Septic Shock: Is EGDT Still Necessary? Greg Martin, MD Associate Professor of Medicine, Associate Division Director for Critical Care, Emory University; Director, Medical and Coronary Intensive Care, Grady Memorial Hospital, Atlanta, Georgia April 29, 2014

A Randomized Trial of Protocol-Based Care for Early Septic Shock The ProCESS Investigators N Engl J Med. 2014 Mar 18. [Epub ahead of print]
Summary
Severe sepsis is a relatively common and potentially fatal condition that is often first encountered in the emergency department (ED), with patients subsequently requiring extensive care in the intensive care unit.[1,2] The basis of treatment for severe sepsis and septic shock follows the Surviving Sepsis Campaign guidelines,[3] in which the early goal-directed therapy (EGDT) hemodynamic intervention is derived almost solely from a single-center study more than 10 years ago.[4]

The investigators sought to determine whether the benefits of this guided-resuscitation strategy could be confirmed in a larger study. They randomly assigned 1341 patients from 31 EDs with severe sepsis and septic shock to receive 1 of 3 strategies: standard resuscitation, protocol-based resuscitation, or EGDT. There was no difference in mortality at any time period after enrollment in the analysis (primarily at 60 days, 90 days, and 1 year), nor was there any difference in organ dysfunction.

Because sepsis remains a common and relatively fatal condition, many groups continue to work to develop new therapies. This group sought to examine the most basic level of intervention for severe sepsis and septic shock: hemodynamic resuscitation. Of note, they found that the earlier demonstrated use of EGDT did not improve outcomes compared with either clinician-guided, standard-care resuscitation or protocol-guided resuscitation. All patients were identified and treated in the same timely manner, so this raises the question of whether EGDT is as effective as originally demonstrated, if at all.

It is likely that goal-directed therapy is effective for certain patients with septic shock — such as those early in their course with low tissue perfusion (low central venous oxygen saturation or an elevated lactate level). But this study also suggests that much of the benefit of sepsis therapy may be accrued by early identification and intervention, rather than a specific intervention involving hemodynamic treatments targeted to tissue perfusion.

Much of this may be due to the success of efforts to increase sepsis awareness, such that “standard care” in the ED now involves screening and early identification, as well as early antibiotics and other interventions.[5] In the absence of that, traditional EGDT may be particularly effective. But in the current era for many hospitals, where patients are identified quickly and such treatments as antibiotics are administered, all of the other components of EGDT appear to have less benefit.