21 Mar 08
Posted in Early goal directed therapy, Fluid management, Inotropic support, Sepsis at 21:37 by Laci
By M W Donnino, B Nguyen, G Jacobsen, M Tomlanovich and E Rivers
Chest 2003;124:90S
Despite the current definition of septic shock, patients with normal or high blood pressure may still display global tissue hypoxia. The following study evaluates early, goal-directed therapy (EGDT) in patients with severe sepsis in the absence of hypotension.
METHODS
This is a post-hoc anlysis of patients presenting to an urban ED in severe sepsis and septic shock. Patients were included if they had SIRS critieria, lactic acidosis (> 4 mmol/liter), and mean arterial pressure (MAP) > 100 mm Hg. Patients were randomized to conventional care (inclusive of central venous pressure (CVP) monitoring) or EGDT. EGDT consisted of 6 hours of resuscitation to goals of CVP between 8–12, MAP between 65–90, and central venous oximetry (ScvO2) greater than 70%.
RESULTS
There was no difference in mean MAP (116.0 mm Hg in the control and 117.6 mm Hg in the treatment group), and there was no difference in APACHE, MODS, and SAPS scores between groups. Forty-eight patients (23 in the control group and 25 in the EGDT group) were analyzed. The mortality was 60.9% in the control group compared to 20% in the EGDT group [p < 0.004]. The mean initial ScvO2 was 45 % and 44 % in the control and treatment groups respectively. At six hours, ScvO2 was higher in the EGDT (76% versus 59%), whereas the lactate and MODS score were reduced (p < 0.05). The EGDT group received more total intravenous fluids than the treatment group (p < 0.05) during the first six hours. At sixty days, mortality in the control (70%) and in the treament group (24%) remained significant (p=0.002).
CONCLUSIONS
This study confirms that patients with severe sepsis accompanied by lactic acidosis may display global tissue hypoxia in the absence of hypotension. Early identification and goal-directed therapy of this subgroup leads to a reduction in morbidity and mortality.
Permalink
10 Dec 06
Posted in Critical Care, Early goal directed therapy at 18:03 by Laci
By J Carlet
Critical Care Medicine 2006;34:2842-2843
The article from Rivers et al. published a few years ago, raised huge international enthusiasm because it was dealing with a simple principle (early goal-directed therapy and good organization) applied to a very complex and multifactorial medical problem considered as a serial killer (severe sepsis and septic shock). It was graded pretty high in the last Surviving Sepsis Campaign guidelines and is an important step of the Surviving Sepsis Campaign. No doubt that it is likely to remain an important component of the second edition of those guidelines, which will be published shortly.
Permalink
20 May 06
Posted in Early goal directed therapy, Sepsis at 9:35 by Laci
By B CH Ho, R Bellomo, F McGain, D Jones, T Naka, L Wan and G Braitberg
Critical Care 2006;10:R80
The purpose of the present study was to measure the incidence and outcome of septic patients presenting at the emergency department (ED) with criteria for early goal-directed therapy (EGDT).
Method
This hospital-based, retrospective, observational study using prospectively collected electronic databases was based in a teaching hospital in Melbourne, Australia. We conducted outcome-blinded electronic screening of patients with infection admitted via the ED from 1 January 2000 to 30 June 2003. We obtained data on demographics, laboratory and clinical features on admission. We used paper records to confirm electronic identification of candidates for EGDT and to study their treatment. We followed up all patients until hospital discharge or death.
Results
Of 4,784 ED patients with an infectious disease diagnosis, only 50 fulfilled published clinical inclusion criteria for EGDT (EGDT candidates). Of these patients, 37 (74%) survived their hospital admission, two (4%) died in the ED, eight (16%) died in the intensive care unit and three (6%) died in the ward. After review of all ward cardiac arrests and non-NFR (‘not for resuscitation’) ward deaths, we identified a further two potential candidates for EGDT for an overall mortality of 28.8% (15 out of 52 patients). Analysis of treatment showed that twice as many (70%) of the EGDT candidates received vasopressor therapy in the ED, and their initial mean central venous pressure (10.8 mmHg) was almost twice that in patients from the EGDT study conducted by Rivers and coworkers.
Conclusion
In an Australian teaching hospital candidates for EGDT were uncommon and, in the absence of an EGDT protocol, their mortality was lower than that reported with EGDT.
Permalink
13 Apr 06
Posted in Critical Care, Early goal directed therapy, Glycemic control, rhAPC, Sepsis, Steroid at 18:38 by Laci
By A Kortgen, P Niederprum, M Bauer
Critical Care Medicine. 2006;34:943-949
Objective
To assess the impact of an algorithm defining resuscitation according to early goal-directed therapy, glycemic control, administration of stress doses of hydrocortisone, and use of recombinant human activated protein C (rhAPC) on measures of organ dysfunction and outcome in septic shock.
Design
Retrospective cohort study.
Setting
Multidisciplinary ten-bed intensive care unit of a university hospital.
Patients
Sixty patients were analyzed: 30 consecutive patients fulfilling criteria for diagnosis of septic shock, treated from September 2002 until December 2003 after implementation of a standard operating procedure (SOP) for severe sepsis and septic shock; and 30 patients with septic shock treated from January until August 2002 in the same unit, who served as controls.
Measurements and Results
Data for blood gas analysis, lactate, glucose, serum creatinine, bilirubin, white blood cells, platelets, and C-reactive protein were obtained from patient files on admission or at time of diagnosis of septic shock and at 7:00 a.m. on days 2 and 4; Sequential Organ Failure Assessment scores were calculated and 28-day survival was assessed. With implementation of the SOP, use of dobutamine (12/30 vs. 2/30), insulin (blood glucose <150 mg/dL, day 4: 26/28 vs. 13/25), hydrocortisone (30/30 vs. 13/30), and rhAPC (7/30 vs. 0/30) significantly increased, whereas volume for resuscitation and use of packed red blood cells were unaffected. Mortality was 53% in the historical control group and 27% after implementation of the SOP (p < .05).
Conclusion
The combined approach of early goal-directed therapy, intensive insulin therapy, hydrocortisone administration, and additional application of rhAPC in selected cases seems to favorably influence outcome. The implementation of a “sepsis bundle” can be facilitated by a standardized protocol while significantly reducing the time until the defined therapeutic measures are realized in daily practice.
Permalink