Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting?
Iuri Christmann Wawrzeniak, Sergio Henrique Loss, Maria Cristina Martins Moraes, Fabiane Lopes De La Vega, Josue Almeida Victorino
Early goal-directed therapy, outcomes, protocol, sepsis
Citation Information :
Wawrzeniak IC, Loss SH, Moraes MC, De La Vega FL, Victorino JA. Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting?. Indian J Crit Care Med 2015; 19 (3):159-165.
Context: Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended. Aims: The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting. Settings and Design: retrospective and observational cohort study at tertiary hospital. Subjects and Methods: All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT. Results: A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively). Conclusions: Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546-54.
Martin CM, Priestap F, Fisher H, Fowler RA, Heyland DK, Keenan SP, et al. A prospective, observational registry of patients with severe sepsis: The Canadian Sepsis Treatment and Response Registry. Crit Care Med 2009;37:81-8.
Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-10.
Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al. The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010;36:222-31.
Levy MM, Artigas A, Phillips GS, Rhodes A, Beale R, Osborn T, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: A prospective cohort study. Lancet Infect Dis 2012;12:919-24.
Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-73.
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296-327.
Slade E, Tamber PS, Vincent JL. The Surviving Sepsis Campaign: raising awareness to reduce mortality. Crit Care 2003;7:1-2.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.
Otero RM, Nguyen HB, Huang DT, Gaieski DF, Goyal M, Gunnerson KJ, et al. Early goal-directed therapy in severe sepsis and septic shock revisited: Concepts, controversies, and contemporary findings. Chest 2006;130:1579-95.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.
Trzeciak S, Dellinger RP, Abate NL, Cowan RM, Stauss M, Kilgannon JH, et al. Translating research to clinical practice: A 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest 2006;129:225-32.
Shapiro NI, Howell MD, Talmor D, Lahey D, Ngo L, Buras J, et al. Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med 2006;34:1025-32.
Sebat F, Johnson D, Musthafa AA, Watnik M, Moore S, Henry K, et al. A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest 2005;127:1729-43.
Gao F, Melody T, Daniels DF, Giles S, Fox S. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: A prospective observational study. Crit Care 2005;9:R764-70.
Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 2007;35:1105-12.
Kortgen A, Niederprüm P, Bauer M. Implementation of an evidence-based "standard operating procedure" and outcome in septic shock. Crit Care Med 2006;34:943-9.
Micek ST, Roubinian N, Heuring T, Bode M, Williams J, Harrison C, et al. Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med 2006;34:2707-13.
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;132:425-32.
Gaieski D, McCoy J, Zeserson E, Chase M, Goyal M. Mortality benefit after implementation of early goal directed therapy protocol for the treatment of severe sepsis and septic shock. Ann Emerg Med 2005;46:4.
Verceles A, Schwarcz RM, Birnbaum P, Mannam P, Patrick H. S.E.P.S.I.S: Sepsis education plus successful implementation and sustainability in the absence of a rapid response team. Chest 2005;128:181S-2. [Abstract].
Armstrong R, Salfen SJ. Results of Implementing a Rapid Response Team Approach in Treatment of Shock in a Community Hospital. Presented at: 43 rd Annual Meeting of the Infectious Diseases Society of America; October 6-9, 2005. p. 154. [Abstract].
Rogove H, Pyle K. Collaboration for instituting the surviving sepsis campaign in a community hospital. Crit Care Med 2005;33:110S. [Abstract]
Stenstrom R, Hollohan K, Nebre R, MacRedmond R, Grafstein E, Dodek P, et al. Impact of a sepsis protocol for the management of patients with severe sepsis and septic shock in the emergency department. Can J Emerg Med 2006;8:S16. [Abstract].
Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008;299:2294-303.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31:1250-6.
Laterre PF, Abraham E, Janes JM, Trzaskoma BL, Correll NL, Booth FV. ADDRESS (ADministration of DRotrecogin alfa [activated] in Early stage Severe Sepsis) long-term follow-up: One-year safety and efficacy evaluation. Crit Care Med 2007;35:1457-63.
ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683-93.
ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-506.
van Beest PA, Hofstra JJ, Schultz MJ, Boerma EC, Spronk PE, Kuiper MA. The incidence of low venous oxygen saturation on admission to the intensive care unit: A multi-center observational study in The Netherlands. Crit Care 2008;12:R33.
Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259-65.
Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative fluid balance predicts survival in patients with septic shock: A retrospective pilot study. Chest 2000;117:1749-54.
Schramm GE, Kashyap R, Mullon JJ, Gajic O, Afessa B. Septic shock: A multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality. Crit Care Med 2011;39:252-8.
Coba V, Whitmill M, Mooney R, Horst HM, Brandt MM, Digiovine B, et al. Resuscitation bundle compliance in severe sepsis and septic shock: Improves survival, is better late than never. J Intensive Care Med 2011;26:304-313.
Castellanos-Ortega Á, Suberviola B, García-Astudillo LA, Ortiz F, Llorca J, Delgado-Rodríguez M. Late compliance with the sepsis resuscitation bundle: impact on mortality. Shock 2011;36:542-7.
Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med 2012;366:2055-64.