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The physicians say it happens in hectic fever, that in the beginning of
the malady it is easy to cure but difficult to detect, but in the course of
time, not having been either detected or treated in the beginning, it
becomes easy to detect but difficult to cure.”
Machiavelli – The Prince Chapter 3
Early Goal Directed Therapy (EGDT),
6 hour protocol
invasive measurements of hemodynamics to guide resuscitation
New era of sepsis management
Rivers et al (2001)
Protocol-based approach in treating sepsis
1341 patients in suspected septic shock
31 centers,
Randomized in a 1:1:1 ratio
Protocol-based EGDT,
Protocol-based standard care
Usual care
within 2 hours of recognition of shock and within 12 hours of arrival to the ED
Process-trial
Central venous catheter placement
Treated based on targets in Rivers’ algorithm: ◦ central venous pressure,
◦ mean arterial pressure, and
◦ mixed venous oxygen saturation.
The amount and timing of volume resuscitation
was specifically dictated in this treatment group.
EGDT
Through a review of the literature
Input of expert physicians,
Targets requiring less invasive measurement
techniques, ◦ systolic blood pressure
◦ clinical and laboratory signs of hypoperfusion.
Protocol-based standard therapy
Care without any direction from study coordinators
Usual care group
•Early treatment with antimicrobial agents,
•conservative transfusion thresholds,
•low tidal-volume ventilation
•moderate glycemic control.
60-day mortality did not differ among the three
groups ◦ 21% in EGDT,
◦ 18% in protocol-based standard care,
◦ 19% in usual care;
95% confidence interval [CI], 0.82 to 1.31; p=0.83), with
comparably insignificant differences in 90-day and 1-year
mortality rates.
Primary outcome
despite its widespread use,
a protocol based on invasive hemodynamic
monitoring does not significantly improve
outcomes in septic shock
compared to less invasive approaches.
Relevance
... is similar to research that found the use of pulmonary artery
catheters did not improve mortality,
... suggests invasive hemodynamic monitoring is not a requirement
for the management of septic shock.
... Can change current standards of care and management?
This study...
Early recognition of sepsis,
as well as cornerstone interventions –◦ the rapid infusion of intravenous fluids,
◦ early broad spectrum antibiotics,
◦ prompt source control
have a greater impact on survival than the use of invasive monitoring
to guide such therapies.
Bottom line
the early or facilitated ◦ recognition of septic shock,
◦ administration of intravenous antibiotics
(76% after 3 hours, 97% after 6)
were associated with rates of survival that were higher than
projected and higher than predicted on the basis of scores on the
Acute Physiology and Chronic Health Evaluation (APACHE) II
"A designer knows he has achieved perfection not when there is
nothing left to add, but when there is nothing left to take away."
- Antoine de Saint-Exupry