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, Aug 2006

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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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. - 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)


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Bernard J Benedetto, Michael A Houston. 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, 2006, pp. 23, 1, DOI: 10.1186/1749-7922-1-23