COMMENTARY

The Most Life-Saving Emergency Medicine Articles of 2014

Amal Mattu, MD

Disclosures

December 19, 2014

A Test for Protocol-Based Sepsis Care

A Randomized Trial of Protocol-Based Care for Early Septic Shock
The ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al
N Engl J Med. 2014;370:1683-1693

Goal-Directed Resuscitation for Patients With Early Septic Shock
The ARISE Investigators; ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, et al.
N Engl J Med. 2014;371:1496-1506

"Early goal-directed therapy" (EGDT) has been a catchphrase in acute care medicine ever since Rivers and colleagues[1] published their ground-breaking article describing a protocol for the management of patients with septic shock in 2001.

EGDT became an almost overnight standard of care because it demonstrated for the first time how a formal protocol could produce dramatic reductions in mortality from a highly lethal condition. However, the protocol was complicated: It included central lines, special catheters, measurements of central venous pressures and central venous oxygen saturations (ScvO2), and cardiac index; and various decision points to determine the need for transfusions, vasopressors, and inotropes. A quick Google image search of "EGDT algorithm" demonstrates numerous attempts at boiling down the protocol into flowcharts, but none appear simple.

Over the past decade, many other researchers have been scrutinizing the components of EGDT to determine whether the protocol really does need to be so complicated or whether there might be specific interventions that are actually the key to improving mortality. The ProCESS trial and the ARISE trial published this past year have shown the latter to be true: A formal EGDT protocol did not improve mortality over non-protocol–based aggressive therapy.

It is important to remember that our approach to caring for patients with septic shock has improved remarkably over the past 13 years, and this is likely attributable to the focus on aggressive early care of these patients that was imparted upon us by Rivers and coworkers. Even if formal protocol-driven therapy is not necessary, the literature has been fairly clear about what types of interventions do improve mortality:

Early recognition of severe sepsis and septic shock is key. Obtain blood cultures and initiate broad-spectrum antibiotics without delay. Provide early crystalloids and add vasopressors for fluid-resistant shock. When initiating mechanical ventilation, use lung-protective strategies with low tidal volumes.

Routine use of central venous catheters and monitoring of ScvO2 do not appear to improve outcomes. Instead, monitoring serial lactate levels as a measure of perfusion appears to be adequate in general. Additionally, blood transfusions should be given less liberally and are probably best reserved for patients with active cardiac or cerebral ischemia in the presence of a hemoglobin level < 7 g/dL.

I look forward to reading your comments, critiques, and your own opinions about the most life-saving emergency medicine articles of 2014. Best wishes in 2015!

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