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August 2015: Update on Early Goal Directed Therapy in Sepsis

This month JC will be taking another look at advances in the management of sepsis. There are some disease processes that warrant frequent revisiting when new data is published and sepsis always makes our top-ten list. For new learners, the importance of having a comprehensive understanding of this disease process and its management cannot be overstated. In 2001, Dr. Emanuel Rivers and colleagues at Henry Ford Hospital in Detroit, Michigan published a milestone article on the management of ED patients with severe sepsis or septic shock. His findings included an overall mortality reduction of 16.0% (NNT of 8) using an Early Goal Directed Bundle (EGDT) that included continuous CVP venous O2 monitoring, 30ml/kg crystalloid, vasoactive drugs to maintain a MAP between 65-90 mmHg and RBC transfusion. This bundle was included the Surviving Sepsis Campaign position paper published in 2004. It was supported by 11 professional organizations (including ACEP) and was widely adopted by hospitals as the new ‘standard of care’. Since its publication, there have been questions regarding which specific components of EGDT offer the greatest benefit and which potential harm. The articles in this package include three recent large studies of broadly representative populations that may help to answer these questions and offer new evidence in the management of the septic patient. As always, free to tweet your perspective

P: In patients with evidence of severe sepsis or septic shock

I: Does Early Goal Directed Therapy (EGDT)

C: Compared to usual standard of care or other protocols

O: Provide better outcomes (mortality, ICU admission rate, length of stay, costs)

 

 Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med. 2001 Nov 8;345(19):1368-77.

Goal-directed resuscitation for patients with early septic shock. ARISE Investigators; ANZICS Clinical Trials Group, N Engl J Med. 2014 Oct 16;371(16):1496-506.

A randomized trial of protocol-based care for early septic shock. ProCESS Investigators, N Engl J Med. 2014 May 1;370(18):1683-93.

 Trial of early, goal-directed resuscitation for septic shock. R, Harvey SE, Bell D, Bion JF, Coats TJ, Singer M, Young JD, Rowan KM; ProMISe Trial Investigators. N Engl J Med. 2015 Apr 2;372(14):1301-11