Chest
Postgraduate Education CornerEarly Goal-Directed Therapy in Severe Sepsis and Septic Shock Revisited: Concepts, Controversies, and Contemporary Findings
Section snippets
Early and Late Sepsis: A Hemodynamic Comparison
Sepsis represents a continuum from an inciting infectious event and host-pathogen interaction to the hemodynamic consequences caused by the relationship among proinflammatory, antiinflammatory, and apoptotic mediators.4 The early stages of sepsis can be accompanied by circulatory insufficiency resulting from hypovolemia, myocardial depression, increased metabolic rate, and vasoregulatory perfusion abnormalities. As a consequence, a variety of hemodynamic combinations create a systemic imbalance
The Therapeutic Components of EGDT
Since the publication of the EGDT study, numerous questions have been raised regarding specific components of treatment. While the trial began patient enrollment in 1997, the protocol goals were consistent with the practice parameters for hemodynamic support of sepsis recommended by the American College of Critical Care Medicine in 1999 (Table 2).35 More recently, these recommendations have been updated,36 but the therapeutic tenets remain the same.
Scvo2 vs S o2: Does it Matter?
An S o2 gives an estimate of the
Myocardial Dysfunction and Brain Natriuretic Peptide
At the hemodynamic juncture at which the goals of central venous pressure (CVP), MAP, and hematocrit are met, a low Scvo2 implies decreased myocardial compliance or dysfunction. Previous work by Parillo et al81 has shown that 10 to 15% of patients with near-normal BP and preload optimization will continue to have significant myocardial depression, necessitating inotropic support. Similar findings were detected in the EGDT study with 13.7% of patients receiving inotropic therapy, which is not
Conclusion
EGDT results in significant reductions in morbidity, mortality, vasopressor use, and health-care resource consumption. Five years after its publication, this study has generated much discussion with regard to the concepts of early sepsis, and has fueled debate regarding diagnostic and therapeutic interventions. Further investigations by the primary investigators and others have brought additional contemporary findings. EGDT modulates some components of inflammation, which are reflected by
ACKNOWLEDGMENT
The authors acknowledge the assistance of our research assistants, Quannience Rivers, Beth Fasbinder, Arturo Suarez, and Alexandria Podczervinski, and our biostatisticians, Suzanne Havstad and Gordon Jacobsen, for their assistance and support in preparing the data presented.
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Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).
Dr. Otero receives research grant support from Biosite, Hutchinson Technologies, Spectral Diagnostics, and the National Institute of Allergy and Infectious Diseases. Dr. Rivers has received advisory board fees from the Lilly Corporation, Hutchinson Technologies, and Chiron; lecture fees from the Lilly Corporation and Edwards Lifesciences; and research support from the National Institute of Allergy and Infectious Diseases, Hutchinson Technologies, and Biosite Inc.
The writing of this manuscript was partially supported (Drs. Otero and Rivers) by grant No. U01AI066569–01 from the National Institutes of Health, National Institute of Allergy and Infectious Disease (NIAID).