Part 1 of the history of sepsis appeared in the November issue.
Explore This IssueACEP Now: Vol 37 – No 12 – December 2018
Prior to 2000, there was no universal sense of urgency for treating septic patients. Care was generally fractured, with little collaboration among the pre-hospital service, emergency department, intensive care unit, and wards. Universal use of ultrasound in emergency departments or intensive care units (ICUs) was non-existent during this period, although global myocardial dysfunction from sepsis was an emerging concept.
In 2001, Rivers et al reported results of a new protocolized resuscitation termed early goal-directed therapy (EGDT).1 EGDT was described as a structured treatment protocol that incorporated elements consistent with the 1992 consensus guidelines focusing on preload, afterload, contractility, and oxygen delivery.2 The absolute mortality benefit of 16 percent (46.5 to 30.5 percent) represented one of the most effective modalities to date. Over the ensuing 12 years, multiple observational studies supported a mortality benefit of varying degrees.3 EGDT was included in the first three iterations of the Surviving Sepsis Campaign (SSC) guidelines and was a central component of emergency medicine–specific guidelines.4
Between 2013 and 2015, three international trials found no mortality difference between EGDT and usual care, with usual care including early identification, early lactate measurement, early antibiotic administration (median: 1–3 hours from identification), and early fluid administration (median: 2–3 L).5-7 In pinpointing reasonable causes for the mortality differences between the Rivers trial and these three international trials that showed no dfference, Nguyen et al identified evolving practice over the ensuing 15 years, the baseline central venous oxygen saturation (ScvO2) >70 percent in all three trials, and the potential of a subset of this patient population who could benefit from normalizing an abnormally low ScvO2.8
It is interesting that four randomized, controlled trials encompassing defining points of two decades are scientifically in opposition but philosophically in alignment. They all required the breakdown of long-held barriers and promoting intentional collaboration across levels of care, locations of care, and service lines.
“The reality is that patients presenting with sepsis are admitted to the intensive care unit via the emergency department, general medical or surgical floors, operating rooms, and inter-hospital transport managed by a broad spectrum of specialties and care providers. As patients travel this landscape, current evidence suggests that the diagnostic and therapeutic expertise provided at each venue significantly impacts morbidity and mortality.”
Although the 2018 SSC bundle recommends antibiotics within one hour of emergency department triage, this has not been adopted by the Centers for Medicare and Medicaid Services (CMS), and there are limited supportive data.