Early Goal Directed Therapy for Severe Sepsis and Septic Shock

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These questions are more for the residents, but anybody can answer.

Are you familiar with this treatment for severe sepsis and septic shock?

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=11794169



Are your attendings?

if so

Are they teaching you this?

How well do you think you are doing as a department?

Do you feel comfortable with running an EGDT protocol?

If you aren't doing this, why?

What kind of road blocks have you encountered?

What has helped you the most in terms of support?



Thanks ahead of time for all your candid answers. I appreciate your honesty with this. Please feel free to voice your opinions, there is no hidden agenda here.

Kyle

We just had a joint EM/IM grand rounds on the River's Protocol. Our only real roadblocks are some minor systems issues with nursing and pharmacy. We generally move the patient out of the ED quickly, so xigris is not an ED issue here.

As far as how I feel about it, I would say much better after the grand rounds.

Not really part of the OP but this type of instruction is what I love about Mayo!

- H

Yes we and our attendings are all over it. We hear about it like 10 times a day. Our biggest difficulties are monitoring CVP because we have limited equipment and you need a line but if you make the effort there's really no trouble.

Originally Posted by FoughtFyr

We just had a joint EM/IM grand rounds on the River's Protocol. Our only real roadblocks are some minor systems issues with nursing and pharmacy. We generally move the patient out of the ED quickly, so xigris is not an ED issue here.

As far as how I feel about it, I would say much better after the grand rounds.

Not really part of the OP but this type of instruction is what I love about Mayo!

- H

Thanks for your response. Just for clarification, EGDT or the "Rivers Protocol" does not include Xigris.

Moving someone pretty quick is fine, if you can achieve your goals (ScvO2 of 70%) in 6 hours. If your ED or ICU can't do this, then EGDT is not being done.

Thanks again, keep them coming.........please state your hospital/training program/ Medschool, unless you don't want to.

Kyle

Originally Posted by KGUNNER1

Thanks for your response. Just for clarification, EGDT or the "Rivers Protocol" does not include Xigris.

Moving someone pretty quick is fine, if you can achieve your goals (ScvO2 of 70%) in 6 hours. If your ED or ICU can't do this, then EGDT is not being done.

Thanks again, keep them coming.........please state your hospital/training program/ Medschool, unless you don't want to.

Kyle

I agree. I only brought it up because it was an area of considerable discussion between our attendings at the conference. We are absolutely doing EGDT. That said, only the initial steps are done in the ED here (i.e., lots of fluids and central access) because the patients leave the ED so quickly. As I understand it, the IM folks continue to the pressors, RBCs, dobutamine, etc. We do have a protocol for Vasopressin or Dopamine in the ED if it comes to that, but it hasn't yet.

What is your take on Xigris?

- H

Originally Posted by FoughtFyr

I agree. I only brought it up because it was an area of considerable discussion between our attendings at the conference. We are absolutely doing EGDT. That said, only the initial steps are done in the ED here (i.e., lots of fluids and central access) because the patients leave the ED so quickly. As I understand it, the IM folks continue to the pressors, RBCs, dobutamine, etc. We do have a protocol for Vasopressin or Dopamine in the ED if it comes to that, but it hasn't yet.

What is your take on Xigris?

- H

I think Xigris works for some patients. Obviously the multiple stratifying analyses of the PROWESS study revealed that the most benefit was those with APACHEII scores of 25 or higher. Unfortunately, traditional ICU scoring systems, such as APACHE, SAPS and MODS don't work well in the ED in predicting mortality or development of multi-organ failure.

In theory, Xigris should work early as well. It doesn't take a very complex understanding of the inflammatory process of sepsis that earlier therapy works better than later. In theory, Xigris should work well in the ED, I think especially those who are in the delivery independent state of shock (SvO2 > 70 with increasing lactate) These are patients who are exhibiting either profound microvascular plugging, or mitochondrial dysfunction. Xigris "should" work well in these patients.

Unfortunately it hasn't been extensively studied in the ultra early phase in humans. We were going to do a large multi center trial with Lilly to address this, but it's recently stalled out.

KG

We just talked about this at the VA two days ago. One of our former attendings at Duke (who left to become an associate PD back at HF) trained at Henry Ford while this was going on, and pushed it heavily. I haven't seen a patient that needed EGDT yet - just coincidental on my part.

As far as Xigris, the Durham VA is possibly going to drop it, due to inappropriate use (pts were either too alive or too dead to get it, but they were getting it anyhow).

UC Davis was trying to do it but was having limited success due to the problems associated with CVP monitoring in the ED. I imagine that they are more up to speed now. I have not seen it used in private practice due to the difficulty (impossibility) of getting CVP monitoring and an attitude that if you know your pt is septic then they should be admitted to the intensivist.

First, this would be a great article for our initial journal club paper and should also be pointed out to people interested in clinical EM research as an example of how good it can be. This is worlds better than a lot of the customer satisfaction/patient education surveys that seemed to get published regulary in annals.

Several of the community hospitals here in Denver are talking more about getting on board with this. The biggest issue is probably going to be length of stay in the ED since most of our ICU players hopefully are in the ED less than 2 and maybe even less than 1 hour. Another issue will probably be early recognition of every patient that would benefit from this. Currently we have no problem monitoring CVP but don't have the catheters/equipment for monitoring central venous O2 which is another requirement of this protocal. I know that the big Kaiser EM group in town just read/discussed this paper and are working on implementing it.

Originally Posted by ERMudPhud

First, this would be a great article for our initial journal club paper and should also be pointed out to people interested in clinical EM research as an example of how good it can be. This is worlds better than a lot of the customer satisfaction/patient education surveys that seemed to get published regulary in annals.

Several of the community hospitals here in Denver are talking more about getting on board with this. The biggest issue is probably going to be length of stay in the ED since most of our ICU players hopefully are in the ED less than 2 and maybe even less than 1 hour. Another issue will probably be early recognition of every patient that would benefit from this. Currently we have no problem monitoring CVP but don't have the catheters/equipment for monitoring central venous O2 which is another requirement of this protocal. I know that the big Kaiser EM group in town just read/discussed this paper and are working on implementing it.

I can't even get our cheap ass department administrator to buy me a vascular probe for our sonosite. I could't imagine her response if I asked her to get us CVP monitoring equipment, and to train our nurses to use the stuff (yeah right, union workers), etc... Oh well, I guess it's just fluids, ABX and pressors until they get to the unit, then they can deal with the goal directed stuff....
Mark

Originally Posted by Apollyon

As far as Xigris, the Durham VA is possibly going to drop it, due to inappropriate use (pts were either too alive or too dead to get it, but they were getting it anyhow).

This always frustrated me as well with Xigris. To meet the APACHE score required for its use someone has to be 4+ sick when it seemed like you're just pouring good money after bad. There always seemed to be people you'd see and say that have got to meet the #'s for the APACHE & fall just short into the range where you had paradoxically WORSE outcomes in the clinical trials for Xigris. I've seen a lot of people start playing fast & loose with using Xigris in re. to using it the way its supported by the data. Over time I've gotten less and less impressed with results from & remember you're treating nearly a hundred people to improve results (possibly) with just a few at best

Kyle

Yes our entire ED group and our residency as well as our critical care teams both medical and surgical are aware of of EGDT. W e have a spesis pathway protocol in the ED that was patterned after this as well. Our CC staff is welcoming many of these patients that may have been admitted to Step down monitored beds to the ICU for close monitoru=ing and aggressive early managment for 6-12 hours now in the ICU...obviously long if needed. We are intubatuing patients more frequently, CVP, SVO2 and in the multiorgan compramised as we havd the other day ( multilopbar pneumonia, MI, ARI, and shock) placing swan-g caths etc. Having an EM/IM program in addition to the EM program helps to potentiate such medical initiatives that's for sure!

PLUS.....our ED and ICU nursing staff have ALL been inserviced about the protocol by the Directors of EM and CCM!....Sweet!

Paul