DIC in septic shock

[CRRT]

I have seen a couple of patients recently with profound septic shock ; one from meningococcemia and one from E. coli sepsis, develop DIC and then lose all 4 extremities. I was thinking what would be options for combating the microvascular thrombosis ? Xigris used to be available 12 years back but was taken off the market because of disappointing data in the PROWESS trial. Was it because Xigris was being used too indiscriminately ? If it had been used solely for a particular subset of pts with profound shock and DIC it would have shown benefit ?

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[SurfingDoctor]

I have seen it with pseudomonas and streptococcus. Never seen anything prevent it.

As for Xigris… maybe. Too much is unknown in sepsis to offer personalized treatments. Maybe some day.

 

[Tipsy McStagger]

Seen it more than once with strep pneumo.

The story of Xigris is much more Machiavellian than "disappointing data." I don't think there's a role for it anywhere. DIC is complex, and simply adding activated protein C I doubt would change the outcome.

 

[SurfingDoctor]

Seen it more than once with strep pneumo.

The story of Xigris is much more Machiavellian than "disappointing data." I don't think there's a role for it anywhere. DIC is complex, and simply adding activated protein C I doubt would change the outcome.

Probably more of a pediatric thing but there are absolutely people born with protein c deficiency. I’ve seen a handful of cases myself. Now, most of them stroke out in the newborn period and don’t survive to adulthood, but it’s not hard to imagine someone heterozygous for some mutation where their protein c was abnormal and a primary cause of acquired and aberrant clot formation. Of course, protein s deficiency looks the same so it’s clearly not a cure all.

That’s probably why plasma exchange has become more and more en vogue. We aren’t smart enough at this juncture to detect the subtleties, so we instead hit the “reset” button to the best of our abilities.

 

[lymphocyte]

I have seen a couple of patients recently with profound septic shock ; one from meningococcemia and one from E. coli sepsis, develop DIC and then lose all 4 extremities. I was thinking what would be options for combating the microvascular thrombosis ? Xigris used to be available 12 years back but was taken off the market because of disappointing data in the PROWESS trial. Was it because Xigris was being used too indiscriminately ? If it had been used solely for a particular subset of pts with profound shock and DIC it would have shown benefit ?

In the PROWESS trial, there was already a predefined subgroup analysis of patients based on Protein C and coagulopathy. It showed no benefit.

Still, like you, I get the feeling that it might have been a useful drug that was pulled from the market too quickly.

There's a great reply in the NEJM on this exact issue.

https://www.nejm.org/doi/full/10.1056/nejmoa1202290

 

[CRRT]

Both patients developed purpura fulminans. I wonder if it could be prevented by giving 1-2 units FFP q6 hes as long as pt could tolerate. That would have repleted protein C and S.

 

[Radetzky]

I would use heparin (assuming not bleeding) and Ceprotin for instances of proper Purpura Fulminans rather than FFP

 

[ShockIndex]

We’ve seen a couple of bad purpura fulminans in relatively young patients in the past 2 months. Both gew Klebs and one also grew Acinerobacter (I think) in their blood cultures. They both started out as flu-like illnesses that quickly spiraled into septic shock with MODS. Both had extremity/appendage ischemia with dangly parts falling off (nose, ears, etc.). One had profound consumptive thrombocytopenia (<5K). Both were worked up for vasculitis, TTP, HLH, etc.

These cases, coupled with a noticeable uptick in massive and submissive PEs have my partners joking about COVID vaccines…nervously.