Abstract
The management of sepsis evolved recently with the publication of three large trials (referred to as the sepsis trilogy) investigating the efficacy of early goal-directed therapy (EGDT). Our goal was to determine if the publication of these trials has influenced the use of EGDT when caring for patients with severe sepsis and septic shock in the emergency department (ED). In February 2014, we surveyed a sample of board-certified emergency medicine physicians regarding their use of EGDT in the ED. A follow-up survey was sent after the publication of the sepsis trilogy. Data was analyzed using 95% confidence intervals to determine if there was a change in the use of EGDT following the publication of the above trials. Subgroup analyses were also performed with regard to academic affiliation and emergency department volume. Surveys were sent to 308 and 350 physicians in the pre-and post-publication periods, respectively. Overall, ED use of EGDT did not change with publication of the sepsis trilogy, 48.7% (CI 39.3% - 58.2%) before and 50.5% (CI 40.6% - 60.3%) after. Subgroup analysis revealed that academic-affiliated EDs significantly decreased EGDT use following the sepsis trilogy while nonacademic departments significantly increased EGDT use. Use of EGDT was significantly greater in community departments versus academic departments following the publication of the sepsis trilogy. There was no change overall in the use of EGDT protocols when caring for patients with severe sepsis and septic shock, but subgroup analyses revealed that academic departments decreased their use of EGDT while community departments increased use of EGDT. This may be due to varying rates of uptake of the medical literature between academic and community healthcare systems.
Highlights
Severe sepsis is commonly encountered in the emergency department (ED)
Early Goal-Directed Therapy” (EGDT), which is based on using objective endpoints to maximize tissue oxygenation, is both a time and resource intensive process that requires close monitoring of central venous pressure (CVP), central venous oxygen saturation (ScVO2), and mean arterial pressure (MAP), necessitating invasive procedures for hemodynamic monitoring
The most common barriers to the use of EGDT included the need for specialty equipment such as continuous ScVO2 monitoring (36.5%) and central venous cannulation (25.5%)
Summary
EGDT, which is based on using objective endpoints to maximize tissue oxygenation, is both a time and resource intensive process that requires close monitoring of central venous pressure (CVP), central venous oxygen saturation (ScVO2), and mean arterial pressure (MAP), necessitating invasive procedures for hemodynamic monitoring. While guidelines have encouraged the use of EGDT, and many EDs invested in the equipment and resources required to implement it, some EDs were unwilling or unable to enact EGDT according to the strict parameters outlined in Rivers’ study. Many have argued that the benefits of EGDT are not due to achieving these strict hemodynamic endpoints, but early recognition and aggressive resuscitation of these very sick patients
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