Three years experience with drotrecogin alfa (activated) protein C in severe sepsis and septic shock at Salmaniya Medical Complex, Bahrain

Objective

To evaluate the role of activated protein C (APC) in severe sepsis and septic shock.

Method

The data were collected in a prospective manner from July 2002 to November 2006 in the adult medical/surgical ICU at Salmaniya Medical Complex Bahrain. The number of demographic variables were collected from patients' files.

Results

A total of 444 patients were admitted to the ICU with the diagnosis of sepsis or severe sepsis. One hundred and forty-nine severe septic patients were assessed for APC: 85 patients received APC, and 64 patients could not receive APC due to financial problems or due to bleeding, coagulation derangement or very recent surgeries. In the total 444 septic patients admitted to the ICU, 152 patients expired (mortality 34.2%) and 141 had positive blood culture; 233 patients received inotrops. The total average APACHE II score was 28.9 and for expired patients was 35.1.

Out of the total 444 septic patients 149 were assessed for APC; in the 85 patients fulfilling criteria for and receiving APC the mortality was 43.5%, and for the 64 patients not receiving APC the mortality was 64%. All suspected septic patients admitted to the ICU received appropriate antibiotic therapy within 4 hours of ICU admission and were upgraded/changed according to culture/sensitivity reports if necessary. In the nonreceiving group (i.e. 64 patients) 12 patients could not receive APC due to financial restriction because initially foreigners were not entitled to this drug in Bahrain, but later this restriction was removed, and the remaining 52 patients could not receive either due to bleeding or very recent surgeries. Some patients could not receive complete treatment either due to bleeding complications or because they died. The mortality was measured at 28 days.

Furthermore, as per our experience, if APC started in the early stage of sepsis and the course is completed the outcome is better – out of 85 patients who received APC, 45 patients received in the early stage and completed the dose and 32 of these patients survived at 28-day mortality. An average three (ventilator-free) organs failed in the survival group and two (ventilator-free) organs failed in the expired group. Seventeen patients started treatment in the early stage and could not complete the course due to bleeding or other complications, 11 patients expired; 13 patients started in the late stage and completed the course, five patients expiring; and 10 patients started in the late stage and eight of these patients expired.

Conclusion

On the basis of our experience and the results of multiple trials, we recommend APC should be given to the patients who meet all the inclusion criteria.