The conventional management of coagulopathy in patients with massive bleeding due to acute or chronic hepatic disease is supportive, and includes fresh-frozen plasma, vitamin K and platelets. A 48-year-old male was admitted to the internal medicine ward with spontaneous bleeding of the psoas muscle combined with alcoholic cirrhosis and coagulopathy. Conventional supportive treatment, including multiple units of packed cells, fresh frozen plasma, prothrombin complex, vitamin K, fibrinogen, tranexamic acid and thrombocytes, was not effective for stopping the bleeding. Twelve days after admission, the patient developed hypovolaemic shock caused by persistent bleeding despite the conventional supportive bleeding management. The patient was admitted to the ICU. Previously conducted supplementary coagulation studies by then revealed a factor V, factor VII and antithrombin deficiency. Supportive management was continued and not effective for stopping the bleeding. A single dose of recombinant factor VIIa (90 μg/kg) was given, after which the bleeding ceased. No further therapy was necessary and the patient was discharged to the internal medicine ward. In patients with life-threatening bleeding and hepatic failure a more generalised decrease in the vitamin K dependent clotting factors must be considered, with most of the time disproportionally low levels of factor VII. In case of ongoing bleeding, despite conventional supportive therapy, recombinant factor VIIa should be considered as lifesaving therapy. © 2015, Netherlands Society of Intensive Care. All rights reserved.