Neuroaxial catheters following abdominal surgery and their impact on the use of Drotrecogin alfa (activated) in sepsis

Introduction

Neuroaxial anaesthesia reduces the risk of postoperative complications, but in high-risk patients undergoing major abdominal surgery the benefits of neuroaxial anaesthesia are less clear [1, 2]. A significant proportion of patients develop sepsis following laparotomy. Recently Drotrecogin alfa (activated) has been shown to reduce the risk of death from sepsis [3]. Due to the increased risk of bleeding the presence of a neuroaxial catheter is an absolute contraindication to its use. We hypothesized that the presence of a neuroaxial catheter excludes a significant number of septic patients from receiving this potentially beneficial therapy.

Method

All patients admitted to our unit over a 1-year period following major intra-abdominal surgery were reviewed. Among those with neuroaxial catheters, data were collected on systemic inflammatory response syndrome (SIRS) criteria, presence of infection, organ failure and hospital survival. Sepsis was defined according to the Critical Care Medicine Consensus Committee.

Results

See Table 1. Sixty-seven patients were admitted following major abdominal surgery. Of these, 57 (85%) had neuroaxial catheters. Of these, 14 developed sepsis (25%). The mortality in this group was 8/14 (57%). In our unit, patients receiving Drotrecogin alfa had a mortality of 29% (expected 53%).

Table 1 Sepsis among patients with neuroaxial catheters after intra-abdominal surgery

Conclusion

The mortality in patients with sepsis in our group undergoing major abdominal surgery was comparable with that observed in the PROWESS study (0.57 vs 0.52) [3]. Given that Drotrecogin alfa has been shown to reduce the risk of death by 6% and that neuroaxial anaesthesia confers little survival benefit following major abdominal surgery, avoiding the use of or early removal of catheters in sepsis may confer a significant increase in survival.