Early Goal Directed Therapy

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Rivers E et al. "Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock". The New England Journal of Medicine. 2001; 345:1368-1377 .

Link to Article: https://www.nejm.org/doi/full/10.1056/NEJMoa010307


Clinical Question

In adults with severe sepsis or septic shock, does the use of early goal-directed therapy (EGDT) reduce the mortality?

  • Type of Trial: RCT

  • Blinding: no blinding of clinicians, study personnel or patients

  • Setting: Single hospital in Detroit, Michigan from March 1997-March 2000

PICO

  • Population:

    • 236 patients with severe sepsis or septic shock defined as:

      • >/= 2 SIRS features AND either SBP<90 mmHg after 20-30cc/kg IVF over 30 min OR blood LA>4 mmol/L

        • Excluded: Age<18 years, pregnancy, other acute neurological/cardiac/GI/respiratory pathology, CI to CVL insertion, uncured cancer, immunosupression, limitations defined for active care

  • Intervention:

    • EGDT for 6 hours

      • Remained in ED for 6 hours and protocolized therapy managed by an ED physician, two residents and three nurses

        • Oxygen +/- intubation and mechanical ventilation

        • CVL catheterization capable of measuring continuous SCVO2

        • 500 cc fluid boluses until CVP 8-12 mmHg

        • Vasopressors or vasodilators until MAP 65-90 mmHg

      • If SCVO2<70%:

        • Transfused red cells until Hct > 30%

        • If still SCVO2 <70%

          • Dobutamine 2.5-20 microgram/kg/min until SCVO2>70%

          • Dobutamine limited or reduced if MAP<65mmHg or pulse>120/mi

  • Control:

    • Usual care for 6 hours without protocol - treatment at discretion of the clinician and patient admitted to ICU as soon as possible after consult + lines inserted

      • Oxygen +/- intubation and mechanical ventilation

      • CVL and arterial cathterization

      • Targets defined without treatment algorithim:

        • CVP>/= 8-12mmHg

        • MAP>/= 65 mmHg

        • UOP>/= 0.5 cc/kg/hr

  • Outcome:

    • Primary outcome: in-hospital mortality

      • Statistically and clinically significant in EGDT intervention group compared to control group (30.5% in intervention vs 46.5% in control, p=0.009)

    • Secondary outcomes: all favored EGDT

      • Severity of Sepsis (30.5% in intervention vs 46.5% in control, p=0.009)

      • 28 day and 70 day mortality (30.5% in intervention vs 46.5% in control, p=0.009)

      • Cause of in-hospital death being CV collapse and MSOF (30.5% in intervention vs 46.5% in control, p=0.009)

    • Tertiary Data Collection

      • EGDT group received more fluid over 6 hour period, but there was no difference in total amount of fluid over 72 hours in either group

      • More red cell transfusions were given in EGDT group

      • Early inotropic use more prevalent in EGDT group (not statistically different over 72h period)

      • Vasopressor use more prevalent in usual care group

      • Intubation/ventilation more prevalent in usual care group

Conclusions

“Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock”


Strengths

  • Adequate trial design

  • 90% completed study

Weaknesses

  • Single center study

  • Non-blinded

  • Intervention was a bundle of care and individual components not investigated separately

  • In-hospital mortality outcome had limitations; some patients will go to institutions or home to die

  • Lead author was a paid consultant for manufacturer of SCVO2 measuring CVL; has registered EGDT and Early goal-directed therapy as trademarks


Take Note

  • ProCESS, ARISE and ProMISe has changed the game; but prior to these trials, this trial was best evidence for EGDT

  • Lots of criticism and concerns for EGDT but despite this has become widespread standard of care

  • Would be nice to test individual elements

  • Overall, provides a way to treat patients with sepsis; but you must mindfully deviate

Sources:

https://www.thebottomline.org.uk

Rachel F

Rachel is a physician assistant who has been holding down the ICU since 2016. She joined the Pulmcast podcast in 2017 and has been hooked on FOAMed ever since. Rachel has a passion for teaching using technology with a special focus on preserving dignity in the ICU. When she's not at work, you’ll find her playing with her golden retriever, hunting for thrift store treasures, and soaking up time with her husband and son.

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ProCESS: A Randomized Trial of Protocol-Based Care for Early Septic Shock

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