Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE

Nguyen, H. Bryant; Jaehne, Anja Kathrin; Jayaprakash, Namita; Semler, Matthew W.; Hegab, Sara; Yataco, Angel Coz; Tatem, Geneva; Salem, Dhafer; Moore, Steven C.; Boka, Kamran; Gill, Jasreen; Gardner-Gray, Jayna; Pflaum, Jacqueline; Domecq, Juan Pablo; Hurst, Gina; Belsky, Justin; Fowkes, Raymond; Elkin, Ronald; Simpson, Steven Q.; Falk, Jay L.; Singer, Daniel J.; Rivers, Emanuel P.

doi:10.1186/s13054-016-1288-3

Cited by 147 publications

(103 citation statements)

References 196 publications

(132 reference statements)

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“…Examples of this include activated protein C and early goal-directed therapy for sepsis. 2,3 Results from other studies, such as the ARDSnet protocol, appear to have better stood the test of time. 4 But these interesting controversies lead to the crucial focal point of our discussion.…”

Section: Change As It Relates To the Evidencementioning

confidence: 99%

Facing Change: When to Embrace, When to Resist

Savel

Munro

2017

American Journal of Critical Care

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Section: Change As It Relates To the Evidencementioning

confidence: 99%

Facing Change: When to Embrace, When to Resist

Savel

Munro

2017

American Journal of Critical Care

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“…For example, PRISM investigators identified subgroups of severely sick patients, and the size of this sample was 4 times larger than the entire cohort studied by Rivers et al These investigators used eight ways to stratify the disease severity and identified the top third of predicted risk of death. However, they found no treatment benefit with EGDT in patients with greater severity of illness (8,9). This failure to replicate the results in the Rivers study suggests that current usual care treatment strategies can provide equal reductions in mortality.…”

Section: Hawa Edrissmentioning

confidence: 99%

“…As expected, patients in EGDT arm received the same interventions used in the EGDT protocol of the Rivers study. These three studies concluded that EGDT did not reduce the 90-day mortality in patients who received EGDT compared to usual care (8,9). Furthermore, EGDT was associated with increased admission to ICU and higher hospitalization costs across a wide range of patients and hospitals.…”

Section: Hawa Edrissmentioning

confidence: 99%

What comes after the Early Goal Directed Therapy for sepsis era?

Edriss

2017

J. Thorac. Dis.

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The idea of sepsis was introduced in the literature in the 4 th century BCE by the ancient Greek Hippocrates when animal and plant decomposition (σηψις, rot) was reported. In the 11 th century, Avicenna described the process of acute inflammation and purulence formation, a "blood rot", and he included body temperature, heart rate, and the state of body fluids in his description (1). However, the word "sepsis" was not used until the 19 th century. Over the past 30 years, the need to understand the underlying pathophysiological process and to identify better clinical criteria for early detection of sepsis has rapidly evolved because of the increasing number of patients with sepsis receiving advanced organ support systems, including mechanical ventilation, renal replacement therapy, and extracorporeal membrane oxygenation, has taxed health care systems (2,3). Furthermore, our awareness of the morbidity, mortality, and cost associated with this condition has increased.Despite the fact that we adopt studies that have the best external and internal validity and we know that patients managed according to evidence-based medicine do better than patients treated according to physician judgment and expertise which can vary considerably, there is no doubt that not every positive outcome found in clinical studies on welldefined patient populations can be applied to "real world" situations with extremely heterogeneous patient populations with the expectation of similar results. In this editorial, I will address the conflicting results on the role of the early goal directed therapy (EGDT) in managing sepsis.In the1990s, there was no standardized protocol for the early identification and treatment of patients with sepsis. The observed mortality then was more than 50%, and this triggered systematic investigations on the early identification and risk stratification of patients with sepsis and septic shock. The well-known study by Rivers et al.on EGDT conducted over 3 years (1997)(1998)(1999)(2000) reported a significant 16% absolute decrease in mortality with an aggressive protocol for sepsis resuscitation in the first 6 hours after presentation to the emergency center (4). This study included 263 patients with severe sepsis and septic shock at a single urban Detroit emergency center and compared an EGDT protocol with standard "usual care" treatment. In the EGDT arm, patients received mandatory arterial catheters and central venous catheters with continuous central venous oxygen saturation (ScvO 2 ) measurements. Patients received crystalloid or colloid until prespecified central venous pressures (8-12 mmHg) and a prespecified mean arterial pressures (MAP ≥65 mmHg) were achieved. If their MAPs were below 65 mmHg, treatment with vasopressors was started. If their ScvO 2 saturations were less than 70%, patients were transfused until their hematocrits were greater than 30%, and if the ScvO 2 remained low, patients were started on dobutamine. Both groups had early cultures.Despite initial concerns regarding the external validity of t...

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“…Because of methodological issues, several recent large multicenter studies failed to demonstrate a beneficial effect of EGDT as compared to usual care. Yet, the conceptual framework underlying EGDT is still considered as the cornerstone for the early management of sepsis and septic shock (7,8).…”

Section: Introductionmentioning

confidence: 99%

Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

et al. 2017

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Severe sepsis and septic shock are major causes of morbidity and mortality in patients entering the emergency department (ED) or intensive care unit (ICU). Despite substantial efforts to improve patient outcome, treatment of sepsis remains challenging to clinicians. In this context, early goal directed therapy (EGDT) represents an important concept emphasizing both early recognition of sepsis and prompt initiation of a structured treatment algorithm. As part of the AME evidence series on sepsis, we conducted a systematic review of all randomized controlled EGDT trials. Focus was laid on the setting (emergency department versus ICU) where EGDT was carried out. Early recognition of sepsis, through clinical or automated systems for early alert, together with well-timed initiation of the recommended therapy bundles may improve patients' outcome. However, the original "EGDT" protocol by Rivers and coworkers has been largely modified in subsequent trials. Currently, many investigators opt for an "expanded" EGDT (as suggested by the Surviving Sepsis Campaign). Evidence is also presented on the effectiveness of automated systems for early sepsis alert. Early recognition of sepsis and well-timed initiation of the SSC bundle may improve patient outcome.

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Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE

Cited by 147 publications

References 196 publications

Facing Change: When to Embrace, When to Resist

Facing Change: When to Embrace, When to Resist

What comes after the Early Goal Directed Therapy for sepsis era?

Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

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