Protocolized Care for Early Septic Shock

The physicians say it happens in hectic fever, that in the beginning of

the malady it is easy to cure but difficult to detect, but in the course of

time, not having been either detected or treated in the beginning, it

becomes easy to detect but difficult to cure.”

Machiavelli – The Prince Chapter 3

Early Goal Directed Therapy (EGDT),

6 hour protocol

invasive measurements of hemodynamics to guide resuscitation

New era of sepsis management

Rivers et al (2001)

Protocol-based approach in treating sepsis

1341 patients in suspected septic shock

31 centers,

Randomized in a 1:1:1 ratio

Protocol-based EGDT,

Protocol-based standard care

Usual care

within 2 hours of recognition of shock and within 12 hours of arrival to the ED

Process-trial

Central venous catheter placement

Treated based on targets in Rivers’ algorithm: ◦ central venous pressure,

◦ mean arterial pressure, and

◦ mixed venous oxygen saturation.

The amount and timing of volume resuscitation

was specifically dictated in this treatment group.

EGDT

Through a review of the literature

Input of expert physicians,

Targets requiring less invasive measurement

techniques, ◦ systolic blood pressure

◦ clinical and laboratory signs of hypoperfusion.

Protocol-based standard therapy

Care without any direction from study coordinators

Usual care group

•Early treatment with antimicrobial agents,

•conservative transfusion thresholds,

•low tidal-volume ventilation

•moderate glycemic control.

60-day mortality did not differ among the three

groups ◦ 21% in EGDT,

◦ 18% in protocol-based standard care,

◦ 19% in usual care;

95% confidence interval [CI], 0.82 to 1.31; p=0.83), with

comparably insignificant differences in 90-day and 1-year

mortality rates.

Primary outcome

despite its widespread use,

a protocol based on invasive hemodynamic

monitoring does not significantly improve

outcomes in septic shock

compared to less invasive approaches.

Relevance

... is similar to research that found the use of pulmonary artery

catheters did not improve mortality,

... suggests invasive hemodynamic monitoring is not a requirement

for the management of septic shock.

... Can change current standards of care and management?

This study...

Early recognition of sepsis,

as well as cornerstone interventions –◦ the rapid infusion of intravenous fluids,

◦ early broad spectrum antibiotics,

◦ prompt source control

have a greater impact on survival than the use of invasive monitoring

to guide such therapies.

Bottom line

the early or facilitated ◦ recognition of septic shock,

◦ administration of intravenous antibiotics

(76% after 3 hours, 97% after 6)

were associated with rates of survival that were higher than

projected and higher than predicted on the basis of scores on the

Acute Physiology and Chronic Health Evaluation (APACHE) II

"A designer knows he has achieved perfection not when there is

nothing left to add, but when there is nothing left to take away."

- Antoine de Saint-Exupry

PAC is a diagnostic and haemodynamic monitoring tool but not a

therapeutic intervention. Our review concluded that use of a PAC did

not alter the mortality, general ICU or hospital LOS, or cost for

adult patients in intensive care.

Pulmonary artery catheters for adult patients

in intensive care