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(Chest. 2006;130:1579-1595.)
© 2006 American College of Chest Physicians

Early Goal-Directed Therapy in Severe Sepsis and Septic Shock Revisited*

Concepts, Controversies, and Contemporary Findings

Ronny M. Otero, MD; H. Bryant Nguyen, MD, MS; David T. Huang, MD, MPH; David F. Gaieski, MD; Munish Goyal, MD; Kyle J. Gunnerson, MD; Stephen Trzeciak, MD; Robert Sherwin, MD; Christopher V. Holthaus, MD; Tiffany Osborn, MD and Emanuel P. Rivers, MD, MPH, FCCP

* From the Department of Emergency Medicine (Drs. Otero and Rivers), Henry Ford Health Systems, Detroit, MI; the Department of Emergency Medicine (Dr. Nguyen), Loma Linda University, Loma Linda, CA; the Department of Critical Care Medicine (Dr. Huang), University of Pittsburgh, Pittsburgh, PA; the Department of Emergency Medicine (Drs. Gaieski and Goyal), University of Pennsylvania, Philadelphia, PA; the Department of Anesthesiology/Critical Care Medicine (Dr. Gunnerson), Virginia Commonwealth University Medical Center, Richmond, VA; the Department of Emergency Medicine (Dr. Trzeciak), Section of Critical Care Medicine, Cooper University Hospital, Camden, NJ; the Department of Emergency Medicine (Dr. Sherwin), Detroit Receiving Hospital, Wayne State University, Detroit, MI; the Department of Emergency Medicine (Dr. Holthaus), Washington University, Barnes Jewish Hospital, St. Louis, MO; and the Department of Emergency Medicine (Dr. Osborn), University of Virginia, Charlottesville, VA.

Correspondence to: Ronny Otero, MD, Department of Emergency Medicine, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202; e-mail: rotero1{at}hfhs.org

Abstract

Studies of acute myocardial infarction, trauma, and stroke have been translated into improved outcomes by earlier diagnosis and application of therapy at the most proximal stage of hospital presentation. Most therapies for these diseases are instituted prior to admission to an ICU; this approach to the sepsis patient has been lacking. In response, a trial comparing early goal-directed therapy (EGDT) vs standard care was performed using specific criteria for the early identification of high-risk sepsis patients, verified definitions, and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands. Five years after the EGDT publication, there has been much discussion generated with regard to the concepts of EGDT, as well as debate fueled regarding diagnostic and therapeutic interventions. However, during this time period further investigations by the primary investigators and others have brought additional contemporary findings. EGDT modulates some of the components of inflammation, as reflected by improved organ function. The end points used in the EGDT protocol, the outcome results, and the cost-effectiveness have subsequently been externally validated, revealing similar or even better findings than those from the original trial. Although EGDT is faced with challenges, a coordinated approach to sepsis management is necessary to duplicate the progress in outcomes seen in patients with conditions such as acute myocardial infarction, stroke, and trauma.

Key Words: biomarkers • brain natriuretic peptide • early goal-directed therapy • implementation • lactate • sepsis bundle • sepsis outcomes • septic shock • severe sepsis


Related Article

Severe Sepsis and Septic Shock: Should Blood Be Transfused To Raise Mixed Venous Oxygen Saturation?
Vinayak Jha, Guillermo Gutierrez, Ronny M. Otero, and Emanuel P. Rivers
Chest 2007 131: 1267-1269. [Full Text] [PDF]





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Copyright © 2006 by the American College of Chest Physicians.