GDT in Septic Shock

Septic shock Sepsis-induced hypotension

persisting despite adequate fluid resuscitation

Sepsis-induced tissue hypoperfusion infection-induced

hypotension, elevated lactate or oliguria

SSC 2013

WHAT IS SEPTIC SHOCK?

WHATS GOAL DIRECTED THERAPY (GDT) ?
EGDT RIVERS PROTOCOL
Comparing mortality outcome of septic
shock between Standard Therapy with
EGDT

STANDARD CARE:
CVP
MAP
UO

EGDT for 6 hours with continueScvO2

monitoring:
CVP
MAP
UO
ScvO2
SaO2
Hematorit
Cardiac Index
VO2
 Figure,S1.,,Protocol,for,early,goal9directed,therapy,(EGDT).,

Protocol:
1. Insert CVC and AL and
continous monitoring of
ScvO2
2. 500 mL crystalloid every 30
min CVC 8-12 mmHg
3. If MAP 65 mmHg
vasopressor
4. If ScvO2 70% transfuse
PRC to achieve hematocrit at
least 30%
5. If ScvO2 still 70%
dobutamin start 2.5
mcg/kg/min titrated every
30 min, max 20 mcg/kg/min
6. Reduce VO2 by sedatives and
mech. ventilation

,
 ;;
;;

RESULT : 46.5% VS 30.5%

How to manage septic shock?
What the guideline said? And hows the
evidence...
Fluid
Drug 1 : Vasopressor
Drug 2: Inotropic
 THE EVIDENCES
ProCESS STUDY
 31 emergency departement in US
1341 patient with septic shock
Divided into 3 groups:
1. Protocol-based EGDT Rivers protocol
2. Protocol-based standard therapy didnt require
CVC, or administration of inotropic or blood transfusion
3. Usual care

Methods
 Figure,S1.,,Protocol,for,early,goal9directed,therapy,(EGDT).,

Protocol:
1. Insert CVC and AL and
continous monitoring of
ScvO2
2. 500 mL crystalloid every 30
min CVC 8-12 mmHg
3. If MAP 65 mmHg
vasopressor
4. If ScvO2 70% transfuse
PRC to achieve hematocrit at
least 30%
5. If ScvO2 still 70%
dobutamin start 2.5
mcg/kg/min titrated every
30 min, max 20 mcg/kg/min
6. Reduce VO2 by sedatives and
mech. ventilation

EGDT ,
Protocol:

1. Peripheral iv access
2. 500-1000 ml fluid bolus
3. Targets SBP 100mmHg; SI 0.8
4. If fluid overload vasopressor
5. If still not achieved bolus
another isotonic IVF250-500 ml `
per hour
6. Reassess q30 min
7. Monitor fluid overload, recheck
lactate and HCT

Standard Therapy
Outcom
e
 $
$
Panel$A$$time$(minutes)$until$a$central$venous$catheter$is$placed.$Panel$B$$time$(minutes)$until$a$central$venous$catheter$for$oximetric$
monitoring$
Panel$A$$time$(minutes)$until$a$central$venous$catheter$ is$Panel$
is$placed.$ placed.$Central$
B$$ venous$catheterization$
time$(minutes)$ defined$catheter$
until$a$central$venous$ as$use$of$oximetric$
for$ catheter$or$multiple$serial$ScvO2$measures.$Panel$C$$$
oximetric$
monitoring$is$placed.$Central$venous$catheterization$defined$as$use$of$oximetric$catheter$or$multiple$serial$ScvO $measures.$Panel$C$$$
Intravenous$fluid$volume$by$hour$(mean$+$SD).$Panel$Intravenous$ fluid$volume$ by$hour$(mean$+$SD).$ Panel$D$$use$of$ resuscitation$
interventions.$
PRBC$$ ScvO2$$central$venous$oxygen$saturation;$PRBC$$
2

Panel$A$$time$(minutes)$until$a$ central$ venous$

D$$use$of$resuscitation$
packed$red$blood$cell;$EGDT$$early$goalHdirected$therapy..$
catheter$
interventions.$
2 ScvO
is$ placed.$
$$central$
Panel$
venous$ oxygen$
B$ $time$
saturation;$
(minutes)$until$a$central$venous$catheter$for$ox
PPvalues$represent$comparisons$across$the$3$arms.$
packed$red$blood$cell;$EGDT$$early$goalHdirected$therapy..$
RESULT:
NO
DIFFEREN
CE
Conclusion
ARISE STUDY
 Emergency departement in 52 centres (mostly AUS or
NZ)
1600 patients with early septic shock
Divided into 2 groups:
1. Protocol-based EGDT Rivers protocol
2. Usual care

Methods
Outcome
Probability of Survival
Odd ratio for death 90 days
Conclusion
ProMISE STUDY
 Thank you
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