To report the results of a pharmacist-directed blood factor stewardship program targeting off-label utilization designed to limit use to established organizational guidelines in high-risk populations. Prospective evaluation of recombinant factor VIIa and prothrombin complex concentrate orders beginning June 2013 through May 2014 and a matched retrospective cohort from June 2012 to May 2013. Matched cohorts were evaluated for 28-day mortality, change in international normalized ratio (INR), adverse events, concurrent blood product use, and cost savings. Forty-two orders for blood factor were ordered between June 2013 and May 2014, 70 orders in the year before (N = 112). Twenty eight–day mortality was not different between the cohorts: 53.9% versus 50% (P = 0.77). Blood factor use with underlying liver failure and active bleeding was strongly associated with 28-day mortality: odds ratio (95% confidence interval), 2.9 (1.5–7.14) and 2.91 (0.01–2.91), respectively. Blood products dispensed increased over the year with plasma products the most significant (1 vs. 4 P = 0.004). All other clinical outcomes were nonsignificant. An annual cost savings of $375,539 was achieved, primarily through a significant reduction in recombinant factor VIIa and avoidance in high-risk patients. Use of off-label blood factors can be controlled through a pharmacist-led stewardship program. Twenty eight–day mortality was not different between the 2 cohorts; however, identification of risk factors for death associated with blood factor use allows for restriction in high-risk populations, creates a discussion of futile care, and yields cost savings.

A case of Wernicke encephalopathy (WE) in the setting of umbilical cord blood transplant is reported. The patient, originally diagnosed with Philadelphia chromosome-positive acute lymphoblastic leukemia, proceeded to an umbilical cord blood transplant. He presented with altered mental status 149 days following transplant. Prompt magnetic resonance imaging, baseline thiamine level, and immediate intravenous replacement allowed for recovery of most symptoms. Accompanying this case is a review of the known cases of WE in hematopoietic cell transplants and their causative factors. This is the first known adult case of WE independent of parenteral nutrition use in the setting of umbilical cord transplant.

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