Friday, April 16, 2010

Paucis Verbis card: Early goal directed therapy

One of the landmark studies in sepsis was conducted by Dr. Manny Rivers (Henry Ford) and published in the New England Journal of Medicine in 2001. By managing patients with severe sepsis and septic shock with an "early goal directed therapy" approach, there was an absolute risk reduction of 16%. Furthermore, the number needed to treat to save a life was 6 patients!

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Early Goal Directed Therapy algorithm. The layout is borrowed from a Cleveland Clinic Foundation (CCF) flowchart.

(click to view larger version)

Feel free to download this card and print on a 4'' x 6'' index card.

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7 comments:

  1. Hi Michelle,

    Can you or a sepsis guru help me with one of the sepsis treatments?

    The above lists glycemia control of 80-110. What are your thoughts on the NICE SUGAR study published in NEJM showing increased mortality with tight glycemic control?

    Thanks,
    Fred

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  2. Hi Fred: Hmm, I'm not sure of the answer. Let me ask around.

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  3. Michelle:

    Scott Weingart has a very interesting podcast on EMCrit Blog (http://bit.ly/9yFnWh) concerning the feasibility of a non-invasive sepsis protocol, using lactate clearance and respiratory variation of IVC size (on ultrasound) in place of central venous oxygen content and CVP, respectively. Worth checking out.

    Leon

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  4. Hi Leon: Right! I forgot about his podcast with the author of the JAMA article on lactate clearance and SVO2 clearance. Definitely worth checking out.

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  5. Hi Fred

    Not a sepsis guru but as an ED/ICU guy my take on NICE-SUGAR is that it trumps previous studies and gives real world docs reassurance that the 80-110 target range is indeed practically impossible to attain without potentially harmful hypoglycaemia.


    Most of my colleagues and I would aim for less than 180 mg/dl (as per 'conventional' treatment arm in NICE-SUGAR). If anyone wants to check out the paper it's at http://tiny.cc/44ga2. I think the CCF flowchart is therefore a bit out of date.

    Best wishes

    Cliff
    http://resus.me

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  6. Hi Fred and Cliff: After checking around with my ICU guys and gals, the consensus is indeed as Cliff says - tight glycemic control is unnecessary and potentially harmful. I would eliminate from your goal directed therapy management algorithm.

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