Krwotok śródczaszkowy jako powikłanie ciężkiej sepsy leczonej aktywowanym białkiem C

Grażyna Michalska-Krzanowska, Elżbieta Stasiak-Pikuła

Summary
Background. Recombinant human activated protein C (rhAPC), or drotrecogin alpha (activated) has been shown to prevent organ damage and decrease mortality in severe sepsis. The use of rhAPC has, however, been associated with a higher incidence of serious bleeding during the infusion period. We describe a case where severe haemorrhagic complications occurred during rhAPC infusion. Case report. A 52-yr-old woman was admitted to the ICU because of multi organ failure, which developed after laparoscopic cholecystectomy followed by ileus and abscess formation at the site of gallbladder removal. Fifteen months earlier she had undergone renal transplantation and was on immunosuppressive drugs. On admission, the patient was comatose and septic (APACHE score 25), with respiratory, cardiovascular and renal failure. Ultrasound examination revealed a subdiaphragmatic abscess. She was intubated and placed on artificial ventilation and inotropic support. A diagnosis of severe systemic sepsis was made and antibiotic therapy was commenced. The abscess was drained and the abdomen left open. Because available standard treatment did not improve the patient´s status, an infusion rhAPC (Xigris, Elli Lilly, USA) was commenced, at a dose of 24 mcg kg^-1 h^-1. This resulted in transient cardiovascular stabilisation, but the patient remained pyretic and oliguric. The rhAPC infusion was stopped and several peritoneal abscesses were removed during a re-laparotomy, after which the rhAPC infusion was reinstituted. The patient´s condition improved and she regained consciousness. Eighteen hours later, massive gastrointestinal and peritoneal haemorrhage occurred, requiring massive transfusion and two surgical interventions. The administration of recombinant human factor VII (NovoSeven, Nordisk, Denmark) stopped the bleeding, but the patient´s neurological status deteriorated and CT-scan revealed acute intracranial bleeding. Two subsequent neurosurgical interventions did not improve her status and she died. Discussion and conclusion. Serious bleeding, including cerebral haemorrhage, can complicate the use of rhAPC. Therefore, use of this drug should be preceded by a detailed neurological examination, and a risk-benefit analysis, especially in cases of severe coagulation disorders.

To jest tylko fragment artykułu. Aby przeczytać całość, przejdź do Czytelni medycznej.