Ron and SCCM sepsis list serve. I agree that there is no reason to believe that EGDT is fatally flawed. It is understandable that a controversial and potential harmfully treatment i.e blood transfusion in septic shock for low ScVO2 should be evaluated further as a single variable.
Yet as you suggest and I am stuck by all of the efforts to dissect out the value of individual components of a Sepsis System while potential reducing attention to very basic and effective interventions outlined in EGDT. One of the first interventions in EGDT, yet not emphasized, addresses supporting the respiratory system, This intervention is based on self evidence which seems compelling, with only a few single center trials showing benefit. Although less well studied i.e. methods of earlier recognition of septic patients or measures to decrease work of breathing (thereby diverting CO previously going to the diaphragms and intercostal muscles to now go to the abdomen) deserves more attention Early identification, prompt resuscitation including decreasing work of breathing and optimizing SaO2 , aggressive fluids, hemodynamic support ,antibiotics and source control is 95% of EGDT protocol of which there is little controversy. The EMS and Trauma systems were started and adopted worldwide, with the obvious benefit to society, with much less rigorous data than is now being asked for with EGDT. When a system is developed there is always refinements based on individual institutions experience as well as well conducted studies. However studing systems is fought with problems due difficulty and expense in conducting randomization to large number of hospitals/locations while looking at a number of variable (as apposed to one variable). Hence the problem now facing Sepsis and Rapid Response Systems. I wonder if this discussion is trumping the discussion and efforts about how do we recognize these at-risk patients earlier and are they getting prompt respiratory and other basic support. This is where the real mortality benifit will come from. Frank Sebat, MD, FCCP, FCCM Director Cardiovascular Intensive Care Kaweah Delta Health Care District Hospital Visalia, CA 559 799 9171 -----Original Message----- From: Ron Elkin <[email protected]> To: Carina Idiesca <[email protected]> Cc: sepsis family <[email protected]> Sent: Thu, Dec 15, 2011 5:45 am Subject: Re: [Sepsis Groups] Paul E. Marik Apology for my error - SSC did indeed recommend use of Xigris. However, SSC data base would accept patients from institutions whose protocol excluded use in all patients due to cost. Ron Elkin On Mon, Dec 12, 2011 at 11:12 AM, Ron Elkin <[email protected]> wrote: My $0.02 Debates, critiques, further studies, and refinements of EGDT should be welcomed. On consideration of each, one must ask 2 questions: 1) Where is the proof that the original EGDT study was fatally flawed? Surely not in the Wall Street Journal. 2) Is there convincing evidence-based/outcomes proof, rather than speculation, that other resuscitation strategies offer equal or greater mortality benefit? Perhaps due to my own bias or ignorance, I have never read or heard a convincing answer to either question. There are other questions and observations to consider: 1) SSC Guidelines have never included a recommendation to use the Edwards catheter or other continuous ScvO2 measuring devices. What is the evidence that Edwards Lifesciences had a corrupting influence on the guidelines? 2) Ely Lily sponsored the guideline process and undoubtedly had an interest in sales of Xigris. Was that a corrupting influence and a negating force for the remaining 51 (2004) and 84 (2008) recommendations by SSC that had nothing to do with Xigris? 3) Ely Lily was not present in the room when guidelines were written and had no editorial influence on the recommendations. SSC did not recommend use of Xigris. They simply recommended institutional protocols to consider its use. An institutional protocol stating the drug could never be used due to cost would have satisfied the guideline requirements. 4) Some detractors of EGDT focus upon individual elements of the bundles, such as failure of CVP to accurately reflect blood volume or fluid responsiveness. This neglects the value of the whole. For example, increasing ScvO2 together with CVP in response to fluid administration does indeed indicate fluid responsiveness. 5) All or none compliance with the resuscitation bundle peaks at about 30% in most of our hospitals. Will adopting more expensive and scarce technologies such as IVC ultrasound, echo, PPV, esophageal Doppler, or tissue oxygenation, each with its own problems, improve or degrade our compliance? Will they really be utilized as continuous or intermittent monitoring modalities, or will they be one-time measures? Is there convincing evidence-based proof that they will improve outcome? Thanks, Ron Elkin MD California Pacific Medical Center San Francisco On Thu, Dec 8, 2011 at 9:49 PM, Carina Idiesca <[email protected]> wrote: Dear All, I would like to ask for a feedback regarding an article authored by Paul E. Marik which was published in the Annals of Intensive Care 2011 1:17. The article is entitled " Surviving sepsis:going beyond the guidelines". Much to my chagrin, it contained unfavorable reviews of the SSC bundles. Hoping to hear from you all, Carina MD. USA PS Since the NICE-SUGAR study, is the majority still using intensive insulin therapy drip for hyperglycemia in the ICU patients? Our pharmacist shared an article (details & source to follow, apologies) regarding the use of insulin drip to treat hyperglycemia as a weak recommendation. 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