Use of drotrecogin alfa (activated) in bariatric surgery patients with severe sepsis syndrome: experience in an urban community teaching hospital.
BACKGROUND
Severe sepsis syndrome (SSS) and septic shock have an associated mortality ranging from 31 to 60%. Drotrecogin alfa (activated), activated protein C (APC), has been shown in a recent trial to decrease mortality from 44 to 31% in patients with SSS and a high risk of death. We present 3 patients who developed SSS after bariatric surgery and were treated with APC as part of comprehensive therapy for sepsis.


METHODS
At our institution, patients must have SSS plus an APACHE II score >or= 25 in order to receive APC. JL is a 43-year-old man who developed SSS (APACHE II score 26) after Roux-en-Y gastric bypass. ML is a 33-year-old man who developed SSS (APACHE II=28) because of a distal obstruction 2.5 years after gastric bypass surgery. TQ was a 35-year-old man who developed SSS (APACHE II=35) in the setting of laparoscopic banding.


RESULTS
After receiving 90% of the 96-hour infusion, JL developed ecchymoses and a decrease in his platelet count; thus, the drug was stopped. ML received a full 96-hour infusion. Both patients made a full recovery from their SSS and were successfully discharged from the hospital. TQ developed septic shock and expired despite all efforts.


CONCLUSIONS
Weight alone should not be considered a contraindication to the use of APC. Close coordination between the intensivist and surgeon is recommended for bariatric surgery patients with SSS, so that a rapid determination can be made as to the patient's risk of death and eligibility to receive APC.
Maimonides Medical Center, Department of Surgery, Brooklyn, NY 11219, USA. rhsavel@yahoo.com
Richard H
RH
Savel
Ravi C
RC
Pulipati
Connie
C
Mangone-Cholewczynski
Richard S
RS
Lazzaro
Jerzy M
JM
Macura
Herbert E
HE
Lehman
D000328:Adult; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D017809:Fatal Outcome; D015390:Gastric Bypass / Q000379:methods; D006801:Humans; D010535:Laparoscopy; D008297:Male; D009767:Obesity, Morbid / Q000601:surgery; D011183:Postoperative Complications / Q000188:drug therapy*; D011486:Protein C / Q000627:therapeutic use*; D011994:Recombinant Proteins / Q000627:therapeutic use*; D018746:Systemic Inflammatory Response Syndrome / Q000188:drug therapy* / Q000209:etiology
D000890:Anti-Infective Agents; D011486:Protein C; D011994:Recombinant Proteins; C421124:drotrecogin alfa activated