Sepsis Multicast 2/5

In Show #2 we will go in depth into the history of sepsis care including surviving sepsis campaign, Rivers landmark Early Goal Directed Therapy (EGDT) trial, and the Jones LACTATE clearance trial. 
Further Details about EGDT and the Rivers trial:
  • Single center study done in 2001; 236 patients
  • Changed early focus of attention in the ER to the "golden hours" much like MI and stroke
  • EGDT arm: early CVL's with MAP, CVP, Scvo2 targets
    • CVP goal 8-12 
      • 12-15 in vented patients
      • If not at goal then bolus with 500 mL NS every 30 minutes until at goal
    • MAP goal 65
    • Scvo2 goal 70%
      • Blood transfusion if Hgb < 10
      • Dobutamine if Hgb > 10
  • Outcomes: 46% mortality in control compared to 30% in EGDT arm
Rivers Trial Criticisms
  • Single center trial
  • Patient population of Detroit; sicker than average patient population?
    • Average Lactate 6.6 - 7.7
  • High transfusion rates: 64% in EGDT arm compared to 18% in control
  • High dobutamine use: 13% in EGDT arm compared to 1% in control 
  • Poor evidence for CVP, Scvo2, and dobutamine specifically in other trials
  • Expense of catheter for continuous scvo2 monitoring
  • formed in 2001/2002
  • Guidelines revised in 2008, 2012
  • Major Revisions of 2012
    • More emphasis on Lactate clearance after Jones trial
    • Preferential use of crystalloids over colloids
    • Norepi preferred pressor
    • Decrease of emphasis on corticosteroids
  • 3 hour bundle: Fluids (20-30 cc/kg), early broad spectrum abx, cultures, and lactate 
  • Time Zero in sepsis is Triage Time in ED and on the wards time of positive sepsis screen
Jones LACTATE trial
  • Compared lactate clearance of 10% to Scvo2 as therapy targets in sepsis 
  • 300 patients, multi-center study, non-inferior
  • Jones vs Rivers in CHEST
We conclude discussing our thoughts on the common arguments on both sides of the EGDT debate. Framing for our future episodes discussing the newer trials. 
SepsisJeremy AmayoComment