Tuesday, November 06, 2007

Early goal directed therapy five years later

Five years after the seminal paper of Rivers, et al. establishing the efficacy of early goal directed therapy (EGDT) for severe sepsis and septic shock this review was published in the November 2006 issue of Chest. It reviews evidence on EGDT since the original paper and covers multiple theoretical and practical aspects of EGDT. The following points are noteworthy:

Experience accumulated since the Rivers study has confirmed the benefits of EGDT.

Treatment modalities for sepsis are time dependent. Goal directed therapy must be given in the first 6 hours. Older studies demonstrated that, when given later in the course of sepsis, goal directed therapy was not efficacious and possibly harmful.

Arrival to the ER of a patient with suspected sepsis carries the same urgency as does the arrival of a patient with suspected stroke, MI or trauma.

Each hospital must have its own plan for implementation. Three options were suggested for those patients presenting to the ER with sepsis: 1) EGDT is carried out entirely in the ER, by ER personnel. This is how it was done in the original study, in which ICU personnel were uninvolved in EGDT and were, in fact, blinded to the initial therapy. 2) Patients who meet criteria after an initial rapid assessment are taken directly to the ICU, and EGDT is initiated there. 3) As soon as assessment indicates severe sepsis, resources are mobilized by calling a rapid response sepsis team which could be assembled from multiple hospital departments. (Option 1 seems logical, but may not be appropriate for ERs that are burdened by overcrowding and understaffing. Option 2 would probably work only in ICUs staffed around the clock by dedicated intensivists. Option 3 might be best for many hospitals).

EGDT must not supplant or in any way diminish the importance of timely administration of appropriate antibiotics.

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