Key Point

Early goal-directed therapy is effective for reducing the mortality of emergency department patients with sepsis and septic shock.

Based on the findings from a 2001 study by Rivers et al, the current sepsis guidelines of the Surviving Sepsis Campaign contain a grade B recommendation for the routine use of early goal-directed therapy (EGDT) in emergency department (ED) patients with sepsis. Whereas the Rivers study validated the efficacy of EGDT (ie, that EGDT “does more good than harm when delivered under optimum conditions and in a uniform fashion”), findings from a new study by Jones and associates in the August Chest validated the clinical effectiveness of EGDT (ie, that the protocol “does more good than harm when delivered under real-world conditions”). Lead study author Alan E. Jones, MD, is Director of Research in the Department of Emergency Medicine at the Carolinas Medical Center in Charlotte, North Carolina.

BEFORE AND AFTER

This study, which may be the largest of its kind, associated EGDT with absolute and relative mortality reductions of 9% and 33%, respectively, in ED patients with severe sepsis and septic shock. It is important, added the authors, that compared with ED sepsis patients who did not receive EGDT, those who did had equal hemodynamic instability at study enrollment based on systolic blood pressure values and sequential organ failure scores.

The study was a prospective before-and-after investigation that compared the mortality rates of adult ED patients treated for sepsis during the year before and the year after implementation of an EGDT protocol in an urban, 800-bed teaching hospital. “Inclusion criteria included suspected infection, criteria for systemic inflammation, and either systolic blood pressure of less than 90 mm Hg after a fluid bolus or lactate concentration of 4 mol/L or greater,” said the authors. Exclusion criteria included contraindication to a chest central venous catheter and need for immediate surgery.

During the preintervention period, treatment was given at the discretion of board-certified emergency physicians. By contrast, during the year after the implementation of the protocol, EGDT recipients were cared for by a multidisciplinary team of ED, ICU, and infectious disease specialists who adhered to a detailed diagnostic and treatment algorithm that was modified from the original developed by Rivers et al.

Specifically, the newer protocol was executed by the physicians and nurses who provided clinical care to the patient, whereas Rivers and colleagues arranged additional physician staffing at the bedside. Also, the protocol was initiated in the ED and patients were moved to the ICU later, with the discontinuation of the protocol at the discretion of the admitting attending physician, as opposed to the six hours of continued care outlined in the protocol of Rivers and colleagues.

SIGNIFICANT TREATMENT BENEFIT

There were 79 patients in the pre-EGDT group and 77 protocol-managed patients. In the latter group, “ED physicians and staff identified the patients, initiated the goal-directed resuscitation protocol, placed the central venous catheter, administered antimicrobial medications, and followed the protocol until a bed in the ICU was available for patient transfer,” related the authors. For the EGDT-managed patients, the mean protocol duration from initiation to transfer from the ED was two hours and 20 minutes.

During the first six hours of resuscitation, the EGDT-managed patients received a significantly greater volume of crystalloids than did patients in the pre-EGDT group (4.66 vs 2.54 L). The percentage of patients given a vasopressor infusion was also greater in the EGDT-managed group (69% vs 34%). The in-hospital mortality rates of the pre-EGDT and EGDT groups were 27% and 18%, respectively, suggesting a number needed to treat of approximately 11 persons.

The lack of a randomized design, a sample size that, though relatively large, was still too small, the possibility of systematic inclusion bias, and the possibility that early antibiotic steroid therapy influenced the mortality results are among the study limitations “that warrant discussion,” the authors pointed out.            

—Timothy Begany

Suggested Reading
Jones AE, Focht A, Horton JM, Kline JA. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest. 2007;132(2):425-432.
Rivers E, Nguyen B, Havstad S, et al. Early goal-
directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377.

Return to table of contents