Does your ED use early-goal directed therapy for sepsis?

I thought that EGDT was standard operating procedure for EDs after Rivers et al published their landmark RCT in 2001 in the NEJM. However, others I have spoken to in different EDs around the country are still not using EGDT.

I'd like to start an informal poll here. Does your ED use EGDT for sepsis? If not, why? Is it because its hard to implement or because the SCVO2 sensors attached to the central lines are too unwieldy or expensive?

Is the EGDT policy dependent on the attending covering the ED that day or is it a formalized process/protocol where all patients identified with sepsis are automatically entered into the protocol by the charge nurses/ICU nurses?

What is your pattern on transitioning care to the ICU? Do you send them as soon as a bed is available and their vitals are stable? Or do you use the 6 hour trial period like Rivers et al used in their study?

Also, please post the name/location of your ED.

thanks

Sorry guys I'm just a dumb med student who recently finished his ED rotation, but I saw several septic patients in the ED and none of them got EGDT so thats why I brought this up.

Anyways, correct me if I'm wrong, but I thought that the Rivers study actually had more people get intubated in the standard therapy group rather than the EGDT group over 72 hours, but the ED phase of the project showed a similar rate of intubation (about 50% of all septic patients got tubed)

Anyways I dont think intubation was distinguishing factor between the groups. The main distinguishing factors were that the EGDT group got more IVF early in the course of therapy (< 6 hours), more RBC transfusions, fewer pulmonary artery caths (Swan-Ganz), higher rate of inotropic (dobutamine) infusions in the early phase (same rate of inotropics over 3 days), and less vasopressor therapy.

So are SCVO2 and CVP measurements done ONLY for sepsis management; I thought these were used for other disease processes. Is it true that many of your EDs dont have the personnel who are familiar with how to obtain these measurements?

I guess a lot depends on how quick the transition to ICU care is. At our hospital, the ICU is always packed full, and it takes awhile to send somebody up. So its not reasonable IMHO to forego the invasive monitoring required for EGDT in the hopes that you will get your patient to an ICU quick enough so they can benefit from the monitoring in the ICU.

There have been multiple validation studies that have come out since 2001 to support Rivers findings of decreased mortality, and some of them showed even greater mortality decreases than the original study did (up to 50% relative reduction).

In addition to that, multiple studies have come out showing that the implementation of Rivers EGDT algorithm (or other very closely related variants) impose no extra costs or resource burdens to the hospital (Trzeciak et al. Translating Research to Clinical Practice: A 1-Year Experience with Implementing Early Goal Directed Therapy for Septic Shock in the Emergency Department. Chest 2006, 129: 225-232).

I dont know, I'm sure a lot of my perspective as a 4th year med student is naive about the difficulties in implementing this research protocol. Its just that I've seen a lot of medical practice defined by studies that were a lot less statistically powerful than Rivers, and this seems to me to be a "slam dunk" in terms of showing us the proper way to care for sepsis patients, yet its not being implemented on a broad scale.

So tell me more about the constraints to implementing EGDT. Do most EDs not carry CVP or SCVO2 measurement equipment already? Is finding someone who knows how to use the equipment difficult and require a lot of training?

Also, I'd like to hear more about objections to the Rivers study generalizability to sepsis patients at large. Besides the practical implementation matters, are there widespread objections to the findings of the study or concerns about bias or flaws? I know one potential source of bias is that the early phase of therapy in the ED dept (first 6 hours) was non-blinded, and it was only the ICU portion that was blinded. Do you think that bias was sufficient enough to cast the findings in doubt?

Also, I wanted to comment about research studies in general and their implementation at academic institutions. Maybe my experience is too limited to support this view, but my gut feeling is that there is a mild inherent resistance to implementation of these studies at large academic medical centers because academics in general dont like to run "protocol" medicine and prefer to think about each patient on a case by case basis without having their care "dictated" by algorithms. Do you think there's any truth to that?