Sepsis in Critically Ill Patients at a Community Acute Care Hospital
In the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study, mortality at 28 days after initiation of treatment was lower among adult patients with severe sepsis (associated with acute organ dysfunction) who were treated with drotrecogin alfa (activated) (DAA) than among those treated with placebo (absolute risk reduction 6.1%). In that study, the rate of serious bleeding associated with DAA was higher than that associated with placebo, but the difference was not significant (3.5% and 2.0%, p = 0.06); however, the risk of serious bleeding with DAA during clinical use has subsequently been reported to be higher. The cost associated with a 96-h course of treatment with DAA for a 70-kg patient is about $11 000. Given the high cost of the drug, the risk of serious bleeding, and the fact that the greatest benefit of DAA appears to be for patients with a higher risk of death (defined as an Acute Physiology and Chronic Health Evaluation [APACHE] II score of 25 or more), preprinted orders were developed at the author’s institution, with criteria to optimize and facilitate the use of DAA. The institution is a 246-bed community acute care hospital in North Vancouver, British Columbia, and the intensive care unit (ICU) is a 9-bed medical—surgical unit. The institutional criteria require that patients have at least 3 of the 4 criteria for systemic inflammatory response syndromes associated with severe sepsis, at least 2 dysfunctional organs or systems (and the time from first organ or system dysfunction must be no more than 48 h before DAA is started), an APACHE II score of at least 25, and no contraindications to therapy. The preprinted order must be completed and signed by an intensivist before the pharmacy department dispenses the DAA. The hospital has intensivist coverage 24 h/day, but when the ICU pharmacist is available, he or she assists in the evaluation of patients for eligibility of DAA use, including completion of APACHE II scoring. Outside the pharmacy’s usual hours of operation, a distribution pharmacist is available for call-back to dispense DAA for eligible patients. cialis professional
The objective of the study reported here was to evaluate the utilization and outcomes associated with DAA in clinical practice at this institution.