Drotrecogin alfa is a newer therapy available for the treatment of severe sepsis. Its use is not well studied in patients following coronary artery bypass graft surgery (CABG). We present a patient who developed sepsis following CABG in which treatment with drotrecogin alfa resulted in significant improvement.
A 78 year-old male presented with an acute myocardial infarction and left ventricular dysfunction (ejection fraction 10%) treated with heparin, aspirin and clopidogrel. He developed hypotension during a cardiac catheterization and required intra-aortic balloon pump support. He underwent emergent CABG. Following surgery his cardiac function improved (EF 30%). He required mechanical ventilatory assistance and four days later developed increased tracheal secretions which decreased following antibiotic therapy. Six days later he developed fever (39.1c), hypotension, leukocytosis, renal failure, and a left upper lobe infiltrate. Intravenous fluids, dobutamine, norepinephrine, phenylephrine and epinephrine were needed to maintain a mean arterial pressure of 60 torr. A transesophageal echo showed biventricular dysfunction (EF 10%). Sepsis due to pneumonia was diagnosed and drotrecogin alfa was started. His hemodynamics improved significantly and he was able to be weaned from the pressor support within five hours. No significant bleeding occurred thereafter. He was transferred from the intensive care unit but he required ventilatory and dialysis support. A decision was made by the family not to maintain ongoing dialytic support. He died thirty days later.DISCUSSION: This case represents the use of drotrecogin alfa in a patient with severe sepsis developing soon after CABG. Drotrecogin alfa is useful for patients with severe sepsis but its use for patients treated with anticoagulant and antiplatelet agents and/or CABG has not been studied. Our patient with cardiogenic shock was treated with aspirin, clopidogrel and CABG. Sepsis, unresponsive to pressor agents, was treated with drotrecogin alfa with dramatic improvement in hemodynamics within several hours and without significant bleeding.
Drotrecogin alfa should be considered for the treatment of severe sepsis in a patient following CABG.
S. Yakoob, None.