Recombinant activated protein C usage in Scotland: a comparison with published guidelines and a survey of attitudes*

Abstract

Summary Severe sepsis is a common cause of admission to the intensive care unit and is associated with a high hospital mortality. This audit explored the current use of, and attitudes towards, recombinant activated protein C therapy across Scotland, and compared these with current guidance. Patients with severe sepsis were followed for three days. Consideration and/or usage of recombinant activated protein C were compared with two different guidelines. Ninety‐seven patients were admitted to the intensive care unit over the audit period. Recombinant activated protein C was used in nine of these patients. Depending on the criteria used, between 50% and 81% of the patients who qualified for recombinant activated protein C therapy did not receive it. Subsequent to the audit, a survey was performed to study intensive care unit consultants’ attitudes to recombinant activated protein C therapy. A total of 125 consultants responded to the survey (77%). Of these, 104 (83%) stated that they used recombinant activated protein C in their clinical practice, 56 (52%) of whom prescribed it to patients with two‐organ failures and an Acute Physiology and Chronic Health Evaluation II score of ≥ 25. Thirty‐nine respondents (38%) stated that two‐organ failures alone would be an adequate trigger for therapy. We conclude that recombinant activated protein C is potentially under‐used to treat severe sepsis. Many consultants seem to reserve the drug for the most severely ill sub group of patients.

The role of steroids in treating septic shock

“…Such guidance provides significant leeway for clinicians, who may range from enthusiasts to sceptics. A recent study by Puxty et al [16] highlights variation in behaviour amongst intensivists with regards to instigation of therapy in septic shock, in this case activated protein C. Many were unconvinced by the evidence, while others used the drug outside of the recommended guidelines. Overall, we feel that this is a natural consequence of the problems of applying published evidence to an individual patient.…”