Early Goal-directed Therapy Protocol Research Articles

The Effect of Implementing the Sepsis Early Goal-Directed Therapy (EGDT) Protocol on Patient Mortality in the Hospital ICU in Cairo, Egypt

Introduction: Sepsis is a life-threatening systemic inflammatory syndrome with a high mortality rate. Early goal-directed therapy (EGDT) is a structured therapy protocol that aims to improve tissue perfusion and oxygenation in sepsis patients.
 Methods: This retrospective observational study analyzed data on sepsis patients in the ICU of a Cairo hospital, Egypt (2020-2023). Patient mortality was compared before and after the implementation of the EGDT protocol.
 Results: Of the 220 sepsis patients, 120 were treated before and 100 after EGDT implementation. Patient mortality in the EGDT group was significantly lower (12% vs 25%, p<0.05).
 Conclusion: Implementation of the EGDT protocol can reduce the mortality of sepsis patients in the hospital ICU in Cairo, Egypt.

Cost-Effectiveness of Early Goal-Directed Therapy Using the FloTrac/EV1000 Platform in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Retrospective Analysis

Background: Coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) is a high-risk surgery with significant morbidity resulting in a prolonged stay in the intensive care unit (ICU) at an increased cost. Early goal-directed therapy (EGDT) using the FloTrac/EV1000 platform improved outcomes in these patients with shorter ICU stay but with extra cost for a FloTrac transducer. Objective: To assess the cost-effectiveness of implementing the FloTrac/EV1000 in these patients. Materials and Methods: The present study was a retrospective study. Sixty adult patients who underwent CABG with CPB were included and divided into two groups: the EV1000 and the Control group. The EV1000 group was managed with EGDT protocol using FloTrac/EV1000 platform. The Control group was managed using a standard protocol. The ICU and hospital stay of both groups were compared. Then, the authors assessed the daily ICU cost by including another 62 patients admitted to the cardiovascular and thoracic (CVT) ICU. Finally, the extra cost of a FloTrac transducer was compared with the saved CVT ICU cost. Results: The EV1000 group had a shorter CVT ICU stay, with mean difference of –23.7 h (95% CI –34.5 to –12.9, p<0.001). The EV1000 group had a shorter ventilator time, as well as a shorter hospital stay. The average daily CVT ICU cost was 10,020.05 Baht. The extra cost of a FloTrac sensor was 5,000 Baht. The saved cost of CVT ICU exceeds the cost of a FloTrac by 5,020.05 Baht. Conclusion: The implementation of EGDT using the FloTrac/EV1000 platform in patients undergoing CABG with CPB improved patients’ outcomes resulting in less CVT ICU cost and better resource management of CVT ICU beds. The extra cost of the FloTrac sensor was offset by the larger amount of CVT ICU cost that was saved. Keywords: Cost-effectiveness; Early goal-directed therapy; FloTrac; Intensive care unit; ICU stay

Echocardiography-guided hemodynamic management of severe sepsis and septic shock in adults: a randomized controlled trial

Background: Echocardiography (ECHO) is used to guide septic shock resuscitation, but without evidence for efficacy. Therefore, we compared the outcome of early goal-directed therapy (EGDT) and ECHO-guided management of hemodynamics in severe sepsis and septic shock.
 Methodology: This was a single center, randomized controlled trial conducted on 100 adult patients with severe sepsis or septic shock. Patients were assessed and treated with either EGDT protocol (Group I - EGDT group) or ECHO-guided resuscitation protocol (Group II - ECHO group). 
 Results: Only 87 patients (45 in Group I and 42 in Group II) were analyzed. There was a significant increase of mean norepinephrine and dobutamine use and a significant decrease in total fluids needed in the first 24 h, time to normalization, time to weaning of vasopressors, total mechanical ventilation (MV) days, MV free days and ICU and hospital stay in ECHO group. At 30 days, the mortality rate in EGDT group was 35.6% which was significantly higher compared to 14.3% in the ECHO group. At 90 days, the overall mortality was significantly higher in EGDT group compared to ECHO group (40.0% vs 16.7% respectively). Hazardous ratio of mortality was 1.630 [95% confidence interval (CI): 1.123 - 2.366] and 1.653 (95% CI: 1.137 - 2.404) at 30 and 90 days respectively in EGDT group compared to ECHO group.
 Conclusions: In severe sepsis and septic shock, ECHO-guided management of hemodynamics resulted in a decrease in mortality, lower total fluid intake, higher vasopressor and inotrope support, earlier weaning of vasopressors; and reduced mechanical ventilation days, as well as ICU and hospital stay.
 Keywords: Echocardiography; EGDT; Severe sepsis; Septic Shock; Adults
 Citation: Alhabashy WS, Shalaby OM, Elgebaly AS, Abd El Ghafar MS. Echocardiography-guided hemodynamic management of severe sepsis and septic shock in adults: a randomized controlled trial. Anaesth. pain intensive care 2021;25(6):722–732;
 DOI: 10.35975/apic.v25i6.1694
 Received: June 20, 2021, Reviewed: August 10, 2021, Accepted: August 13, 2021

The Impact of EGDT on Sepsis Mortality in a Single Tertiary Care Center in Lebanon.

Background EGDT (Early Goal Directed Therapy) or some portion of EGDT has been shown to decrease mortality secondary to sepsis and septic shock. Objective Our study aims to assess the effect of adopting this approach in the emergency department on in-hospital mortality secondary to sepsis/septic shock in Lebanon. Hypothesis Implementation of the EGDT protocol of sepsis in ED will decrease in-hospital mortality. Methods Our retrospective study included 290 adult patients presenting to the ED of a tertiary center in Lebanon with severe sepsis and/or septic shock. 145 patients between years 2013 and 2014 who received protocol care were compared to 145 patients treated by standard care between 2010 and 2012. Data from the EHR were retrieved about patients' demographics, medical comorbidities, and periresuscitation parameters. A multivariate analysis using logistic regression for the outcome in-hospital mortality after adjusting for protocol use and other confounders was done and AOR was obtained for the protocol use. 28-day mortality, ED, and hospital length of stay were compared between the two groups. Results The most common infection site in the protocol arm was the lower respiratory tract (42.1%), and controls suffered more from UTIs (33.8%). Patients on protocol care had lower in-hospital mortality than that receiving usual care, 31.7% versus 47.6% (p=0.006) with an AOR of 0.429 (p =0.018). Protocol patients received more fluids at 6 and 24 hours (3.8 ± 1.7 L and 6.1 ± 2.1 L) compared to the control group (2.7 ± 2.0 L and 4.9 ± 2.8 L p=<0.001). Time to and duration of vasopressor use, choice of appropriate antibiotics, and length of ED stay were not significantly different between the two groups. Conclusion EGDT- (Early Goal Directed Therapy-) based sepsis protocol implementation in EDs decreases in-hospital mortality in developing countries. Adopting this approach in facilities with limited resources, ICU capabilities, and prehospital systems may have a pronounced benefit.

Echocardiogram-guided resuscitation versus early goal-directed therapy in the treatment of septic shock: a randomized, controlled, feasibility trial

ObjectiveEchocardiography is often used to guide septic shock resuscitation, but without evidence for efficacy. We conducted an intensive care unit (ICU)-based randomized controlled feasibility trial comparing echocardiography-guided septic shock resuscitation (ECHO) with early goal-directed therapy (EGDT).MethodsWe conducted a single center, randomized controlled feasibility trial at a 468-bed academic tertiary care center in Utah, USA. Adult patients with early septic shock were assessed and treated at defined intervals over 6 h using an echocardiogram-guided resuscitation protocol or a slightly modified EGDT protocol. Feasibility outcomes were fluid balance, dobutamine administration, and time to lactate clearance. The primary clinical outcome was changed in sequential organ failure assessment score at 48 h (delta SOFA). Secondary outcomes included inpatient mortality, ICU-free days, and ventilator-free days at 28 days.ResultsThirty participants, 15 per group, were randomized and completed the study. Baseline characteristics were similar between groups. Patients were randomized within a median of 3.5 h of meeting inclusion criteria but had received a median of 3 L crystalloid by then. Fluid administration during the study protocol was similar in both groups (median ECHO 0 vs EGDT 1 L, p = 0.61). Eleven (73%) subjects in each arm received ≤ 1 L fluid. Dobutamine administration was also similar (20% vs 13%, p > 0.99). Twenty-one patients (70%) had lactate clearance prior to the first study assessment. No difference was observed in delta SOFA (median − 4 for ECHO vs − 6 for EGDT, p = 0.10) nor mortality (33% ECHO vs 20% EGDT, p = 0.68).ConclusionsNo experimental separation was observed in this randomized, controlled feasibility trial. Early lactate clearance, coupled with substantial fluid administration before randomization, suggests that patients were already resuscitated before arrival in the ICU. Future trials of echocardiogram-guided sepsis resuscitation will likely need to enroll in the emergency department.Trial registrationThis study was retrospectively registered at clinicaltrials.gov (identifier NCT02354742, title Echo vs EGDT in severe sepsis and septic shock) on February 3, 2015. Registration was completed before review or analysis of any data.

Segmented regression analysis of emergency departments patient visits from Septicemia in Taiwan

BackgroundThe protocol for early goal-directed therapy (EGDT) is effective for improving both the costs and outcomes of septicemia treatment, including a significant reduction in case fatality. However, this complicated protocol may have a downside. Furthermore, the Joint Taiwan Critical Care Medicine Committee has launched a nationwide educational program after the publication of the Surviving Sepsis Campaign (SSC) to improve the overall survival rate from septicemia in the emergency care system of Taiwan. ObjectivesTo assess the impact of the EGDT protocol and SSC education programs on island-wide septicemia-related emergency department (ED) visits. MethodsSegmented regression techniques were utilized to assess the differences in annual rates and changes in septicemia-related ED visits between 1998 and 2012. We considered annual incidence of two medical comorbidities as potential confounders: metastatic malignant neoplasms and malignant neoplasms of the lymphatic and hematopoietic tissues. ResultsThe EGDT protocol was associated with decreased septicemia-related ED visits in 2002 (level change; p < 0.001), while the SSC education program led to a slight increase in septicemia-related ED visits in 2007 (slope change; p < 0.001). For the EGDT protocol, the number of patient visits decreased by 32.9% after the protocol was implemented in 2002 compared with the expected number without the intervention. For the SSC education program, the number of patient visits increased by 20.2% (compared with the predicted number) in 2007 after the education program was implemented. ConclusionsThe EGDT protocol and SSC education program were associated with significant immediate changes and lagged intervention effects on island-wide septicemia-related ED visits.

Early Goal-Directed Therapy: The History and Ongoing Impact on Management of Severe Sepsis and Septic Shock.

The use of early goal-directed therapy (EGDT) for the management of severe sepsis and septic shock, a practice put forth by Dr. Rivers et al. in 2001, ushered in a new era of targeted sepsis therapy. After its publication, several further studies helped validate the protocolized approach to sepsis management, ultimately leading to its incorporation into the Surviving Sepsis Campaign guidelines. Since that time, however, a trio of large multi-center randomized controlled trials have taken place to evaluate the efficacy of EGDT when compared with usual care and have demonstrated that strict adherence to the entirety of the original EGDT protocol is unnecessary for improved outcomes. Some recommendations, such as higher goal hemoglobin and hematocrit levels and liberal crystalloid fluid resuscitation, are likely harmful. Despite controversy over a number of the recommendations, early identification of sepsis, source control, and prompt empiric antibiotic administration remain the mainstay of treatment for patients with sepsis and septic shock.

Comparative study on the outcome of Early Goal Directed Therapy (EGDT) versus standard care in pediatric septic shock patients: A prospective open labeled randomized controlled trial

Background : Sepsis in children is a noteworthy cause of morbidity and mortality all over the world. Given the crucial need to reduce the mortality from sepsis, conflicting results from adult studies and lack of high quality pediatric controlled study warrant a trial to examine the effectiveness of early goal directed therapy (EGDT) versus standard care in Indian patients. Methods : The trial was a prospective open labeled randomized controlled trial conducted from 1st July 2015 to 30th June 2017. All children from one month of age to 12 years with septic shock fulfilling the inclusion criteria were enrolled in the study. Eligible patients were randomized and allocated one of the two study groups (EGDT Group and standard care group). If the patient was assigned to EGDT, the EGDT protocol adapted from Rivers et al. was commenced by the treating team within one hour of enrollment. If the patient was assigned to standard care, no changes were made to the plan of the treating team. Results : The 110 patients were recruited from July 2015 to June 2017. Out of 110 patients, 54 patients were randomized to the EGDT group and 56 randomized to the standard care group. The trial had to be stopped after an interim analysis by the independent data monitoring committee indicated the futility of the study. The overall all-cause mortality at 28 days of the study population was 53.6%. Children in the EGDT group had 46.3% mortality while children in the standard care group had 60.7% mortality (p=0.13). There was 14.4% absolute risk reduction of mortality in the EGDT group. There was no difference in any secondary outcome regarding the proportion of patients achieving therapeutic end points at 6 hours, use and duration of organ support, SOFA and PeLOD score and length of PICU and hospital stay. Conclusion : Our study suggests that the implementation of the early goal directed therapy (EGDT) by the addition of intermittent ScvO2 monitoring and protocolized management did not improve mortality in the EGDT group compared to standard care group. The implementation of EGDT needed the greater intensity of treatment in the form of inotrope and packed RBCs transfusion requirement.

The Physiology of Early Goal-Directed Therapy for Sepsis.

In 2001, Rivers and colleagues published a randomized controlled trial of early goal-directed therapy (EGDT) for the treatment of sepsis. More than a decade later, it remains a landmark achievement. The study proved the benefits of early aggressive treatment of sepsis. However, many questions remain about specific aspects of the complex EGDT algorithm. Recently, 3 large trials attempted to replicate these results. None of the studies demonstrated a benefit of an EGDT protocol for sepsis. This review explores the physiologic basis of goal-directed therapy, including the hemodynamic targets and the therapeutic interventions. An understanding of the physiologic basis of EGDT helps reconcile the results of the clinical trials.

Early goal-directed therapy: status and renew

Early goal-directed therapy(EGDT) emerged as a novel approach for reducing septic shock mortality and the EGDT protocol requires invasive patient monitoring to guide resuscitation with intravenous fluids.EGDT was incorporated into guidelines published by the international Surviving Sepsis Campaign, but remains controversial.Recently, large randomized trials showed that EGDT did not significantly decrease mortality in patients with septic shock compared with usual care.Fliud resuscitation and monitoring is the most important in septic shock.Therefore the EGDT is still valuable in present stage.Further, development practical methods for accurately assessing optimal fluid administration is needed. Key words: Early goal-directed therapy(EGDT); Severe sepsis; Septic shock; Mortality; Children

Initial Care for Patients with Severe Sepsis and Septic Shock: The Next ICU Quality Measure.

In 2001, the landmark trial of early goal-directed therapy versus standard care for the treatment of severe sepsis and septic shock was published. The marked decrease in mortality with early recognition of sepsis and quantitative resuscitation revolutionized the treatment of patients with these conditions. Specific pieces of the early goal-directed therapy protocol have not been routinely adopted into bedside care; however, early administration of antibiotics, resuscitation with intravenous fluids, and attainment of hemodynamic stability to achieve end-organ perfusion have become the standard of care. To help ensure all patients receive optimal therapy at the first signs of severe sepsis or septic shock, the Surviving Sepsis Campaign has developed a core set of initial process steps and treatment goals grouped into a care bundle. Recognizing the benefit of early quantitative resuscitation on patient care, the National Quality Forum adopted a severe sepsis and septic shock care bundle that is similar to the Surviving Sepsis Campaign bundle. This care bundle has been adopted by the US Centers for Medicare & Medicaid Services, with reimbursement to be influenced beginning in 2017. The purpose of this review is to summarize evidence supporting the sepsis quality measure and care bundle and simplify key components of the care bundle where pharmacists can be impactful in ensuring optimal patient care and bundle compliance.

Early goal-directed resuscitation of patients with septic shock: current evidence and future directions.

Severe sepsis and septic shock are among the leading causes of mortality in the intensive care unit. Over a decade ago, early goal-directed therapy (EGDT) emerged as a novel approach for reducing sepsis mortality and was incorporated into guidelines published by the international Surviving Sepsis Campaign. In addition to requiring early detection of sepsis and prompt initiation of antibiotics, the EGDT protocol requires invasive patient monitoring to guide resuscitation with intravenous fluids, vasopressors, red cell transfusions, and inotropes. The effect of these measures on patient outcomes, however, remains controversial. Recently, three large randomized trials were undertaken to re-examine the effect of EGDT on morbidity and mortality: the ProCESS trial in the United States, the ARISE trial in Australia and New Zealand, and the ProMISe trial in England. These trials showed that EGDT did not significantly decrease mortality in patients with septic shock compared with usual care. In particular, whereas early administration of antibiotics appeared to increase survival, tailoring resuscitation to static measurements of central venous pressure and central venous oxygen saturation did not confer survival benefit to most patients. In the following review, we examine these findings as well as other evidence from recent randomized trials of goal-directed resuscitation. We also discuss future areas of research and emerging paradigms in sepsis trials.

Is there a benefit for a care protocol in the treatment of septic shock?

Severe sepsis and septic shock have a short-term mortality in excess of 20 % [1]. In 2001, a single-center ED-based study of a 6-hour early goal-directed therapy (EGDT) protocol reported a significant reduction in in-hospital mortality (30.5 vs 46.5 %) [2]. This EGDT protocol mandated early central venous catheterization to monitor central venous pressure, central venous oxygen saturation, and to guide use of intravenous fluids, vasopressors and packed red cell transfusions. Many trials have been published in the subsequent decade raising the question of whether all elements of the protocol are necessary.

Early goal-directed therapy in pediatric severe sepsis and septic shock

Pediatric severe sepsis and septic shock is one of leading causes of death in PICU. Although antibiotics and comprehensive treatments have continuous improvements, its mortality rate is still high. Present study confirms early goal-directed therapy can significantly reduce the mortality of severe sepsis and septic shock. The purpose is to introduce the early goal-directed therapy protocol and to guide Chinese pediatrician to improve outcome of pediatric severe sepsis and septic shock and increase the survival rate in clinical practice. Key words: Sepsis; Severe sepsis; Treatment; Early goal-directed therapy

Targeting an Early and Substantial Increase in Mean Arterial Pressure Is Critical in the Management of Type 1 Hepatorenal Syndrome: A Combined Retrospective and Pilot Study

Appreciation of the central role for arterial vasodilatation in the pathogenesis of hepatorenal syndrome (HRS) has led to routine use of vasoconstrictors in combination with albumin as a medical therapy for HRS. Various vasoconstrictors have been explored but the optimal approach for such therapies has not yet been established. The purpose of this study was to examine the role of targeting an early and substantial increase in mean arterial pressure (MAP) in the management of type 1 HRS, a condition associated with very poor prognosis. A total of 59 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled into a retrospective cohort study. Subjects having a substantial increase of more than 10mmHg in MAP by day 3 after initiation of therapy were categorized as MAP responders and the rest as MAP non-responders. In addition, five patients were enrolled into a prospective pilot study in which a titration protocol of vasoconstrictors was followed to achieve early goal-directed therapy (EGDT). MAP responders achieved significantly higher incidence of treatment success or total response, less requirement of dialysis and more incidence of liver transplantation. More importantly, this response is associated with better short-term and long-term overall survival as well as transplant-free survival. The effectiveness of such an approach was further confirmed in the pilot study which followed an EGDT protocol. Using an early and substantial increase in MAP as a therapeutic target is associated with favorable clinical outcomes in the management of type 1 HRS.

Management of bleeding following major trauma: is a target haemoglobin of 7 to 9 g/dl high enough?

In the latest recommendations for the management of bleeding following major trauma, Spahn and colleagues recommend a target haemoglobin of 7 to 9 g/dl to initiate blood transfusion [1]. In their rationale the authors use a subgroup of trauma patients from the Transfusion Requirements in Critical Care study; however, patients with active blood loss were excluded from this trial. Expressing a current opinion about transfusion and trauma patients, in 2006 McIntyre and Hebert wrote: 'It is important to put RBC [red blood cell] transfusions into the context of three main time frames, i.e. prehospital care, initial 24-48 h after admission to hospital and thereafter, because each frame has its own set of circumstances which may dictate the need for different timing, volume and rapidity of transfusions' [2]. To our knowledge, the only trial to evaluate a target haemoglobin in shock involved early goal-directed therapy in septic shock [3]. The early goal-directed therapy protocol included maintaining a haematocrit of 30% (haemoglobin at 10 g/dl). In the results, the early goal-directed therapy group had a significantly higher haematocrit than the control group and also received more transfusions. Raising the target haemoglobin to 10 g/dl has two interesting effects: haemodilution is reduced, harmful in the present case; and the transfusion delay is decreased. Riskin and colleagues showed that reducing the transfusion delay may decrease the mortality rate [4]. For the first time, three studies suggest that transfusion may be associated with a reduced mortality rate [5]. The real beneficial effect of blood transfusion is probably that it gives time to stop the bleeding.

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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.

Measurement of Plasma STREM-1 in Patients With Severe Sepsis Receiving Early Goal-Directed Therapy and Evaluation of Its Usefulness

The plasma level of soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) has been shown to be helpful in identifying critically ill patients with infection. However, it remains unknown whether it can be used to predict prognosis in patients with severe sepsis. This study investigated whether various inflammatory mediators, including sTREM-1, could be used as reliable markers to predict the prognosis of patients receiving early goal-directed therapy (EGDT). We prospectively enrolled patients 18 years or older with severe sepsis from April 2009 to May 2010 at a 2,000-bed university hospital. Patients were eligible if the initial resuscitation according to EGDT protocol was immediately performed at the emergency department. Plasma sTREM-1, C-reactive protein, and procalcitonin concentrations were measured on days 0, 3, 7, and 14. Soluble TREM-1 concentrations were significantly higher at admission and pre-EGDT in nonsurvivors (n = 16) than in survivors (n = 47) (514.1 pg/mL [interquartile range, 412.7-1,749.5 pg/mL] vs. 182.4 pg/mL [interquartile range, 54.3-327.0 pg/mL]; P = 0.001). Procalcitonin and C-reactive protein levels did not significantly differ, whereas central venous oxygen saturation and lactate levels at admission were significantly different between the two groups. The only sTREM-1 level remained significantly higher in nonsurvivors until death. On multivariate regression analysis, log(sTREM-1) (P = 0.028), central venous oxygen saturation (P = 0.022), and Simplified Acute Physiology Score II (P = 0.048) values at admission were independently significant. These results suggest that plasma sTREM-1 level at admission could be used as a marker to identify patients with a poor prognosis despite complete initial resuscitation in severe sepsis.

Emergency Department Sepsis Protocol does not Impact Time to Antibiotics

Background: Early goal directed therapy (EGDT) can reduce mortality in an Intensive Care Unit (ICU) popula- tion with severe sepsis. It is not clear whether EGDT can be effectively implemented in an Emergency Department (ED) with existing resources to achieve the same goals. Objectives: To assess the impact of EGDT in our ED with existing resources on time to antibiotics (ABX) and patient out- comes. Methods: We performed a before and after study of the effects of the EGDT protocol on patients over age 21 with severe sepsis admitted to the ICU. Time to ABX was the primary outcome, mortality and other care processes were secondary. Descriptive statistics, Fisher's exact chi-square, and Wilcoxon rank sum tests compared time periods. Multivariate analy- ses with logistic and Cox proportional hazard regression models were performed. Results: 192 cases: 91 before and 101 after protocol. Groups were similar in demographics, co-morbidities, severity scores, and overall mortality of 17.7%. Patients with higher Mortality in ED scores (MEDS) received ABX sooner than patients with lower MEDS after adjusting for time period. There was no difference in time to ABX between time periods after adjusting for disease severity (Hazard Ratio: 0.88, 95% CI: 0.65-1.18; OR: 0.88, 95% CI: 0.49-1.57). Conclusion: Our EGDT protocol did not change management, time to ABX, or mortality of septic patients admitted to the ICU, when relying on existing resources. Further study is needed to evaluate barriers to EGDT and feasibility of translat- ing resource intensive protocols to the bedside in routine ED care.

Evaluation of a modified early goal-directed therapy protocol

Evaluation of a modified early goal-directed therapy protocol