The PROWESS trial demonstrated that drotrecogin Alfa (DA) reduced mortality in patients with severe sepsis and septic shock. The trial, however, excluded many patients, especially those with an increased risk of bleeding. Evidence-based medicine dictates that the results of a trial be applied only to patients that are similar to the group studied. We therefore, prospectively studied the utility of DA in geriatric patients with severe sepsis.
All patients over the age of 70 with severe sepsis, assessed by the critical care service were evaluated for administration of DA. Only patients with APACHE II scores of 25 or greater and who did not meet any of the PROWESS exclusion criteria were given DA. The reason for not administering DA was recorded.
Between January 1 and April 30, 2003, 158 patients were evaluated. One hundred fifty seven patients (99.4%) were not eligible for DA administration. Ninety-nine patients had low APACHE II scores (63%). Eighty-five patients (54%) had active internal bleeding predominantly from the GI tract. Fifty five patients (35%) required dialysis, 15 (9.5%) had GI bleeding within 6 weeks, 8 (5%) were concurrently receiving heparin, 23 (15%) recently received platelet inhibitors, 6 (4%) had severe thrombocytopenia, 18 (11.4%) had a poor life expectancy, 5 (3%) had cerebral complications and 4 (3%) had severe hepatic failure. Many patients had more than one contraindication to DA. One patient received DA and was discharged from the hospital.CONCLUSIONS: DA has limited utility in the treatment of severe sepsis in geriatric patients. Further trials are required to accurately define all the patients with sepsis that would potentially benefit from DA.
T. Khan, None.