Xygris question

The most recent place I worked used it quite often. I did see really sick pts do fairly well, but I am not convinced it was a result of Xigris. We did D/C it at least once do to bleeding but I can't remember any more than that. It was actually a pain having pts on it because at $800+ per dose, the pharmacy was slow to get us the dose and I felt like I was constantly on the phone trying to get it from pharm in order to give the drug on time. Only time will tell if this drug does what the reps and some of the studys say it will.

We use xigris quite often in our ICU...we did a lot of the clinical trials for Lilly (and are still doing them) and I think it made our docs more eager to use it. We have had pretty good results with some very sick patients but I think it is because our docs usually start the drug early in the process when the patient first shows signs of organ dysfunction related to sepsis...instead of waiting until the patient is almost dead! I can only remember bleeding probs in a couple patients (one of whom died as a result of bleeding) but they both had coag problems before the xigris was started but did not meet the critieria for disqualification from its use.

oh ok i thought i saw my name ... heehehehehe

we use Xigris imediately when patient is septic. we use it at an early stage. and it works all the time!!!!

bleeding is of course the bad complications. we always monitor their coags level every morning. the risks out weighs the benefits.

Xigris is expensive. Actually for a drip , it costs around 4 to 5 thousand depending on the patient weights.

i am glad that so far it works for us here.

We also use Xigris frequently in our ICU. It seems to be more effective if you can use it earlier in the patients septic course.

We've been using it for the past several months, but since we don't get too many septic patients in neurosurgery, I don't have enough experience with it to give an educated opinion on whether it works or not.

We've actually had a BMT pt that was transferred to MICU service (we just happened to have a bed) that's been on it for a few days now. His platelet count was only 26 when he was admitted to our unit, but he was placed on Xigris anyway. He seemed to actually be improving somewhat.

Only thing really negative I've heard about the drug is the cost. Major $$$$$$$$$$ per dose.

Greetings, Snowymtns husband here, As an ICU/CCU nurse with less than 10 years experience, I must say that, beyond any doubt, Xigris has improved the M&M outcomes of pts experiencing septic shock syndromes remarkably. As an RN in the MICU @ the University of Chicago, many of the teaching attendings in the ICU were adept at recognizing the ear;y signs of septic shock and initiating apprpriate treatments. This usually begins by recognition of and organ system failing. Typically the cardiovascular system i.e. hypotension. WE usually start loading fluids on these people until there BP returns. If they don't have central access, we aquire it, hopefully with an introducer and a TLC or SG cath. Next we may add an inotrop like dopamine or dobutamine. Most literature supports dobutamine but I think it depends on the doc and his educational bias. Next, if hypotension isnt resolved with multiple bags of crystalloid and dop/dob docs will add vasopressin. Now here's the key, at this point fluid rescuscitation hasnt worked, first line inotrop's havent worked and you've added vasopressin because you suspect your posterior pituitary is out of this vital pressor agent. Time for Xigris????????? Yes, because you can bet that this process has gone on for hours now, you may or may not have noticed that you very sensitive kidneys are NOT making urine and probably havent been. Also, what you not seeing is the effect that hypotension is having on your liver. Can you say, hepatic infarction? The liver is unable to replace the coag factures that are being used up by your body to mount it's defence response. Xigris must be employed now to replace the c-reactive protiens that are being gobbled up and are crucial to the entire inflammatory response effort your pt is going through. You MUST plug the leaks before your crystalloids will be effective. That is the role of Xigris. The key part of the early recognition process and "early goal directed therapy" for sepsis will save a patients life if implemented sooner rather that later. Antibiotics have a key role here but must be employed early to be effective. If your fluid based efforts are not yeilding results, septic shock MUST be considered. Xigris will save these patient when when the other therapies arent working but is must be used early on. Buy the time you get to 12-15 liters of fluid, dop/dob, vasopressin, levophed, neosyn, and epi drips, and your patient's coags are gone, it's to friggin late. Pt's done

PS Cost should never be a consideration for employment of this therapy. Is the best $6800 you'll ever spend

RobC RN ICU

In my own experience, if you controlled the inflammatory process, covered the pt with antibiotics, and supported the pt with blood products, then sepsis is not so difficult to treat, and in cases where inflammation is strictly and vigorously treated, sepsis can be overcome. I've had pts maxed out on dop, levo, and vaso. PRBC's x2 were given almost daily, with 1 unit FFP and PLT because the pt was bleeding so profusely, so Xigris was obviously ruled out. However, it was only when the inflammatory process was controlled that the pt was able to progress.

Hey snwymnt's husband,

I understand the concept of septic patients forming extensive micro-thrombi and thus 'using-up' an excessive amount of clotting factors....and that xigris works mostly by preventing this...but you lost me on that 'c-reactive protein' thing. ??? CRP is a marker for acute inflammation...and is thought to perhaps help 'boost' the body's immune response...but does it have anything to do with clotting? And i was under the impression that this micro-clot formation was an abnormal response brought on by sepsis...not some aspect of the normal immune mechanism??

Also, yes the kidney's are easily damaged by hypoperfusion, but the liver isn't as succeptible(sp?) to damage (infarction!?) from this same hypoperfusion???(yes, severe hypotension will hurt any organ, but kidneys are perhaps the most 'fragile') I think the primary reason the liver is unable to 'keep up' with the septic patient's 'burning of clotting factors' has less to do with liver infarction and more to do with the 'speed' that these same factors are being used up. Liver failure isnt always a 'given' in these patients....especially early on.

We've had great success with Xigris, but then it's been started early, and we've had little incidence of bleeding. I think it's a keeper.

My only problem has been that thus far, patients have had to stay in the ICU until the whole course was completed [that is unless they were doing so well that it was discontinued before the 96 hours was up], but we're working on changing that.

There is an awesome website http://www.sepsis.com that has a great animation of the sepsis cascade that explains what is going on at the cellular level with hypoperfusion and explains about the c reactive proteins and how Xigris helps to stop the cascade. Hope it helps!

KC CCRN,

Thanks, that site is a good one. (that whole lilly-sepsis education thing is a direct result of their producing xigris!...great info.)

While reading through it, it repeatedly refers to "protein-C" as a link in the sepsis induced cascade...I'm thinking this is different from " C-reactive protein" which is a common lab-test/marker for acute inlammation?? I wonder if anyone can shed some light on this? If they're not the same thing, it's easy to see why they would become confused. If they ARE the same thing, that would be good to know as well!

Thanks again.

You're right, they are not exactly the same thing, but similiar enough to be confusing. C-reactive protein (CRP) test is a non specific lab test that indicates if an inflammatory process is going on. CRP is virtually absent in a healthy person, appears rapidly in response to many injuries. It can also be elevated in pt's with MI, rheumatoid arthritis, rheumatic fever, malignancy, post op and bacterial/viral infections.

Activated protein C is found in the inflammatory response cascade. This guy's job is to break down clots. Since the whole inflammatory response is a viscous cycle, it gets turned on and then continues to restimulate itself, causing clotting then clot lysis in the microcirculation. Because of this, activated protein c levels are low in severe sepsis. This is how Xigris works, it helps stop the cascade by replenishing activated protein c and making the fibrinolytic system work better. ((UUGGH too many big words for a saturday morning)

Hope this helps. It can be a mind-boggling thought process when you delve into the whole coagulation system!