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Sepsis II: Monitoring and Resuscitation
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy (EGDT). A concept introduced by Rivers and colleagues in 2001. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. Although early recognition and treatment remains the cornerstone of sepsis management, further well-designed trials have shown that there was no difference in mortality between EGDT and standard management. This finding was confirmed in the 2014 ARISE and 2015 ProMISe trials. Other criticisms of the Rivers trial was that it was single center and the ED staff were not blinded to the treatment arms [6].
Infections in Cirrhosis in the Critical Care Unit
Published in Cheston B. Cunha, Burke A. Cunha, Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
John M. Horne, Laurel C. Preheim
Patients with cirrhosis are also at increased risk of sepsis, which can be defined as life-threatening organ dysfunction that occurs because of the dysregulation of the host response to infection. Prompt recognition of sepsis can be challenging since both sepsis and severe cirrhosis can present with similar signs and symptoms. Early goal-directed therapy (EGDT) for sepsis focuses on intensive hemodynamic management to maintain central venous pressure (CVP) of 8–12 mmHg, mean arterial pressure greater than 65 mm Hg, urine output greater than 0.5 mL/kg/h, and central venous oxygen saturation (Scvo2) of ≥70%. Although the survival benefit of EGDT vs usual care remains controversial, the aims of treatment should focus on correction of hypoperfusion with volume administration and vasopressor support, early administration of appropriate antimicrobial therapy, and source control [52].
Critical care and emergency surgery
Published in Stephen Brennan, FRCS General Surgery Viva Topics and Revision Notes, 2017
The recommendations for initial resuscitation are centred around the Rivers trial (2001) of early goal-directed therapy, which showed significant improvement in (a) hospital mortality, (b) 28-day mortality and (c) 60-day mortality.
Impact of protocolized postarrest care with targeted temperature management on the outcomes of cardiac arrest survivors without temperature management
Published in Annals of Medicine, 2022
Dean-An Ling, Chien-Hua Huang, Wen-Jone Chen, Po-Ya Chuang, Wei-Tien Chang, Chih-Wei Sung, Wei-Ting Chen, Hooi-Nee Ong, Min-Shan Tsai
A protocolized bundle care approach of postarrest care, including targeted temperature management (TTM), improves the quality of care and the outcomes of cardiac arrest survivors [3]. The protocolized approach has been applied to several medical conditions, including resuscitation, sepsis, ventilator-associated pneumonia, and central line insertion, and has facilitated medical teams to provide more consistent care and overcome barriers [3–6]. For resuscitation, establishing a formal and structured emergency resuscitation protocol is beneficial in increasing the return of spontaneous circulation (ROSC) rate [4]. With regard to sepsis care, although a randomized trial did not reveal early goal-directed therapy (EGDT) to be beneficial in reducing all-cause mortality at 90 days, the improvement of quality of medical care along with the establishment of a protocol was proposed as a reason for similar outcomes in the EGDT and control groups [7]. TTM has been incorporated as part of postarrest care regardless of the initial rhythm. The optimal goal temperature has been evaluated in recent studies such as the TTM and TTM2 trials [8–12]. The refinement of protocolized postarrest care since 2002 might be one explanation for the comparability of outcomes between the hypothermia and normothermia group [11,12].
Antibiotics in the first hour: is there new evidence?
Published in Expert Review of Anti-infective Therapy, 2021
Claire Dupuis, Jean-Francois Timsit
Consequently, SIRS, sepsis, severe sepsis and septic shock were for many years considered as a continuous process and the first step of the management of septic patients consisted in early identification of high-risk patient to promptly stop the process. Early goal-directed therapy was therefore introduced and validated in 2001, and involved early identification of sepsis, appropriate culture source control, and early administration of appropriate antibiotics, followed by early hemodynamic optimization of oxygen delivery and decreasing oxygen consumption. Surviving Sepsis Campaign (SSC) guidelines from 2004 thus incorporated the EGDT in the first 6-h sepsis resuscitation bundle. Nearly two decades after the Rivers trial management has evolved, with various propositions of different but quite similar bundles. Bundles are groups of treatments that produce greater benefit when implemented together than as individual therapies. The different bundles recommended by the SSC are listed in Table 2. They include early identification of at risk patients, and early AT but also hemodynamic optimization, source control, and appropriate supportive care. Hence, it is clear that the impact of early AT should be analyzed according to the stage of sepsis and the time of completion of the other bundles. For a better understanding we therefore tried to specify, for each reported study, the population involved (sepsis or septic shock) and the other treatments assessed.
The importance of a hospital-dedicated sepsis response team
Published in Expert Review of Anti-infective Therapy, 2020
The PROCESS-trial investigated Early Goal Directed Therapy in sepsis [6]. While the study itself was negative, it demonstrated that early sepsis recognition, early antimicrobial therapy, and early fluid resuscitation are key features of successful sepsis therapy [7]. The SSC emphasized the importance of the first treatment measures by defining an 1-hour-bundle consisting of lactate measurement, blood cultures, intravenous broad-spectrum antibiotics, as well as fluid resuscitation and vasopressors in case of septic shock [8]. However, there is often a difference between recommended sepsis therapies and adoption by physicians. Under such condition, implementation of guidelines improved sepsis outcome [9–11]. Failure to deliver adequate resuscitation may have several reasons such as failure to monitor and failure to escalate. Failure to escalate comprises uncertainty of the staff, whom to call in case of emergency leading to suboptimal response to urgency [12]. Rapid response teams (RRTs) can resolve such issues.