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Abstract

Introduction: Implementation of the Surviving Sepsis Guidelines decreases mortality from severe sepsis and septic shock. Hypothesis: A CVP measurement of > 12 mm Hg during our early goal directed therapy (EGDT) protocol will decrease ICU and hospital mortality below APACHE IV predicted values. Methods: This multi-center retrospective study evaluated 452 consecutive patients admitted to the ICU in ten community hospitals with an APACHE IV admission diagnosis of severe sepsis/ septic shock between 08/1/2011- 03/30/2012. All patients were treated with a standardized EGDT protocol located in the Sutter eICU. All patients were classified by the highest CVP value achieved during EGDT into the following categories- <8; 8-12; and >12 mm Hg. The study outcomes, ICU and hospital mortality, were compared to APACHE IV predicted outcomes in each of these categories. The analyses were repeated in subgroup analyses, where patients were further stratified into low risk (n=301), moderate risk(n=78), and high risk (n=73), based on their predicted mortality rates of 0-24.99%, 25-49.99%, and 50-100% respectively. Results: EGDT was associated with lower observed ICU and hospital mortality when compared to predicted values for the entire study population (8.4% vs 20.3% p=0.001; and 20.5% vs 32.8% p=0.01). Observed mortality among subjects in the CVP< 8 category was similar to predicted values. Subjects in the CVP 8-12 and >12 categories showed lower ICU mortality (p=0.001 and 0.003 respectively) and hospital mortality (p=0.01 and 0.046 respectively) than predicted. Further, subgroup analysis revealed no differences between observed and predicted mortality among subjects in either the low or high risk groups when comparing across CVP categories. However, in the moderate risk group, hospital and ICU mortality were reduced among subjects in the CVP > 12 category compared to those in either the 8-12 or <8 categories(p=0.04 and 0.02). Conclusions: This study validates a mortality benefit with a minimum CVP target of 8 mm Hg among subjects with severe sepsis/septic shock and additionally suggests that a higher CVP target of 12 mm Hg may further lower mortality, particularly among those with an APACHE IV-predicted moderate risk of dying.