Pharmacy & Therapeutics- August 2008 - (Page 476) CASE REPORT: Low-Dose Drotrecogin Alfa in Sepsis 2. Laboratory orders: Prior to starting drotrecogin alfa infusion, please obtain: a. Blood cultures ×2 if not done within the previous 48 hours b. Serum pregnancy test Y N (circle one) 3. Nursing considerations: a. Infuse drotrecogin alfa for a cumulative total of 96 hours. b. 0.9% sodium chloride is used for preparation of I.V. drotrecogin alfa bags; do not infuse with any other medications. c. If the patient is being transfused within 2 units of packed cells due to an acute bleed, please notify attending physician immediately. d. If the patient is to have any invasive procedure performed, including the changing of a line over a guidewire, chest tube placement, any operative procedure, or central line insertion, please notify the attending physician and discontinue the drotrecogin alfa, as noted on the “guidelines for stopping the infusion.” If drotrecogin alfa has been interrupted for over 1 hour, the time will need to be added to the end of the infusion for a total infusion equal to 96 hours. e. Notify the attending physician for further instructions if the patient requires hemodialysis or renal replacement therapy (CVVH, CVVHD, CAVH, CAVHD). f. Each bag of drotrecogin alfa can be hung no more than 12 hours from the time of preparation in the pharmacy. g. If therapeutic anticoagulation is indicated for the patient, discontinue drotrecogin alfa and notify the attending physician immediately. Step 6. Guidelines for stopping drotrecogin alfa infusion Should clinically important bleeding occur, immediately stop the infusion of drotrecogin alfa. Continued use of other agents affecting the coagulation system should be carefully assessed. Drotrecogin alfa should be discontinued 2 hours prior to undergoing an invasive surgical procedure or procedures with an inherent risk of bleeding. Once adequate hemostasis has been achieved, initiation of drotrecogin alfa may be reconsidered 12 hours after major invasive procedures or surgery, or may be restarted immediately after uncomplicated, less invasive procedures. APACHE = Acute Physiology and Chronic Health Evaluation; bpm = beats per minute; CAVH = continuous arteriovenous hemofiltration; CAVHD = continuous arteriovenous hemodialysis; CVVH = continuous venovenous hemofiltration; CVVHD = continuous venovenous hemodialysis; FiO2 = fraction of inspired oxygen; INR = International Normalized Ratio; IBW = ideal body weight; ICU = intensive-care unit; PaO2 = partial pressure of arterial oxygen; PaCO2 = partial pressure of arterial carbon dioxide; PROWESS = Recombinant Activated Human Protein C Worldwide Evaluation in Severe Sepsis; SIRS = systemic inflammatory response syndrome. References continued from page 471 severe sepsis. Crit Care 2003;7(2):155–163. 11. Matthay MA. Severe sepsis: A new treatment with both anticoagulant and anti-inflammator y properties. N Engl J Med 2001; 344(10):759–762. 12. Bernard GR, Ely EW, Wright TJ, et al. Safety and dose relationship of recombinant human activated protein C for coagulopathy in severe sepsis. Crit Care Med 2001;29(11):2051–2059. 13. Leady M, Kraft C, Alaniz C. Pharmaceutical spotlight: Recombinant human activated protein C (rhAPC) or drotrecogin alfa (activated). P&T 2002;27(4):190–194. 14. Abraham E, Laterre PF, Garg R, et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med 2005;353(13):1332–1341. 15. Castelli EE, Culley CM, Fink MP. Challenge and rechallenge: Drotrecogin alfa (activated)-induced prolongation of activated partial thromboplastin time in a patient with severe sepsis. Pharmacotherapy 2005;(8):1147–1150. 16. Warren HS, Suffredini AF, Eichacker PQ, et al. Risks and benefits of activated protein C treatment for severe sepsis. N Engl J Med 17. Barie PS. ‘All in’ for a huge pot: The PROWESS–SHOCK trial for refractory septic shock. Surg Infect 2007;8(5):491–494. 18. Dellinger PR, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32(3):858–873. I 476 P&T® • August 2008 • Vol. 33 No. 8
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