Published in:
01-08-2006 | Correspondence
Drotrecogin alfa in tropical infections and refractory multi-organ failure
Published in: Intensive Care Medicine | Issue 8/2006
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Sir: We have been following the scientific literature on the use of activated protein C (APC) [1, 2], the negative selective interpretation of the data [3], and the responses to this interpretation [4]. We would like to add to this debate by presenting our data regarding the use of APC in severe tropical infections, on which there is no published literature currently. Malaria, leptospirosis and dengue can lead to refractory multi-organ failure. A total of ten such patients have received APC in our ICU since the drug became available in India. Table 1 shows the details of these patients. All ten needed invasive mechanical ventilation, nine had refractory shock and required catacholamines, and all ten had azotaemia, with eight needing renal replacement therapy for anuria. In all patients APC was started within 24 and 48 h of initiation of these life-sustaining therapies. All these diseases involve coagulopathy and bleeding, but with the availability of blood and products it is unusual to have fatality due to bleeding. Instead, the common cause of death is multi-organ failure despite adequate control of bleeding and haemodynamics.
Table 1
Clinical profile of patients (APACHE Acute Physiology and Chronic Health Evaluation, SAPS Simplified Acute Physiology Score, period 1 first 24-h in intensive care unit, period 2 24-h period preceding drotrecogen initiation, no. organs failed number of organs failed prior to initiating drotrecogen alfa as per criteria of PROWESS study [1], S survived to hospital discharge and alive at 90 days, D died)
|
Case no.
|
Diagnosis
|
Age (years)
|
Sex
|
APACHE II
|
SAPS II
|
No. organs failed
|
Outcome
|
||
|---|---|---|---|---|---|---|---|---|---|
|
Period1
|
Period2
|
Period1
|
Period2
|
||||||
|
1
|
Falciparum malaria
|
26
|
F
|
64
|
55
|
40
|
39
|
6
|
S
|
|
2
|
Falciparum malaria
|
56
|
F
|
17
|
21
|
37
|
40
|
6
|
S
|
|
3
|
Leptospirosis
|
46
|
M
|
17
|
20
|
34
|
37
|
7
|
S
|
|
4
|
Dengue
|
19
|
M
|
19
|
49
|
38
|
70
|
7
|
S
|
|
5
|
Dengue
|
62
|
F
|
15
|
18
|
39
|
37
|
7
|
S
|
|
6
|
Vivax malaria
|
41
|
M
|
25
|
30
|
53
|
79
|
7
|
D
|
|
7
|
Falciparum malaria
|
55
|
M
|
34
|
34
|
61
|
61
|
6
|
D
|
|
8
|
Mixed vivax, Falciparum malaria
|
24
|
M
|
15
|
25
|
31
|
37
|
6
|
S
|
|
9
|
Leptospirosis
|
44
|
M
|
17
|
18
|
36
|
43
|
7
|
S
|
|
10
|
Dengue
|
48
|
M
|
11
|
15
|
25
|
34
|
5
|
D
|
|
Av.
|
–
|
–
|
–
|
23
|
29
|
38
|
47
|
6.4
|
–
|