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A case report of a new pulmonary embolism occurring in a patient receiving continuous infusion of recombinant activated protein C
World Journal of Emergency Surgery
A case report of a new pulmonary embolism occurring in a patient receiving continuous infusion of recombinant activated protein C Bernard J Benedetto*1 and Michael A Houston2
0 University of North Carolina Medical Center, University of North Carolina School of Medicine , Chapel Hill, NC , USA
1 Rhode Island Hospital, Brown University School of Medicine , 2 Dudley Street, Providence, RI , USA
Background: There are no guidelines governing the concomitant use of recombinant human activated protein C (rhAPC) and deep venous thrombosis/pulmonary embolism (DVT/PE) prophylaxis in critically ill patients. It is unknown if rhAPC provides any protection against DVT/PE in this population of patients. Methods: Case report. Results: This report describes the first case of a radiographically demonstrated pulmonary embolism occurring in a patient receiving continuous therapeutic infusion of rhAPC. Conclusion: The administration of rhAPC alone may not be sufficient DVT/PE prophylaxis in high risk patients. The risks associated with concomitant anticoagulation and rhAPC therapy are unknown. Further research is necessary to determine the safest and most effective regimen for DVT/PE prophylaxis in patients receiving rhAPC.
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Background
Recombinant human activated protein C (rhAPC) has
been demonstrated to improve mortality in critically ill
patients with septic shock [1]. It is thought that rhAPC
exerts its effect via multiple mechanisms involving
antiinflammatory, antioxidative, antiapoptotic and
anticoagulant pathways [2]. The anticoagulant effect of rhAPC
leads to a 23% incidence of severe bleeding
complications in treated patients [1]. This risk has led to the general
practice of discontinuing the use of all other forms of
anticoagulation, including deep venous thrombosis (DVT)
prophylaxis, when rhAPC is used. It is unknown what
DVT or pulmonary embolism (PE) prophylaxis is safe and
appropriate in patients receiving rhAPC. Further, it is not
known if rhAPC alone provides any protection against
DVT/PE. We present a case report of a patient who
developed a new, documented PE while receiving a continuous
infusion of rhAPC.
Case presentation
A 48 year old male resident of a psychiatric institution
presented to the emergency department with diarrhea,
vomiting and decreased mental status. He had a history of
hypertension, schizophrenia, hypothyroidism and factor
XII deficiency. He was not receiving any anticoagulation
for his Factor XII deficiency at the time of presentation.
According to his emergency department record he was
febrile to 38.7 Celsius with mild abdominal distension
and tenderness on physical examination. A computed
tomographic (CT) scan of his abdomen did not
demonstrate any intraabdominal abnormality. An empiric
diagnosis of infectious diarrhea with dehydration was made
and the patient was discharged back to his facility on
Levofloxacin and Metronidazole and intravenous fluids.
Three days later, he represented to the emergency
department with persistent diarrhea and a metabolic acidosis. A
repeat CT scan was obtained which demonstrated an
illdefined rectosigmoid mass, but no obstruction. The
pulmonary artery was seen on the uppermost cuts of this scan
and there was no evidence of pulmonary embolus at this
time (Figure 1). Sigmoidoscopy revealed no mass or
mucosal abnormality and the patient was admitted to the
medical intensive care unit with continued broad
spectrum antibiotics, intravenous hydration and
hemodynamic monitoring. He was hemodynamically stable.
Sequential compression devices were documented to be
in place for DVT/PE prophylaxis.
On hospital day two, the patient developed increasing
abdominal tenderness which was associated with fevers
up to 39.5 degrees Celsius and acute renal failure. Surgery
was consulted and recommended urgent operative
exploration. Upon exploration the patient was found to have
mesenteric venous thrombosis with a segment of ischemic
small bowel. He underwent small bowel resection and
was returned to the intensive care unit for continued
resuscitation. At this time a heparin infusion was initiated
given the patient's known factor XII deficiency and
demonstrated mesenteric venous thrombosis. His partial
thromboplastin time (PTT) was maintained between 60
and 80 seconds. The following day he had not improved;
he was returned to the operating room where a second
segment of ischemic bowel was discovered and further
resection was performed. The patient again returned to
the intensive care unit in critical condition requiring
pressor support with levophed and continued ventilatory
support with a PaO2 to FiO2 ratio of 180. At this point he was
evaluated and found to be a candidate for rhAPC. This was
initiated six hours after the completion of his operation.
Due to concerns about potential bleeding complications,
the heparin infusion was discontinued when the rhAPC
was started. At the time of heparin discontinuation the
patients PTT was 82 (...truncated)