Using transcutaneous oxygen pressure measurements as selection criteria for activated protein C use.
BACKGROUND
Limited resources and the expense of Activated Protein C (APC) (drotrecogin alfa) may contribute to the reluctance to utilize this drug in sepsis. Employing the PROWESS criteria resulted in absolute reduction in 28-day mortality of 6.1%, representing a relative risk reduction of 19.4%. Additional patient categorization and selection may lead to less frequent drug use with the same survival advantage. We used transcutaneous partial pressure of oxygen (PtcO2) as an indicator of microcirculatory perfusion to identify which septic patients may benefit from APC.


METHODS
Nineteen patients consecutively admitted with severe sepsis or septic shock that fulfilled the PROWESS criteria for APC treatment. APC was administered to patients with the PROWESS selection criteria, only if the PtcO2 information demonstrated tissue ischemia.


RESULTS
Nineteen patients met the PROWESS criteria. Ten patients demonstrated poor tissue perfusion using PtcO2 monitors and received APC. Nine patients had adequate tissue perfusion and did not receive APC. There were no differences in age, gender, APACHE II scores, lactate levels, or organ failure between the two groups. The 10 patients who received APC had a mortality of 3 of 10 (30%). The survivors of this group uniformly converted to PtcO2 values consistent with survival within 12 hours to 24 hours of drug administration. The nine patients who did not receive APC had a mortality of 2 of 9 (22%), not statistically significant from those who received the drug (p = 0.89).


CONCLUSIONS
Withholding APC did not result in an increase in mortality from severe sepsis in those patients who demonstrated adequate PtcO2 values. The transcutaneous oxygen measurement may be a useful adjuvant in addition to the other selection criteria for better identification of patients who may benefit from APC.
Chapital
Alyssa D
AD
Department of Surgery, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii, USA.
Yu
Mihae
M
Ho
Hao Chih
HC
Wang
John
J
Koss
Wega
W
Takanishi
Danny M
DM
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D001785:Blood Gas Monitoring, Transcutaneous; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008833:Microcirculation / Q000503:physiopathology; D008875:Middle Aged; D018579:Patient Selection; D011486:Protein C / Q000627:therapeutic use*; D011994:Recombinant Proteins / Q000627:therapeutic use; D015203:Reproducibility of Results; D018805:Sepsis / Q000097:blood* / Q000188:drug therapy* / Q000401:mortality; D016896:Treatment Outcome
D000890:Anti-Infective Agents; D011486:Protein C; D011994:Recombinant Proteins; C421124:drotrecogin alfa activated