Critically evaluate the role of Early Goal Directed Therapy (EGDT) in septic shock.
EGDT definition:
Within 6 hours of presentation to the Emergency Department intensive monitoring of specific circulatory parameters with the aggressive management of these parameters to specified targets:
Parameters
Interventions
Rationale:
The principle of applying EGDT for septic shock is based on the observations that:
Evidence:
The evidence for the intervention is based on an American, single-centre RCT (Rivers 2001) and a recent Chinese multicenter study supporting EGDT -
Surviving Sepsis Guidelines: Grade 1C (inconsistent results, well done observational studies/control RCTs) recommendation
Limitations of Rivers study include the following:
Study population limited to ED presentations and did not include ward patients Single centre
Non-blinded
Control group had an above-average mortality rate
Unclear which interventions are most important – whole EGDT protocol or one single component
Target parameters are restrictive
Use of ScvO2 and pressure monitoring has not been tested in the target population Transfusion target to improve DO2 contradicts restrictive transfusion practice and may be associated with increased mortality in the critically ill
Results of ANZ ARISE and related international studies (ProCESS and ProMISE) Awaited
Adverse effects:
Protocols for implementing EGDT usually result in more fluid being administered, more use of vasoactive medication and more use of blood transfusion.
Therefore potential adverse effects relate to:
Proscriptive targets may not suit all (eg higher MAP needed for elderly patients, lower MAP and Hct targets for young, fit patients).
Statement of Candidate’s Own Practice:
Summary statement including any reasonable strategy.
Also LITFL have an excellent autopsy of this technique. Additonally, Paul Marik recently published an opinion piece in CHEST which is an excellent summary of modern approaches to the acute management of sepsis. Lastly, the ProCESS and ARISE studies have now added damning empirical evidence to the theoretical objections.
Upon my initial inspection, the college answer seemed extremely detailed, and seemed unlikely to be reproduced by the time-starved exam candidate.
A succinct version would be better... but, in an attempt to create one, my version also became hideously bloated. There is simply no way to approach this answer without a vast amount of detail.
Such was the extent of this bloat, that the original answer to this question has mutated into a whole chapter on the merits and demerits of early goal-directed therapy.
An then was re-summarised again.
Thus:
Rivers, Emanuel, et al. "Early goal-directed therapy in the treatment of severe sepsis and septic shock." New England Journal of Medicine 345.19 (2001): 1368-1377.
Jones, Alan E., et al. "The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis." Critical care medicine 36.10 (2008): 2734.
Kumar, Anand, et al. "Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock*." Critical care medicine 34.6 (2006): 1589-1596.
Early Goal-Directed Therapy Collaborative Group of Zhejiang Province. "The effect of early goal-directed therapy on treatment of critical patients with severe sepsis/septic shock: A multi-center, prospective, randomized, controlled study." Zhongguo wei zhong bing ji jiu yi xue= Chinese critical care medicine= Zhongguo weizhongbing jijiuyixue 22.6 (2010): 331.
Yealy, Donald M., et al. "A randomized trial of protocol-based care for early septic shock." The New England journal of medicine 370.18 (2014): 1683-1693.
Power, GSarah, et al. "The Protocolised Management in Sepsis (ProMISe) trial statistical analysis plan." Critical Care and Resuscitation 15.4 (2013): 311.
Delaney, Anthony P., et al. "The Australasian Resuscitation in Sepsis Evaluation (ARISE) trial statistical analysis plan." Critical Care and Resuscitation 15.3 (2013): 162.
Marik, Paul E. "Early Management of Severe Sepsis: Concepts and Controversies." CHEST Journal 145.6 (2014): 1407-1418.
Peake, Sandra L., et al. "Goal-directed resuscitation for patients with early septic shock." The New England journal of medicine 371.16 (2014): 1496.
Yealy, Donald M., et al. "A randomized trial of protocol-based care for early septic shock." The New England journal of medicine 370.18 (2014): 1683-1693.