Anyone see this on the front page of the Wall Street Journal? Check out the link. http://wsj.com/article/SB121867179036438865.html?mod=most_emailed_day

Anyone have any thoughts on your institutions practice of EGDT or lack thereof? Thought the article had a very negative tone, concentrating way too much on the use of Sv02 catheter, which is not an integral part of the therapy, nice to have but not necessary. Does the rivers protocol work because we are simply more aggressive at managing these patients? Physiologically the protocol makes sense. Will be interested to see the multicenter trial and what is deemed "standard therapy." My guess is all arms will have similar outcomes as all will likely have early recognition and more aggressive therapy than has been used in the past whether or not invasive monitoring is used.

Either way Rivers has pushed the treatment of sepsis to the forefront of EM, and improved early recognition of severe sepsis and its aggressive management, whether or not you choose to use the protocol.

I was under the impression that the use of the SvO2 monitoring was indeed pretty important. You can't have feedback control without measurements.

Certainly the climate is becoming such that any appearance of financial conflicts of interest will be more closely scrutinized now, which I think is fine. I also think it will be good to see more data from other hospitals.

Yes monitoring is important, but continuous monitoring is not necessary. a venous gas from a normal central line will give your your svo2, you just need to recheck it during therapy to meet your goals.

Yes monitoring is important, but continuous monitoring is not necessary. a venous gas from a normal central line will give your your svo2, you just need to recheck it during therapy to meet your goals.
Has that been shown to be effective in trials? I didn't know such a study had been done.

Great question. The article taught me some things I didn't know. I didn't know that Rivers had modified and patented (and therefore stands to profit from) the O2 detector. I certainly don't think that invalidates the study but it is good to know, just like any disclosure.

As for the sepsis debate ABEM certainly thinks it's important. This year's LLSA included the Eichacker article that notes that in marketing their expensive, problematic new sepsis drug Xigris Eli Lilly came up with an innovative and possibly unethical marketing campaign. LLSA also selected the Nguyen article on sepsis.

Eichacker article (not full text damn NEJM) (http://content.nejm.org/cgi/content/short/355/16/1640)
Nguyen article (http://www.annemergmed.com/article/PIIS0196064406002484/fulltext)

Anytime you mix profit motive and science it creates controversy. As for Rivers anytime you write The Paper and become the big man in the field there will be lots of people trying to tear you down.

Great question. The article taught me some things I didn't know. I didn't know that Rivers had modified and patented (and therefore stands to profit from) the O2 detector. I certainly don't think that invalidates the study but it is good to know, just like any disclosure.

As for the sepsis debate ABEM certainly thinks it's important. This year's LLSA included the Eichacker article that notes that in marketing their expensive, problematic new sepsis drug Xigris Eli Lilly came up with an innovative and possibly unethical marketing campaign. LLSA also selected the Nguyen article on sepsis.

Eichacker article (not full text damn NEJM) (http://content.nejm.org/cgi/content/short/355/16/1640)
Nguyen article (http://www.annemergmed.com/article/PIIS0196064406002484/fulltext)

Anytime you mix profit motive and science it creates controversy. As for Rivers anytime you write The Paper and become the big man in the field there will be lots of people trying to tear you down.

The WSJ article just scratched the surface and was rather one sided. But controversy makes good front page news. Most of the docs quoted in the article had more "hidden agendas" than met the eye.

Rivers developed a patent for the ScvO2 cath actually for cardiac arrest patients, not sepsis, while at Henry Ford Hospital. When docs in large academic hospitals develop patents, the University or Health System gets the Lion's share. In this case, Rivers actually turned over the patent to HFH, he saw very little if any $ in royalties. The cash amount he has received is actually peanuts compared to what most academic researchers receive when they make the "lecture circuit". Again, most of they guys throwing stones make many times more per year through industry. I can guarantee that Rivers' motivation for the study was not to get rich selling catheters. Rivers stopped taking any payment from Edwards several years ago just to shut up his critics. Pick any top sepsis researcher in the field and see if they've done the same.

You may criticize the article for some of it's limitations, that's fair, but it is not fair to question the integrity of Dr. Rivers or his motivations.

KG

A re-study of something potentially so important is worthwhile given the small n in the original study, but I am underwhelmed by much of this criticism. Manny Rivers didn't invent the concept of Sv02 measurement, and he never says (either in this article or if you see him speak in person) that you can't do EGDT without one of these special catheters. It is certainly easier to use one of them than sending of repeat VBGs from the line, but none of this changes the bottom line solid advice about caring for sepsis aggressively while in the ED rather than tap-dancing around while the patient gets sicker.

You may criticize the article for some of it's limitations, that's fair, but it is not fair to question the integrity of Dr. Rivers or his motivations.

KG
I'm not questioning his anything although the article clearly was.

Regardless of what the WSJ says, EGDT is the new trend. Even though it may stir up controversy in the next few years, much like TPA in stroke patients, it will gradually be adopted by more institutions. This isn't to say that either is supported by strong evidence, but when the hospital administrators say you must do it, then your hands are tied.

Some hospitals, like the one where I practice, tie performance incentive bonuses to goals. One of our incentives is a 10% reduction in lactic acid levels within 24 hours, establishing EGDT in a timely fashion, etc.

I'm not questioning his anything although the article clearly was.

DocB, not saying you were, even though it may appear that way in the words I chose. The statement was directed at the insinuations in the WSJ. Sorry if I came across as attacking you personally. :)

KG

Some hospitals, like the one where I practice, tie performance incentive bonuses to goals. One of our incentives is a 10% reduction in lactic acid levels within 24 hours, establishing EGDT in a timely fashion, etc.

Nice carrot. Really, when you look at the resources we throw at all trauma patients (with a combined mortality of around 5%), STEMI (mortality reduction for the 90 min window is not different than 160 min - however recurrent ischemia and reinfarction are lower) and stroke centers (mortality no different, morbidity obviously improved) it makes sense to apply similar resources to a disease that has a 30-45% mortality and we can reduce absolute mortality by up to 16% with EGDT in the first 6 hours with minimal amount of resources. Currently most hospitals provide NO extra resources for these patients.

KG

Yeah I was not impressed w/ the WSJ article. It seemed to focus alot on this catheter. I wasn't aware that Rivers held a patent on a catheter but when I found out I said, "so?"

I mean the concept of measuring SvO2 is sound clinically and that article is practically a standard for an influential single paper.

I personally do not get all worked up when I find out that *gasp* a doctor may be profiting from his research or *gasp* he may have recieved honoraria from a drug company. Good for him, the federal government is certainly not worried about funding his retirement.

there is plenty of critical care literature (will have to dig, working in the ED today) showing that continous svco2 is not necessary. frequent vbgs from the central line are adequate.

The beauty of egdt is that it doesn't really require fancy expensive therapies.

There are many SYSTEMS problems in terms of implementation.

There are many SYSTEMS problems in terms of implementation.

staff not knowing what svo2 is.
staff not knowing how to monitor it.
staff not knowing where the itmes to monitor it are.
lab wondering why vbg's are being ordered over and over, thus cancelling the order.
staff not being on board/up to date with egdt- the rationale or the implementation of it.

just to name a few. :laugh:

Well, the tone of the article is similar to that of the NY Times. When profiling doctors who were doing what they called "concierge" medicine, you could practically hear the reporter's shock (http://www.nytimes.com/2005/10/30/health/30patient.html?_r=1&sq=concierge%20medicine&st=cse&oref=slogin&scp=1&pagewanted=print) that doctors would do away with insurance reimbursement. I mean, who takes cash these days anyway? And what about all the people who can't afford to pay their doctors a retainer??? :rolleyes:

More and more it's become clear to me that mainstream media believes that it's somehow sinful for physicians to actually, you know, make a living. We're supposed to practically give away our services. And in the same paper they will cluck approvingly at examples of profligate spending by wall street.

*grumble*

Anyway, back to the topic at hand. Sorry for the threadjack.

We are increasingly becoming a society that believes in magic. You are going to have a medical system which arguably has the most demanding training in the world and attracts the best and brightest while you're expecting medical students to happily start their careers to and $250,000+ in debt. You will complain that it takes six months to get into a primary doctor when your plumber makes more money than your internist. Your insurance premiums aren't going going 15 percent/year AND you'll be able to get a knee MRI in 30 minutes when you feel it's necessary because you've spent five minutes on webmd prior to coming to the emergency department. You complain that you had to wait "for hours" when you came to be seen for your non-urgent issue. We express disbelief that GM is in debt after they had an over $50 billion writedown on health care costs.

Journalists are no different. I like to aggravate my neighbor (an accountant) whenever we get into a discussion of healthcare policy by suggesting that he cut his fees by half so poor people can have their taxes done by a white glove accountant too. This usually cuts our discussions short.

More and more it's become clear to me that mainstream media believes that it's somehow sinful for physicians to actually, you know, make a living. We're supposed to practically give away our services.

Nice carrot. Really, when you look at the resources we throw at all trauma patients (with a combined mortality of around 5%), STEMI (mortality reduction for the 90 min window is not different than 160 min - however recurrent ischemia and reinfarction are lower) and stroke centers (mortality no different, morbidity obviously improved) it makes sense to apply similar resources to a disease that has a 30-45% mortality and we can reduce absolute mortality by up to 16% with EGDT in the first 6 hours with minimal amount of resources. Currently most hospitals provide NO extra resources for these patients.

KG

Most in this thread seem to be concentrating on the potential conflict of interest. As a trialist I don't care about this. What I care about a lot is the implication that the intention-to-treat analysis gave a different answer (not signficant as opposed to significant) than the analyzed group. That's a big deal and if true a complete accounting of the excluded groups is needed, since it implies that subjects were differentially excluded.

That said, I know Dr Rivers and consider him absolutley ethical and dedicated to research to improve health care.

But replication trials are the way to go when there is a question.

BTW of more than 100 RCTs of various treatments for severe sepsis and shock in the last 30 years, only EGDT and activated protein C have shown a potentially important benefit and the former is by far the more important. For now, it should be what you do. And the message I took away from the data was that most folks are still underresucitated when you've got their MAP back.

Cheers, BN

In your experience, does the relatively high mortality of the patients treated in the traditional group match up with what you see clinically?

In your experience, does the relatively high mortality of the patients treated in the traditional group match up with what you see clinically?

For severe sepsis, yes

In your experience, does the relatively high mortality of the patients treated in the traditional group match up with what you see clinically?

The historical mortality for severe sepsis/septic shock at Henry Ford was even higher than in the EGDT trial.

In your experience, does the relatively high mortality of the patients treated in the traditional group match up with what you see clinically?

From Carolinas, yes (not that Seaglass and I saw the same patients or anything!!)
....on an aside, Seaglass, how is the new diggs? I hope that things are going well!:)

I see.

Although I'm just a final year, I have an interest in sepsis. I just finished an elective in one of the big EDs in Australia where they're running one of the trials on EGDT mentioned in this article (starting late this year, I think). This ED saw a lot of sepsis and there were a lot of guys with interesting takes on EGDT. They thought, among other things, that the mortality they see from severe sepsis wasn't that high, for a start. They also felt that the Rivers Protocol threw a lot of things in the box to see the final result - who is to say whether it was the transfusions which conferred the most benefit, or the actual early-therapy bit (but many felt it was the latter). Anyways, it was interesting seeing another take on it, and their results will be interesting in a few years.

Dr Rivers is almost an EM God here in Detroit and certainly one of the hardest working man of the city. I dare you to find any "famous" doctor as it were that isn't in some way involved in the development of medical patents or a "business" interaction. Sorry in advance, not trying to fish here, just havn't posted much but at school here in detroit and interested in EM this topic relates as it were..

In my adult ED (which I have recently abandoned in favor of the kiddie ED), I have a 1-12 nursing ratio with a long boarding time for ICU patients. It's not uncommon for a nurse to have 8 ED patients, 2 floor boarders and 2 ICU boarders. Even supernurses can't do all of the orders on time.

EGDT is great but very labor intensive. Also, can't do CVP in my ED. So I use a poor-man's protocol using large volume resuscitations (3-4 Liters to start then 1 Liter at a time). After 3-4 liters I check for JVD, rales and often US looking at the IVC. Also use multiple broad spectrum Abx and transfusions if the patient has Hb<8. As a result, I often get my ICU admissions denied because the patients are resuscitated.

Anyone else in the same boat?

In my adult ED (which I have recently abandoned in favor of the kiddie ED), I have a 1-12 nursing ratio with a long boarding time for ICU patients. It's not uncommon for a nurse to have 8 ED patients, 2 floor boarders and 2 ICU boarders. Even supernurses can't do all of the orders on time.

EGDT is great but very labor intensive. Also, can't do CVP in my ED. So I use a poor-man's protocol using large volume resuscitations (3-4 Liters to start then 1 Liter at a time). After 3-4 liters I check for JVD, rales and often US looking at the IVC. Also use multiple broad spectrum Abx and transfusions if the patient has Hb<8. As a result, I often get my ICU admissions denied because the patients are resuscitated.

Anyone else in the same boat?

Absolutely. I'd say the barriers to effective EGDT and ED overcrowding go hand in hand.

Interesting article about the Rivers controversy in Annals of EM (http://www.annemergmed.com/article/S0196-0644(08)01897-0/fulltext). It addresses some of the issues brought up in the Wall Street Journal article. I think Ed Panachek's comments sum up the feelings of a lot of EPs out there (I have a ton of respect for Ed) when he says that he thinks that early goal directed sepsis therapy works but it may not be totally reproducable outside of Detroit and we're not sure which elements are the most important (my paraphrase).

BTW I'm going to move this to the EM Journal Club because this kind of highbrow academic discussion is what it's for and it needs the traffic;).