Monday, September 07, 2009

Early goal directed therapy update

This review was written by the Detroit group that originated the protocol. As a subset of the larger array of interventions recommended in the Surviving Sepsis Guidelines EGDT can viewed as a “bundle within a bundle.”

Controversy about EGDT broke out last year. Since EGDT was studied as a package of interventions questions have arisen as to the value of the individual components (e.g. do all patients need a central line and a hct target of 30?). An NIH study in early stages of development plans to address this. Arms of the study will include “Rivers protocol minus the central line” and “usual care.” (How ethical is it to have a usual care group given all the studies that show improved outcomes with protocol driven therapy---see below?).

Delivery of the entire package of EGDT as opposed to individual components had a great deal of prior evidence and pathophysiologic rationale to recommend it according to the paper:

Comprehensive resuscitation is a way to optimize systemic oxygen delivery (preload, afterload, arterial oxygen content, contractility), balance oxygen delivery with systemic oxygen demands, optimize the microcirculation, and use metabolic end points to verify efficient cellular oxygen use. Although there is much discussion about the components required to accomplish a comprehensive resuscitation, no single component dictates the overall intent of the resuscitation. These components are interrelated and should be considered as a continuum of care and not as isolated variables.

The paper reviews the data that have accumulated since the original Rivers paper, overwhelmingly supporting the EGDT protocol:

Eleven peer-reviewed publications (1569 patients) and 28 abstracts (4429 patients) after the original EGDT study have been identified from academic, community, and international settings. These publications total 5998 patients (3042 before and 2956 after EGDT). The mean age, sex, Acute Physiology and Chronic Health Evaluation II scores, and mortality were similar across all studies. The mean relative and absolute risk reduction was 46% (±26%) and 20.3% (±12.7%), respectively. These findings are superior to those from the original EGDT trial, which showed figures of 34% and 16%, respectively. When peer-reviewed publications are compared, the relative risk reduction exceeded 25% and absolute risk reduction exceeds 9% in all studies. This evidence shows effectiveness across a broad range of mortality risks.[9]

Finally, EGDT is cost effective:

Hospital costs for severe sepsis and septic shock account for over $54 billion of the Medicare and Medicaid budget. Reports in the literature have noted reductions in ICU length of stay, hospital length of stay, duration of mechanical ventilation, renal replacement therapy, vasopressor therapy, and pulmonary artery catheterization with early hemodynamic optimization. [68] , [69] These studies have shown that sepsis-related hospital costs can be reduced up to 20%. [70] , [71]

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