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    EGDT

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    aLineLan
    Early Goal Directed Therapy (EGDT) is recommended for patients with severe sepsis or septic shock. EGDT involves aggressive fluid resuscitation, vasopressor therapy, inotropic support, and blood transfusion to reach targets for central venous pressure, mean arterial pressure, urine output, and central venous oxygen saturation in order to balance oxygen delivery with demand. A landmark 2001 study showed EGDT reduced mortality in severe sepsis patients by 16% compared to standard therapy.

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    EGDT

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    Early Goal Directed Therapy (EGDT) is recommended for patients with severe sepsis or septic shock. EGDT involves aggressive fluid resuscitation, vasopressor therapy, inotropic support, and blood transfusion to reach targets for central venous pressure, mean arterial pressure, urine output, and central venous oxygen saturation in order to balance oxygen delivery with demand. A landmark 2001 study showed EGDT reduced mortality in severe sepsis patients by 16% compared to standard therapy.

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    Early Goal Directed Therapy (EGDT) is recommended for patients with severe sepsis or septic shock. EGDT involves aggressive fluid resuscitation, vasopressor therapy, inotropic support, and blood transfusion to reach targets for central venous pressure, mean arterial pressure, urine output, and central venous oxygen saturation in order to balance oxygen delivery with demand. A landmark 2001 study showed EGDT reduced mortality in severe sepsis patients by 16% compared to standard therapy.

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    148 views33 pages

    EGDT

    Uploaded by

    aLineLan
    Early Goal Directed Therapy (EGDT) is recommended for patients with severe sepsis or septic shock. EGDT involves aggressive fluid resuscitation, vasopressor therapy, inotropic support, and blood transfusion to reach targets for central venous pressure, mean arterial pressure, urine output, and central venous oxygen saturation in order to balance oxygen delivery with demand. A landmark 2001 study showed EGDT reduced mortality in severe sepsis patients by 16% compared to standard therapy.

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    Surviving Sepsis

    2008 Guidelines

    Early Goal Directed Therapy


    MAZEN KHERALLAH, MD, FCCP
    INFECTIOUS DISEASE AND CRITICAL CARE MEDICINE

    Therapy Across the Sepsis Continuum


    Infection
    Microorganism invading sterile tissue

    SIRS

    Sepsis

    Severe Sepsis Septic Shock


    Sepsis with organ failure Vascular collapse Renal Hemostasis Lung LA Refractory hypotension

    A clinical response arising from a nonspecific insult, with 2 of the following: T >38oC or <36oC HR >90 beats/min RR >20/min WBC >12,000/mm3 or <4,000/mm3 or >10% bands

    SIRS with a presumed or confirmed infectious process

    Chest 1992;101:1644

    Sepsis Syndromes
    1992: SCCM/ACCP

    Parasite

    Virus Infection
    Fungus
    Shock

    Severe Sepsis

    Sepsis

    SIRS
    Sev er SIR e S Trauma

    BSI

    Bacteria

    Burns

    Surviving Sepsis Campaign


    Launched in Fall 2002 as a collaborative effort of

    European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine Goal: reduce sepsis mortality by 25% in the next 5 years Guidelines revealed at SCCM in Feb 2004
    Critical Care Medicine March 2004 32(3):858-87. Website: survivingsepsis.org

    THE SEVERE SEPSIS BUNDLES: SSC/IHI


    6 Hour Bundle

    24 Hour Bundle
    Glucose control maintained < 150 mg/dL Drotrecogin alfa (activated) administered in accordance with hospital guidelines Steroids given for septic shock requiring continued use of vasopressors for > 6 hours Lung protective strategy with plateau pressures < 30 cm H2O for mechanically ventilated patients

    Measure serum lactate Blood Cultures prior to antibiotics Broad spectrum antibiotics within 3 hours of presentation, 1 hour in hospital Initial fluid resuscitation with 20-40 mL/kg crystalloid (or equivalent colloid) if hypotensive (SBP < 90 mmHg or MAP < 70) or lactate > 4 mmol/L Vasopressors If septic shock or lactate > 4 mmol/L: CVP and ScvO2 or SvO2 measured CVP maintained 8-12 mm Hg Inotropes (and/or PRBCs if Hct < 30%) delivered for ScvO2 <70% or SvO2<65% if CVP > 8 mmHg

    http://www.ihi.org

    SCCM 2009: Sepsis Management "Bundles" Boost Guideline Implementation, Reduce Mortality
    15,022 Patients

    7% Absolute Risk Reduction 19% Relative Risk Reduction

    Society of Critical Care Medicine (SCCM) 38th Critical Care Congress. Late breaker. Presented February 2, 2009

    SUMMARY: SEPSIS GUIDELINES 2008


    Strong Recommendation (1): Recommended
    A
    DVT Prophylaxis H2 Blocker PUD Prophylaxis No Routine Use of SGC No Renal Dose Dopamine No High Dose Steroids

    B
    Antibiotics within 1 hr for Septic Shock Glycemic Control Crystalloid = Colloid PPI PUD Prophylaxis Low VT for ALI HOB >45 Limited Transfusion No Antithrombin II No Erythropoietin Intermittent = Continuous sedation
    Weaning Protocol/SBT

    C
    EGDT and Protocolized Resuscitation

    D
    Antibiotics within 1 hr in No septic Shock Patients 7-10 day Antibiotic Duration Consider Limiting Support

    Fluid Challenge BC prior to Abx Source Control Dopamine or Norepinephrine Limit P plateau <30 cm H2O PEEP De-escalation Antibiotic Therapy Conservative Fluid in ALI with no Shock

    Avoid NMB

    SUMMARY: SEPSIS GUIDELINES 2008


    Weak Recommendation (2): Suggested
    A B
    APC in high risk and non-surgical equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis NIV for ALI/ARDS mild/moderate hypoxemia

    C
    PRBCs or Dobutamine APC for high risk and surgical Low dose steroids for septic shock ACTH test not to be done B/S < 150 Prone Position in ARDS

    D
    Wean Steroids

    Therapy Across the Sepsis Continuum


    Infection SIRS Sepsis Severe Sepsis Septic Shock

    Steroids

    Drotrecogin Alpha Early Goal Directed Therapy Antibiotics and Source Control Insulin and Tight Glucose Control
    Chest 1992;101:1644

    Therapy Across the Sepsis Continuum


    Infection SIRS Sepsis Severe Sepsis Septic Shock
    CVP > 8-12 mm Hg MAP > 65 mm Hg Urine Output > 0.5 ml/kg/hr ScvO2 > 70% SaO2 > 93% Hct > 30%

    * Early Goal Directed Therapy


    Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand: Fluids, Blood, and Inotropes
    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368.

    Rivers E, Nguyen B, Havstad S, et al 2001;345:1368-1377.

    Early Goal-Directed Therapy Results: 28 Day Mortality


    60 50 40
    Mortality %

    49.2%

    P = 0.01*
    33.3%

    Vascular Collapse 21% vs 10%


    p=0.02

    30 20 10 0
    Standard Therapy N=133 EGDT N=130

    MODS 22% vs 16%


    P=0.27

    *Key difference was in sudden CV collapse, not MODS NEJM 2001;345:1368-77.

    The Importance of Early Goal-Directed Therapy for Sepsis-induced Hypoperfusion


    NNT to prevent 1 event (death) = 6 - 8 Standard therapy EGDT

    60 50

    Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

    Mortality (%)

    40 30 20 10 0

    In-hospital mortality (all patients)

    28-day mortality

    60-day mortality

    If venous O2 saturation target not achieved: (2C)


    Consider further fluid Tansfuse packed red blood cells if required to

    hematocrit of 30% and/or Dobutamine infusion max 20 g.kg1 .min1

    Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

    SIRS Screen
    First section screens for SIRS

    SIRS includes objective vital signs data:


    Temperature

    100.4 or 96.8 F Heart Rate 90 Respiratory Rate 20 WBC count 12,000 or 4,000, or greater than 0.5K/uL bands

    If the patient has 2 or more of the above, they screen positive for SIRS

    Infection Screen
    Second section screens for infection

    The patient is screened for infection if they have SIRS Does the patient have suspected or documented infection? Has the patient received antibiotics (not prophylaxis)? If one of the above is confirmed, the patient is screened for organ dysfunction

    Severe Sepsis Screen


    Third section screens for Organ Dysfunction
    Respiratory:

    SaO2 < 90 % Cardiovascular: SBP < 90 Renal: urine output < 0.5ml/hr; creatinine increase > 0.5mg/dl from baseline CNS: altered LOC, Glascow coma scale 5
    Any one of the above, in addition to positive

    results from sections 1 and 2, indicates severe sepsis.

    SBAR
    The RN should approache the MD, informing him using SBAR technique, that the patient has screened positive for severe sepsis.

    SBAR Communication Technique


    Situation:

    caring for John Smith Screened positive for severe sepsis Background: for SIRS (describe) Known or suspected infection Organ dysfunction (describe) Assessment:
    Share Positive

    RN

    complete VS and SaO2

    SBAR Communication Technique


    Recommendation:
    I

    need you to come and evaluate the patient to confirm if they have severe sepsis. It is recommended that I get an ABG, lactate, and CBC, Can I proceed and get these? Any other labs you would like me to obtain? If the pt is hypotensive: Can I start an IV and give a bolus of NS 20 ml/kg?

    Resuscitation Goals (Grade 1C)


    Central venous pressure (CVP): 812mm Hg Mean arterial pressure (MAP) 65mm Hg Urine output 0.5mL.kg1.hr 1 Central venous (superior vena cava) or

    mixed Venous oxygen saturation 70% or 65%, respectively Hemoglobin >10 mg/dL

    Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

    Initiation of Resuscitation (1C)


    Begin resuscitation immediately in

    patients with CVP < 8, hypotension or elevated serum lactate >4mmol/l; Do not delay pending ICU admission.

    Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

    CVP <8 mmHg


    Central line placement and CVP

    monitoring 500 mL 0.9% NaCl bolus every 15 minutes to maintain a CVP goal Colloids if CVP <4 Transfuse 1 unit of PRBCs if Hg <10

    A higher target CVP of 1215 mmHg is recommended in the presence of


    Mechanical ventilation Pre-existing decreased ventricular

    compliance Increased intra-abdominal pressure

    MAP <65 mmHg


    Arterial line placement Norepinephrine 2-20 mcg/min Vasopressin 0.04 Unit/min Phenylephrine 40-200 mcg/min Hydrocortisone 50 mg IV every 6

    hours

    ScvO2 <70%
    Arterial line placement Transfuse 1 PRBCs if Hg level <10 mg/dL Start Dobutamine 2.5-20 mcg/kg/min IV

    infusion Intubation and ventilation

    Critical Care is A Promise


    If you are admitted to our ICU with severe sepsis we will:


    Obtain blood cultures and lactic acid level Start antibiotics within one hour Target a central venous pressure target to 8

    mmHg Target a mean arterial blood pressure target of 65 mmHg Target a central venous O2 saturation of 70% Target your urine output to >0.5 mL/Kg/Hour

    Thank You

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