Sepsis, Early Goal Directed Therapy

September 2005

Sepsis – Early Goal Directed Therapy

Search Strategy: This practice change is based on relatively new research (Rivers paper), so you decide to review papers which have subsequently referenced his work by performing a Web of Science referenced citations search. This identifies all of the articles you decide to review.

A hot paper has been accepted by your hospital administration as the new standard of care for the management of septic shock patients. In an attempt to maintain objectivity, you decide to research the evidence supporting the new early goal directed therapy of ED patients which intuitively makes sense. Looking at the protocol, you note that a severely septic patient with hypotension refractory to an initial fluid bolus (or with an initial blood lactate exceeding 4 MMOL/L) should receive an arterial catheterization and central venous catheterization with central venous pressure transducer set-up within six hours of presentation. Though not unreasonable, you question whether one size fits all. Additionally, you question the impact on other patients: the acute myocardial infarction or stroke who presents while you are placing these sepsis-monitoring lines and whose care is delayed as a result. Therefore, you further resolve to search and review the available evidence.

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PICO Question

Population: Adults (over age 18) presenting to ED with sepsis (>2 SIRS + source)

Intervention: Early goal directed therapy (crystalloid, antibiotics, steroids, vasopressors, central pressure monitoring)

Comparison: Adults with sepsis treated in standard fashion

Outcome: Mortality, Morbidity, Hospital Length of Stay, Effect on Other ED Patients

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Years

First years: Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. NEJM 2001; 345: 1368-1377.

Second years: A Multidisciplinary Community Hospital Program for Early and Rapid Resuscitation of Shock in Nontrauma Patients. Chest 2005; 127: 1729-1743.

Third years: Early Lactate Clearance is Associated with Improved Outcome in Severe Sepsis and Septic Shock. Crit Care Med 2004; 32: 1637-1642.

Fourth years: Meta-analysis of Hemodynamic Optimization in High-Risk Patients.. Crit Care Med 2002; 30: 1686-1692.

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Forms

First, Second Year Residents: use the Therapy Critical Review Form

Third Year Residents: use the Prognosis Critical Review Form

Fourth Year Residents: use the Meta-analysis Critical Review Form

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Articles

Article 1: Early Goal Directed Therapy in Severe Sepsis and Septic Shock, NEJM 2001; 345: 1368-1377
ANSWER KEY

Article 2: Multidisciplinary Community Hospital Program for Early & Rapid Resuscitation of Shock in Nontrauma Patients, Chest 2005; 127: 1729-1743
ANSWER KEY

Article 3: Early Lactate Clearance Is Associated with Improved Outcome in Severe Sepsis & Septic Shock, Crit Care Med 2004; 32: 1637-1642
ANSWER KEY

Article 4: Meta-analysis of Hemodynamic Optimization in High-risk Patients, Crit Care Med 2002; 30: 1686-1692
ANSWER KEY