Use of drotrecogin alfa (activated) in bariatric surgery patients with severe sepsis syndrome: experience in an urban community teaching hospital.

BACKGROUND: Severe sepsis syndrome (SSS) and septic shock have an associated mortality ranging from 31 to 60%. Drotrecogin alfa (activated), activated protein C (APC), has been shown in a recent trial to decrease mortality from 44 to 31% in patients with SSS and a high risk of death. We present 3 patients who developed SSS after bariatric surgery and were treated with APC as part of comprehensive therapy for sepsis. METHODS: At our institution, patients must have SSS plus an APACHE II score >or= 25 in order to receive APC. JL is a 43-year-old man who developed SSS (APACHE II score 26) after Roux-en-Y gastric bypass. ML is a 33-year-old man who developed SSS (APACHE II=28) because of a distal obstruction 2.5 years after gastric bypass surgery. TQ was a 35-year-old man who developed SSS (APACHE II=35) in the setting of laparoscopic banding. RESULTS: After receiving 90% of the 96-hour infusion, JL developed ecchymoses and a decrease in his platelet count; thus, the drug was stopped. ML received a full 96-hour infusion. Both patients made a full recovery from their SSS and were successfully discharged from the hospital. TQ developed septic shock and expired despite all efforts. CONCLUSION: Weight alone should not be considered a contraindication to the use of APC. Close coordination between the intensivist and surgeon is recommended for bariatric surgery patients with SSS, so that a rapid determination can be made as to the patient's risk of death and eligibility to receive APC.

Successful thrombolysis of submassive pulmonary embolism after bariatric surgery: expanding the indications and addressing the controversies.

BACKGROUND: Venous thromboembolic (VTE) disease is a much-feared complication of bariatric surgery. The most common unexpected cause of death in the morbidly obese patient is pulmonary embolism (PE). Recent data supports the expanded use of systemic thrombolytics in hemodynamically stable patients with PE and echocardiographic evidence of right ventricular (RV) dysfunction. METHODS: We report a morbidly obese 28-year-old female who presented with dyspnea 3 weeks following bariatric surgery. The patient developed a submassive PE, despite being on low molecular weight (LMW) heparin (dalteparin) postoperatively. The patient was admitted to the surgical intensive care unit of an urban community teaching hospital and underwent successful thrombolysis. RESULTS: Although the patient was not hypotensive, she was tachycardic and highly symptomatic. Spiral CT scanning revealed a large saddle embolism. Transthoracic echocardiography revealed moderate-to-severe acute RV dysfunction with paradoxical septal motion. The patient was started on i.v. heparin followed by an infusion of alteplase 100 mg i.v. over 2 hours. She had no mental status changes during the infusion or evidence of hemorrhage. She had a rapid improvement of her symptoms. Repeat CT scanning revealed marked resolution of the PE. She was discharged home in excellent condition. CONCLUSION: To our knowledge, this is the first report of systemic thrombolysis for a submassive PE after bariatric surgery in a hemodynamically stable patient with RV dysfunction. Given the high incidence and morbidity of VTE disease in this population, and the expanding indications for thrombolytic therapy, successful cases such as these should be documented.