/kg, in a prospective, 
randomized, controlled study. We hypothesize that the administration of RiaSTAP in this 
manner will reduce peri-operative bleeding and transfusion requirements. 
 
Background 
Severe postoperative bleeding is a serious complication after cardiac surgery and results in 
increased morbidity and mortality12.  The bleeding is often multifactorial and influenced by 
both surgical factors and impaired hemostasis. The impaired hemostasis after cardiac 
surgery may be caused by enhanced fibrinolysis, platelet (PLT) dysfunction and 
coagulopathy secondary to the exposure of blood to artificial surfaces, and the surgical 
trauma3.   
 
In children less than 12 months old with congenital heart disease, bleeding after cardiac 
surgery is further complicated as the fibrinogen of these patients is qualitatively 
dysfunctional4.  Moreover, the coagulation systems of neonates and children undergoing 
CPB are profoundly affected by hemodilution5 and by consumption6.  As a result, neonates 
and young infants undergoing complex cardiac repairs often receive multiple units of blood 
products, both in the operating room (OR) and intensive care unit (ICU).   
 
Preoperative fibrinogen concentration is an independent predictor of post-operative 
bleeding volume. Fibrinogen concentration, even when within the normal range, is a 
limiting factor for post-operative hemorrhage7.  The prophylactic infusion of fibrinogen 
concentrate has been shown to reduce bleeding after coronary artery bypass graft (CABG) 
surgery without evidence of hypercoagulability8.  Moreover, ROTEM FIBTEM test guided 
fibrinogen concentrate administration was associated with reduced transfusion 
requirements and 24 hour postoperative bleeding in patients undergoing aortic valve 
operations and ascending aortic reconstructions9. 
 
The goal of the study is to determine whether the use of Human Fibrinogen Concentrate, 
RiaSTAP, will decrease blood loss and the need for component blood therapy in neonates 
and infants undergoing cardiopulmonary bypass.  We hypothesize that the administration 
of RiaSTAP after termination from cardiopulmonary bypass will reduce peri-operative 
bleeding and transfusion requirements. 
 
Fibrinogen replacement therapy is currently indicated as prophylaxis for congenital 
fibrinogen deficiency and as therapy for acquired fibrinogen deficiency caused by liver 
failure, disseminated intravascular coagulation, massive transfusion and cardiac surgery.  
Fibrinogen supplementation can be provided by transfusion of (1) fresh-frozen plasma 

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Christopher Tirotta, MD 
(FFP), (2) cryoprecipitate, (3) RiaSTAP or some combination of these three.   
 
FFP has several limitations including the need for ABO compatibility, the time required to 
thaw it, a low fibrinogen content, which means that large volumes must be given thereby 
increasing the risk of hemodilution, the risk of transfusion-related complications (i.e., 
transfusion-related acute lung injury [TRALI] and viral transmission) and the presence of 
relatively high concentrations of citrate, which can acutely lower ionized calcium, leading 
to decreased myocardial contractility and hypotension. 
 
Cryoprecipitate is prepared by controlled thawing of frozen plasma to precipitate high 
molecular weight proteins, which include factor VIII (FVIII), von Willebrand factor (VWF) 
and fibrinogen. The precipitated proteins are separated by centrifugation, re-suspended in 
a small volume of plasma (typically 10-20 mL) and stored frozen at –20 °C. Cryoprecipitate 
is usually administered as a pool of four to six units.  Although cryoprecipitate contains a 
higher concentration of fibrinogen than FFP (usually around 15 g/L), it shares many of the 
same disadvantages of FFP.  For example, the fibrinogen concentration is not standardized 
among batches of cryoprecipitate and blood group matching is needed prior to transfusion. 
In addition, cryoprecipitate must be thawed, a clear disadvantage in the setting of massive 
hemorrhage.  Furthermore, like FFP, it contains a relatively high concentration of citrate10 
and carries a risk of viral transmission. 
 
RiaSTAP is a purified fibrinogen concentrate derived from the plasma of healthy donors 
using the Cohn/Oncley cryoprecipitation procedure11 .  The FDA approved RiaSTAP in 
2009 under the accelerated approval regulations for orphan drugs12.  RiaSTAP is indicated 
for the treatment of acute bleeding in patients with congenital fibrinogen deficiency (CFD), 
including afibrinogenemia and hypofibrinogenemia and has several advantages over FFP 
and cryoprecipitate.  First, the fibrinogen concentration is standardized.  Second, it is 
stored as a lyophilized powder at room temperature and can be reconstituted quickly with 
sterile water.  Third, infusion volumes are low, allowing for rapid administration without 
delays for thawing or cross-matching13. Fourth, the manufacturing processing of RiaSTAP 
includes solvent/detergent exposure or pasteurization, thus minimizing the risk of viral 
transmission.  RiaSTAP is manufactured from cryoprecipitate into a glycine precipitate, 
which is then further purified by multiple precipitation/adsorption steps. The 
manufacturing process has been demonstrated to reduce the risk of virus transmission in 
an additive manner: cryoprecipitation, Al(OH)3 adsorption/glycine precipitation/Al(OH)3 
adsorption, heat treatment (60o C for 20 hours in an aqueous solution), and two 
subsequent glycine precipitation steps (initial and main glycine precipitation steps). These 
steps have been validated independently in a series of in vitro experiments for their 
capacity to inactivate and/or remove both enveloped and non-enveloped viruses.  
However, there is still a small risk of acquiring an infectious disease, despite the testing of 
plasma donor and the above outlined steps, mostly due to the transmission of prions, the 
causative agent in Creutzfeldt-Jakob disease.  Finally, RiaSTAP does not contain any citrate 
so the risk of decreased myocardial contractility and hypotension is minimized. 
 
RiaSTAP is contraindicated in patients who have manifested severe, immediate 
hypersensitivity reactions.  Thrombosis has also been reported in patients treated with 

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Christopher Tirotta, MD 
RiaSTAP, but the risk appears to be low14.  However, Jakobsen, Tang and Folkersen 
reported an increased risk of neurological thromboembolic complications and renal failure 
in their retrospective review of 1,876 adults undergoing coronary artery bypass graft 
surgery (CABG) treated with fibrinogen concentrate. 
 
Our institution has been using RiaSTAP on this high-risk patient population since April 
2013.  In a separate, retrospective analysis our group has compared a group of 50 patients 
who received RiaSTAP with 50 age, diagnosis and procedure matched patients prior to 
April 2013.  Our analysis demonstrates that there is a statistically significant reduction in 
the need for FFP and cryoprecipitate, without an increase in thromboembolic events, when 
RiaSTAP is used at a dose of 70 mg/kg.15 
Criteria For Subject Selection 
Number of subjects:  30 
 
Gender of subjects: There are no gender-based enrollment restrictions for this study.  
Gender distribution should reflect the gender distribution of the patient population and the 
gender distribution of Congenital Heart Disease (CHD) in general which is slightly skewed 
towards male patients in a 60:40 ratio of males to females. 
 
Age of Subjects: Age will range from full term (at least 37 weeks gestational age) 
newborns to 12 months old, inclusive. 
 
Racial and Ethnic Origin: There are no racial and ethnic restrictions for this study. 
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX.  
 
Inclusion Criteria: All neonatal and infant cardiac patients presenting for open-heart 
surgery at Nicklaus Children’s Hospital will be eligible for enrollment in the study. 
 
Exclusion criteria: Patients who fall outside of the age range for the study will be 
excluded.  Patients known to have had an anaphylactic or severe reaction to the drug or its 
components will not be enrolled.  At the time of the rewarming ROTEM, any patient with a 
FIBTEM MCF > 15 mm, will be excluded. 
 
Vulnerable subjects: Patients in the study population are neonatal and infant cardiac 
surgical patients and are considered vulnerable subjects. 
 
Methods and Procedures 
Randomization: 
We plan to enroll 30 neonates and infants scheduled for elective cardiac surgery.  Patients 
will be randomized to one of two groups with 15 patients in each group; Group 1 will 
receive an infusion of RiaSTAP, right after the termination of CPB at a dose of 70 mg/kg and 

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Christopher Tirotta, MD 
Group 2 will receive a placebo of Normal Saline 0.9% (NS) during the same time period.  
The volume of NS will be calculated to be the same volume that would be used IF the 
patient were receiving RiaSTAP.  This will be the only difference between the groups.   
 
Both Groups will receive the normal standard of care both before and especially after this 
event.  This will be the only event that is different for the two groups. To avoid selection bias, 
the Pharmacy will perform the randomization using Research Randomizer.  Briefly, for 
each patient, a randomly generated integer between 1-30 will be produced.  If the number 
is even, the patient will be assigned to Group 1.  If the number is odd, the patient will be 
assigned to Group 2.  The randomization process and schedule will be provided by the 
Principal Investigator’s office, but the actual patient assignment will be done by Pharmacy. 
 
All operating room and ICU personnel will be blinded to the patient’s Group assignment.  
The only persons who will have access to the identity of the Group assignment from the 
time of randomization until 24 hours after surgery will be members of the Pharmacy staff.  
NONE of these individuals will be involved in patient care.  The DSMB will be unblinded 
AFTER the study treatment period concludes (24 hours after surgery).   
Endpoints: 
Primary efficacy endpoints will be estimated as follows: 
 postoperative bleeding (EBL) during the first 24 hours (hr) after surgery (cc/kg),  
 the identity and total volume of transfused blood products (cc/kg) given in the peri-
operative period, separated out into its components,  
 hemoglobin concentration 2 hr. and 24 hr. after surgery and  
 effects of fibrinogen infusion on global hemostasis 2 hr. and 24 hr. after surgery (PT, 
PTT, INR, fibrinogen level, platelet count and ROTEM analysis).   
Post-operative period begins after the patient leaves the operating room.  The need for 
Factor VII use and dose will also be included as a primary end point.  Factor VII is typically 
used only if there is profuse bleeding not amenable to component transfusion therapy.   
 
Secondary end points will include:  
 the number of post-op hours requiring ventilator support,  
 Length of Stay (LOSH) in the hospital,   
 Length of Stay (LOS ICU) in the Cardiac Intensive Care Unit (CICU) and  
 the need for re-exploration for bleeding within the first 12 hours.   
 
The primary safety endpoints that will be monitored are the presence of a clinical adverse 
events.  Clinical adverse events (AEs) are defined as any clinical signs of central or 
peripheral thromboembolism, respiratory or circulatory failure, or allergic reactions 
during hospital stay.  It will also include infection with a blood-borne pathogen.  
Thromboembolic phenomenon will include catheter and/or vessel occlusion.  Any signs or 
symptoms of thromboembolism will prompt a Doppler ultrasound examination to confirm 
the diagnosis.  All patients will be monitored for AEs until discharge. 
 

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Christopher Tirotta, MD 
Anesthetic Management: 
Standard non-invasive monitors will be employed including Electrocardiogram (EKG), 
Non-invasive blood pressure (NIBP), Pulse Oximetry (SaO2), capnography, and Near 
Infrared Spectroscopy (NIRS). 
 
For patients greater than six months of age, premedication with midazolam will be used.  
Dose will be 1 mg/kg Per Os (PO), with a maximum of 20 mg.  Anesthesia will be induced 
with Propofol 2 mg/kg or fentanyl 5 mcg/kg, if the patient already has an indwelling IV 
catheter.  Otherwise an inhalational induction with Sevoflurane 5% will be done.  
Anesthesia maintenance will be with Sevoflurane and dexmedetomidine 1 mcg/kg/hr.  No 
more than 10 mcg/kg of fentanyl will be used.  Once the patient is anesthetized and 
intubated a Foley catheter will be placed along with an Arterial line (A-line) and a double 
lumen Central venous line (CVL).  Hemodynamics will be maintained by adjusting the 
Sevoflurane concentration in increments of 0.5% to maintain blood pressure within 20% of 
baseline. Propofol 0.5 mg/kg will also be used for this purpose.   
 
Cardiopulmonary Bypass (CPB) Management: 
After purse strings sutures are placed, heparin 300 International Units (IU) will be 
administered by the surgeon directly into the right atrium (RA) in order to maintain an 
ACT greater than 400 seconds. After CPB, the heparin will be reversed by the 
administration of protamine (1 mg protamine/100 IU of residual heparin activity as 
measured by the Medtronic Hepcon) to an ACT of <130 s. The CPB circuit included a 
membrane oxygenator and centrifugal pumps.  Standard non-pulsatile CPB technique with 
moderate hypothermia (bladder temperature 28–30°C) or deep hypothermia (bladder 
temperature 18–20°C) and hemodilution will be used depending on the surgical repair. 
Cardioprotection will be achieved with antegrade cold blood cardioplegia. Weaning off CPB 
will be performed after rewarming to a bladder temperature of at least 36°C.  We will use 
the Medtronic Hepcon Hemostasis Management System Plus to optimize and monitor 
heparin and protamine dosing. 
 
Patients under 10 kg in body weight will have the CPB pump primed with one unit of 
Packed Red Blood Cells (PRBC) and 200 cc Fresh Frozen Plasma (FFP).  In patients over 10 
kg a pure crystalloid prime will be used.  Target hemoglobin (Hg) while on CPB will be 9 
gm/dL, but the transfusion trigger for additional units of PRBC will be 7 gm/dL. 
 
Drug protocol: 
The following laboratory studies will be obtained prior to surgery: Complete Blood Count 
(CBC), Prothrombin time (PT), International Normalized Ratio (INR), Partial 
Thromboplastin time (PTT), Platelet count, and a Fibrinogen level; an electrolyte profile 
will also be done.  An Activated Clotting Time (ACT) and a Thromboelastometry analysis 
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX(, a device that assesses the 
viscoelasticity of whole blood and other parameters, will be done after an A-line is placed 
(Figure 1). 

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Christopher Tirotta, MD 
 
A blood products transfusion algorithm was developed based on four previous studies 
published in the literature, modified for pediatrics16171819 (Figure 2). Blood is measured in 
the cell saver reservoir and the suction canister every fifteen minutes while in the OR.  
Clinically significant bleeding, requiring treatment, will be defined as a rate in excess of 10 
cc/kg/hr calculated every 15 minutes while in the OR.  Calculations will be done every 60 
minutes in the CICU. 
 
After rewarming, but prior to the termination of CPB a ROTEM analysis will be done.  
Platelets or FFP will be administered at this time, while still on CPB, if the ROTEM results 
indicate a deficiency of either component.  Then immediately after the termination of CPB, 
RiaSTAP or NS will be administered depending on the group assignment.  Then, as per 
routine care, a ROTEM analysis and fibrinogen level will be assessed and the transfusion 
algorithm will be continued.  If the ROTEM indicates a fibrinogen deficiency, cryoprecipitate 
will be given.  Thereafter, as per routine care, a ROTEM analysis will be done at least every 
30 minutes while in the OR or sooner at the discretion of the OR team. Once the patient 
leaves the OR a ROTEM will be done at least every 60 minutes for the first six hours or until 
clinically significant bleeding has stopped, whichever comes first; ROTEMs can be done 
more frequently at the discretion of the ICU staff caring for the patient.  The blood products 
transfused after separation from CPB will be based on the protocol below (Figure 3). 
Dosing amounts of the required component therapy will be based on the formula below: 
 
PRBC: Volume required = Blood volume (V) x desired Hct increase / Hct of red cell unit 
(70%) 
FFP: 20 cc/kg 
Plateletpheresis: 20 cc/kg 
Cryoprecipitate: 10 cc/kg 
 
The ROTEM analysis algorithm is below (Figure 4). 
 
Four main scenarios based on clinical observation and TEM results were possible: 
1. Insignificant bleeding—normal TEM  no transfusions 
2. Insignificant bleeding—abnormal TEM  no transfusions 
3. Significant bleeding—normal TEM  surgical reevaluation 
4. Significant bleeding—abnormal TEM  transfusion of blood products as indicated by: 
a. fib-TEM MCF < 7 mm  cryoprecipitate  
b. hep-TEM MCF <50 mm  platelets,  
c. hep-TEM CT > 240 seconds  FFP, 
d. hep-TEM CFT > 110 seconds  cryoprecipitate and /or platelets depending on 
MCF 
 
If clinically indicated (continuing bleeding) or to verify the treatment effect and control 
heparin reversal, a second set of in-TEM, hep-TEM, and fib-TEM analyses will also be 
performed during wound closure. ACT will be tested in all patients to control for heparin 
reversal. If patients have both a pathological ACT and TEM, protamine will be administered. 

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Christopher Tirotta, MD 
 
Postoperative bleeding in the ICU will be defined as the total amount of chest tube drainage 
after closure of the sternum and during the first 24 postoperative hours. If the sternum is 
not closed, it will be defined at the total chest tube drainage during the first 24 
postoperative hours.  An intensive care nurse blinded to group assignment will record the 
bleeding every hour. The amount of transfused red blood cells (RBC), FFP, cryoprecipitate 
and platelets during the hospital stay will be recorded in cc/kg. The transfusion triggers 
will be as described above. The CICU physicians and nurses will not be informed of the 
preoperative fibrinogen concentration or group assignment. 
 
Patient Assessment: 
Primary efficacy endpoints will be postoperative bleeding during the first 24 hours (hr) 
after surgery (cc/kg), the total volume and identity of transfused blood products (cc/kg), 
hemoglobin concentration 2 hr. and 24 hr. after surgery and effects of fibrinogen infusion 
on global hemostasis 2 hr. and 24 hr. after surgery (PT, PTT, INR, fibrinogen level, platelet 
count and ROTEM analysis).  Secondary end points will include the number of post-op 
hours requiring ventilator support, Length of Stay (LOS) in the Cardiac Intensive Care Unit 
(CICU), the need for re-exploration for bleeding within the first 12 hours, and LOS in the 
hospital.  The need for Factor VII use and dose will also be included.   
 
The primary safety endpoint is a clinical adverse event.  Clinical adverse events are defined 
as: 
1. Any clinical signs of central or peripheral thromboembolism. This then will be 
confirmed by Doppler ultrasound.  Assessments will be made once per shift (once 
every eight hours) 
2. Respiratory or circulatory failure.  Parameters of respiration, like respiratory rate 
(RR), end-tidal CO2 (ETCO2) and circulation, like heart rate (HR), rhythm, blood 
pressure (BP), arterial oxygen saturation (SPO2) are monitored continuously while 
in the ICU.  Respiratory failure will be defined as the need for reintubation after 
extubation.  Circulatory failure will be defined as cardiac arrest. 
3. Allergic reactions during hospital stay.  These will include signs or symptoms like 
urticaria, wheezing, angioneurotic edema, and anaphylaxis. 
4. Infection with a blood borne pathogen.  Manifestation of an infection with a blood 
borne pathogen is unlikely to occur during the study treatment period, which ends 
24 hours after the end of surgery.  If this were to occur, it would not manifest itself 
for weeks or even months. 
 
Patients will be assessed once per shift (once every eight hours) for signs of 
thromboembolism.  Any evidence of thromboembolism will warrant a vascular ultrasound 
to assess the integrity of the vessel. 
 
Adverse events will be monitored until discharge. 
 
All patients will be assessed for signs and symptoms of thromboembolism, per routine 
care.  Specifically, patients will be assessed for signs and symptoms of central and arterial 

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Christopher Tirotta, MD 
line thrombosis.  These include edema, leg pain and tenderness, erythema, and 
discoloration for venous thrombosis, as well as loss of distal peripheral pulses, pain, pallor, 
paresis, paresthesias, decreased skin temperature for arterial thrombosis. If any of these 
signs and symptoms appear, Doppler Ultrasound examinations of the affected area will be 
performed. 
 
The Safety Team, which consists of the Cardiac Intensive Care Unit physicians, will evaluate 
each event when it occurs; they will not be blinded to patient assignment after 24 hours.   
Please see safety assessments and timing below.  These represent minimums as prescribed 
by the protocol.  Assessments may be more frequent (See table 1). 
 
Stopping Criteria:   
 
A statistically significant increase in thromboembolic phenomenon between Group 1 and 
Group 2 will trigger a stop in enrollment.  This will be monitored by the Safety Team. 
 
Table 1: Assessments 
 
Assessment 
Timing in OR 
Timing in ICU 
EBL 
q 15 min 
hourly 
ROTEM 
q 30 min as needed 
hours 2 and 24, or as 
needed hourly until 
bleeding ceases 
peripheral thromboembolism 
N/A 
q8 hrs, or as needed 
hemoglobin 
as needed 
hours 2 and 24 
PT/PTT, platelets, fibrinogen 
prior to surgery if 
not previously 
done 
hours 2 and 24 
 
 
 
 
 
 
 
 
 
 
 
 
Schedule of Events 
 
 
Pre-Operative  
Intraoperative  
2 hours  
Post-Operative  
24 hours  
Post-Operative  
When occurs   60 ± 14 days  
Informed Consent/Assent 
x 
 
 
 
 
 
Eligibility Assessment 
x 
 
 
 
 
 

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Christopher Tirotta, MD 
Demographic Data 
x 
 
 
 
 
 
Medical History 
x 
 
 
 
 
 
Baseline Assessment  1 
x 
 
 
 
 
 
Body Weight and Height 
x 
 
 
 
 
 
Concomitant Medications4 
x 
x 
 
 
 
 
Randomization 
 
x 
 
 
 
 
Administration of Study Drug  
 
x 
 
 
 
 
Pharmacy Prep of Study Drug  
 
x 
 
 
 
 
Laboratory Studies 2 
x 
 
x 
x 
 
 
Adverse Events  
 
x 
x 
x 
x 
x 
Surgical  and Cardiopulmonary 
Bypass Data3 
 
x 
 
 
 
 
Estimated Blood loss (EBL) 5, 6 
 
 
 
 
 
 
ROTEM Analysis9,11 
x 
X
7, 10 
x 
x 
X
8 
 
Identification of total transfused 
blood products 12 
 
 
 
x 
 
 
Thromboembolitic Assessment 13 
 
 
 
 
x 
 
 
Factor VII   
 
 
 
 
x 
 
Length of Stay ICU and Hospital  
 
 
 
 
x 
 
Mechanical ventilation duration 
 
 
 
 
x 
 
Need for Re-exploration first 12 
hours  
 
 
x 
x 
 
 
Phone assessment 
 
 
 
 
 
x 
 
1. 
Assessment includes allergies, diagnosis, procedure(s) 
2. 
Laboratory collection and assessment includes CBC, prothrombin time (PT), international normalized 
ratio (INR), partial thromboplastin time (PTT), fibrinogen level. Pre-Operative includes complete 
platelet count, and electrolyte profile.  
3. 
Time in/out, sternal closure time, bypass start/stop time, total bypass time, total cross clamp time, total 
regional low perfusion time, blood components administered for patients under 10 kg in body weight, 
and pure crystalloid prime for patients over 10 kg in body weight, activated clotting time (ACT), 
thromboelastometry analysis after A-line assessment.  
4. 
During intraoperative period concomitant medications include anesthesia induction medication, 
heparin, and protamine.  
5. 
Estimated blood loss will be assessed every 15 minutes while in the OR and every 60 minutes in the 
CICU.  Clinically significant bleeding defined as a rate in excess of 10 cc/kg/hr.   
6. 
Total EBL at 24 hour time point.  
7. 
Prior to Termination of CBP  
8. 
If bleeding occurs  
9. 
If fibrinogen deficiency noted on ROTEM, administer cryoprecipitate 
10. 
Every 30 minutes as routine or sooner as per OR team discretion. 
11. 
Assess post-operatively for every hour for 6 hours or until clinically significant bleeding ceases and 
additionally as per ICU team’s discretion.  
12. 
Includes total prime, total CPB, total Anesthesia, total CICU, total platelets, total PRBC, total FFP, 
total Cryo, total cell saver. 
13. 
Assess every 8 hours central and arterial line for signs and symptoms. Thrombosis including edema, 
leg pain and tenderness, erythema, and discoloration for venous thrombosis, loss of distal peripheral 
pulses, pain, pallor, paresis, paresthesias, decreased skin temperature for arterial thrombosis. 
Confirmed by Doppler Ultrasound. Report when occurs. 
14. 
Any untoward event reported from the time subject signs consent. Should be reported as soon as the 
study team becomes aware.   
 
Data Analysis and Data Monitoring 
Safety Monitoring 
For the safety monitoring, adverse events will be documented. Aggregate and individual 
subject data related to safety, data integrity and overall conduct of the trial will be 
reviewed after enrollment of 10, 20 and 30 subjects. 

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Christopher Tirotta, MD 
Methods to Minimize Bias 
To avoid selection bias, patients will be randomized to their treatment assignment group 
by the research pharmacists using the Research Randomizer.  The randomization 
procedures are detailed in the Methods and Procedures section of this protocol.  All 
operating room and ICU personnel will be blinded to the patient’s Group assignment.  An 
intensive care nurse blinded to group assignment will record postoperative bleeding every 
hour.  Since the study is blinded and the practitioners caring for the patient will not know if 
the subject received the study drug or placebo, for the study treatment period (ending 24 
hours after surgery), the Cardiac Intensive Care Unit staff will monitor the incidence of 
adverse thromboembolic events and intervene with routine care, if necessary.  In order to 
maintain patient safety, the ROTEM analyses must be interpreted by the anesthesiologist 
caring for the patient in order to guide transfusion therapy.  This is the standard of care 
and an integral part of the protocol.  The hospital staff anesthesiologists are also 
investigators in the study including the Principal Investigator. As part of routine care, if the 
ROTEM results indicate a deficiency of platelets or FFP, either component will be 
administered while still in the OR. In addition, if the ROTEM indicates a fibrinogen 
deficiency after termination of CPB, cryoprecipitate will be given. After review of the 
ROTEM values, the identity of the study drug may be discernable.   In order to avoid the 
ascertainment bias from this knowledge, study data will be analyzed by a biostatistician 
independent of the investigator prior to any presentation or publication of study results.  
The biostatistician will be blinded to the study treatment assignment.    
Statistical Analyses 
All quantitative measures will be analyzed using descriptive statistics [mean +/- standard 
deviation (SD), etc.].  Treatment and placebo group comparisons will be made with the 
Student’s t-test (continuous variables) or Fisher’s exact test (categorical variables). A p-
value of ≤ 0.05 will be considered statistically significant.  For group comparisons of 
variables that will be analyzed at more than onetime point, Analysis of Variance (ANOVA) 
for repeated measurements will be used followed by Student’s t-test if the ANOVA (group 
or interaction between group and time) indicated a statistically significant difference 
(p≤0.05). 
Data Storage and Confidentiality 
All data for the study will be stored on a Nicklaus Children’s Hospital password protected 
computer.  Access to the data will be limited to the Investigators and study personnel.  All 
subject identifiers will remain strictly confidential.  After the study closure, all consent 
forms and study data will be kept in a locked cabinet in the Research Institute Clinical 
Research Coordinators’ office at Nicklaus Children’s Hospital. 
Transition From Research Participation 
The study treatment period ends 24 hours after surgery.  All patients will be provided 
routine care within the CICU.  A follow-up phone call will be made 60 (± 14) days after the 
end of the study treatment period.20 Subjects will be asked about any adverse events or 

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Christopher Tirotta, MD 
hospitalizations.    
 
We will maintain surveillance for blood borne infections (Cytomegalovirus, HIV, Hepatitis, 
etc.) by contacting the parents of the study participants and asking them if their child has 
been diagnosed with any blood borne illness since they took part in the study.   
 
We will also ask if their child received any additional blood products aside from the one 
received during their participation in the study.  
 
We will again provide the parents our study team’s contact information and advise them 
that it is important to notify us if their child develops any of the above referenced illnesses. 
 
 

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Christopher Tirotta, MD 
 
Figure 1 ROTEM Assays 
 
 
 
 
 
ROTEM
® Assays
Assay
ap-tem®
ex-tem®
fib
-
t em®
hep-tem® 
in-tem®
Indicatons for Use
Provides information on 
clot fir
m
n ess af ter  bl ocki ng  
hyperfib
r
inol ysi s by  
aprotinin
Used to monitor the  
coagulation process via 
the extrinsic pathway and 
its interaction with throm-
bocytes in citrated blood
Provides information on 
fib
r
inogen level  and qual ity 
of fib
r
in pol yme r izat ion in 
citrated blood by inhibiting 
thrombocytes
Used to monitor the  
coagulation process via 
the intrinsic pathway, in 
the presence of unfraction-
ated heparin, in citrated 
whole blood specimens
Used to monitor the  
coagulation process via the 
intrinsic pathway in citrated 
whole blood specimens
Principle
Plasmin antagonist  
Aprotinin prevents fib
r
ino -
lysis in vitro. Evidence of 
fib
r
inol yt ic act ivi ty is  
obtained by comparing  
the results of ex-tem® 
and ap-tem® 
Reagent contains concen-
tration of tissue factor and 
phospholipids used for a  
mild extrinsic activation of 
the coagulation system
Reagent contains  
thrombocyte inhibitor and 
recalcific
a
t ion reagent . 
Used in conjunction with 
ex-tem® test
Reagent contains heparinase 
that inactivates heparin in 
vitro. Also contains an opti-
mized calcium ion concen-
tration in a buffer to start 
the coagulation reaction
Reagent contains an  
concentration of ellagic acid 
creating a standardized mild 
activation of the contact 
phase through negatively 
loaded surface. Sample is 
recalcifie
d
 wi th st ar -tem
®
Storage/Stability
-  Store at +2 - +8°C
-  Stable until the expiration 
on label. Vials must be 
used within 14 days after 
opening
-  Store at +2 - +8°C
-  Stable until the expiration 
on label. Vials must be 
used within 8 days after 
opening
-  Store at +2 - +8°C
-  Stable until the expiration 
on label. Vials must be 
used within 14 days after 
opening
--  Store at +2-+8°C
-  Stable until expiration  
on label. 
-  Reconstituted reagent is 
stable for 30 days at  
+2 - +8°C
  Store at +2-+8°C
-  Stable until expiration  
on label. Vials must be 
used within 8 days after 
fir
s
t  openi ng
BR-2011-18-v02

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Christopher Tirotta, MD 
Figure 2 Transfusion Algorithm 

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Christopher Tirotta, MD 
Figure 3. Blood Transfusion Protocol 
 
Dosing amounts of the required component therapy will be based on the formula below: 
 
PRBC: Volume required = Blood volume (V) x desired Hct increase / Hct of red cell unit 
(70%) 
 
FFP: 20 cc/kg 
Plateletpheresis: 20 cc/kg 
Cryoprecipitate: 10 cc/kg 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Christopher Tirotta, MD 
 
Figure 4.   Rotem Experience 
 
 
 
 
ROTEM
® Experience
Using Detailed Hemostasis Information
BR-2011-24
NORMAL
SCREENING
(INTEM, EXTEM)
No hemostasis 
problem 
INTEM/EXTEM
Factor 
deficiency?
HEPTEM
Heparin? 
Other deficiencies 
masked by heparin?
FIBTEM
Fibrin polymerization 
problem or 
fibrinogen deficiency? 
platelet disorder?
APTEM
Hyperfibrinolysis?
ABNORMAL
Suggests: 
a potential 
bleeding disorder
Additional tests?
(exclusion of primary 
hemostatic disorder)
Consider:
surgical intervention
Suggests:
surgical bleeding
Additional information
Screening tests:
INTEM – Intrinsic
EXTEM – Extrinsic
Contains 
heparinase compare 
to INTEM
Contains platelet 
inhibitor
compare to EXTEM
Contains fibrinolytic 
inhibitor
compare to EXTEM
Please note: Results from the ROTEM® delta should not be the sole basis for a patient diagnosis, but should be evaluated 
together with the patient’s medical history, the clinical picture, and if necessary, further coagulation tests.

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Christopher Tirotta, MD 
Risk/Benefit Assessment 
Risk Category:  Greater than minimal. 
 
Potential Risk:  According to the manufacturer RiaSTAP is “contraindicated in patients 
known to have had an anaphylactic or severe reaction to the drug or its components”.  
“Thrombotic events have been reported in patients receiving RiaSTAP.  The most severe 
adverse reactions observed are thrombotic episodes (pulmonary embolism, myocardial 
infraction and deep vein thrombosis.  The most common adverse reactions observed in 
clinical studies (frequency > 1%) were fever and headache”.   Moreover, “RiaSTAP is made 
from pooled human plasma.  Products made from human plasma may contain infectious 
agents, i.e., viruses and, theoretically, the Creuzfeldt-Jakob disease (CJD) agent.” 
 
Protection against risks:  The patients will be assessed for thromboembolic events at 
least once per shift.  If symptomatic evidence exists that a venous or arterial occlusion has 
occurred an Ultrasound will be ordered.  Assessment for anaphylactic reactions will be 
made at the time of drug administration by the anesthesiologist.  There is no additional 
surveillance for blood borne infectious agents.  As with any patient, bloodborne illnesses 
will be diagnosed and treated at the time of occurrence. 
 
Potential Benefits to the Subjects:  The study drug can potentially decrease blood loss 
and decrease the need for transfusion therapy. 
 
Alternative to Participation:  Usual standard of care will be employed for all patients not 
participating. 
 
 
 

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Christopher Tirotta, MD 
Subject Identification, Recruitment and Consent 
Method of Subject Identification and Recruitment 
 
All neonatal and infant patients scheduled for open-heart surgery will be recruited. 
Process of Consent 
 
Principal Investigator, Sub-Investigators, Clinical Research Coordinators, and 
Cardiac Nurse Practitioners will be authorized to obtain consent.  No undue coercion will 
be employed on any potential patients and families to enroll. 
Subject Capacity 
 
Since the study patients will be neonates and infants, consent will be obtained from 
the parents or legal guardian of the child. 
Subject/Representative Comprehension 
 
The person obtaining consent will provide a detailed overview of the study protocol 
to all prospective patients/families.  All potential risks and benefits of the study drug will 
be discussed with the family.  All questions will be answered and no enrollment will be 
allowed unless the study subjects/families have a complete understanding of the protocol. 
Consent Forms 
 
Informed consent will be obtained for all study patients.  The parent or legal 
guardian will sign the consent form. 
Documentation of Consent 
 
The Principal Investigator, Sub-Investigators, Clinical Research Coordinators, and 
Cardiac Nurse Practitioners will be responsible for the documentation of consent. 
Costs to the Subject 
 
Study participants will not incur any additional costs due to enrollment in the study. 
Payment for Participation 
 
Payments will not be made to study participants. 
 

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Christopher Tirotta, MD 
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