VAMC Checklist for Drotrecogin Alfa 
 
Contraindications (Check any that apply):                             Review warnings
Active Internal Bleeding  
Recent (within 3 months) - Hemorrhagic stroke
Recent (within 2 months) intracranial or intraspinal surgery, or severe head trauma requiring hospitalization
Trauma with an increased risk of life-threatening bleeding     
Presence of an epidural catheter
Intracranial neoplasm or mass lesion or evidence of cerebral herniation
Known hypersensitivity of drotrecogin alfa or any component of the product
Relative Contraindications (Check any that apply):
Concurrent therapeutic heparin (>/= to 15 units/kg/hr)
Platelet count <30,000 (even if corrected by infusions)
Prothrombin time (INR)> 3.0
Recent (within 6wks) significant GI bleed requiring blood transfusion (unless surgically corrected)
Recent (within 3 days) administration of thrombolytic therapy (not counting low-dose for occluded catheters)
Recent (within 1 week) administration of ASA>650mg or glycoprotein IIb/IIIa inhibitors.
Recent (within 3 months) ischemic stroke.
Intracranial arterio-venous malformation of aneurysm.
Known bleeding diathesis.
Chronic severe hepatic disease (portal htn, cirrhosis, chronic jaundice).
Suspected or proven infection:
Positive culture 
White cells in a normally sterile body fluid
Perforated viscus 
Radiological and clinical evidence of pneumonia 
Other syndrome with high probability of infection 
Monitoring:
Patient will NOT be monitored in an ICU. 
Patient WILL be monitored in an intensive care unit.
Acuity:
Less than 48 hours after the onset of the first sepsis-induced organ dysfunction.
More than 48 hours has elapsed.
SIRS (Check any that apply):  (Note: </= is equivalent to LESS THAN or EQUAL to. ).
Core temperature of >/= 100.4 F (38 C) or </= 96.8 F (36 C) .
Heart Rate of >/= 90 beats per minute.
RR  >= 20 breaths/min or PaCO2 </= 32mmHg or mechanical ventilation for acute (not chronic) respiratory process.
WBC
>/= 12,000/mm3 or <= 4,000/mm3 or   >/= 10% immature neutrophils.
Enter the calculated APACHE II Score (calculator): (leave at zero if not completed yet).
Organ Dysfunction (check any that apply):
CARDIOVASCULAR: Arterial systolic BP </= 90 mmgHg OR a mean arterial pressure (MAP) </=70 mmHg for at least 1 hour despite adequate fluid resuscitation or adequate intravascular volume status. OR, the need for vasopressors to maintain systolic blood pressure (SBP) >/= 90 mmHg or MAP >/=70 mmHg.
RENAL: Urine output < 0.5 mg/kg/hr for > 1 hour, despite adequate fluid resuscitation.
RESPIRATORY: PaO2/FiO2 </=200
HEMATOLOGIC: Platelet count < 80,000 or decreased by 50% from the highest value in the previous 72 hours.
METABOLIC: pH </=  7.30 or base deficit >/= 5 meq/L with plasma lactate > 1.5 x the upper normal limit.
 
Approved by Physician:  Date/Time:
   (Must be a critical care fellow or an infectious diseases/ critical care / pulmonary attending)

Patient name / SS#:    Reviewer: