egdt there and back -...
TRANSCRIPT
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EGDT There and
BackNathan I. Shapiro, MD, MPH
Beth Israel Deaconess Medical Center
Boston, MA
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Disclosures• Grants from the US National Institutes of Health
• Industry Research Grants
– Cheetah Medical, Thermo-Fisher, Rapid Pathogen Sctreening
• Consulting – Cyon Therapeutics
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Chest: 1988: 94:1176-1186
• Design: single center, prospective, randomized
• Population: 70 high-risk surgery patients and trauma patients
• Intervention: supranormal oxygen delivery (CI>4.5, DO2>600)
• Outcome: Mortality 4% (Treatment) versus 30% (control)
Shoemaker et al, Chest:1988:94:1176-1186
Boyd et al: JAMA:1993:270:2699-2707
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• Design: 56 site multi-center, prospective, randomized trial
• Population: 762 high-risk ICU patients (SAPS > 11)
• Interventions:
A)supranormal oxygen delivery (CI>4.5)
B) Sv02 > 70%
Gattinoni et al: NEJM:1995:333(16): 1025-1032
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Gattinoni et al: NEJM:1995:333(16): 1025-1032
Hayes et al: NEJM: 1994:330:1717-1722
Gattinoni - Survival
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Kern & Shoemaker: Crit Care Med: 2002:30:8: 1686-1692
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• Gattinoni like Hayes….
•“It is impossible to resuscitate dead cells and failed organs, even with oxygen. “
• “Clearly, intensive care unitsgive too much, too late, to too few.”
William Shoemaker, NEJM, editorial
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• Early, protocolized resuscitation to targeted physiologic endpoints
• Facilitates early, aggressive resuscitationRivers, Nguyen et al NEJM: 354 (19): November 8,2001
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Goal Directed Therapy Treatments
Treatment
(6 hours)
Standard
(6 hours)
P-
Value
Total Fluids 5000cc
(+3000)
3500cc
(+2400)
<0.001
RBC Transfused 64% 19% <0.001
Dobutamine 13.7% 0.8% <0.001
ScvO2 > 70% 95% 60% <0.001
Study Team Yes No
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Single Center EGDT Studies
Site Author n design Protocol
Henry Ford Rivers 263 Random EGDT ONLY
Cooper Trzeciak 38 Hist Control YES
BIDMC Shapiro 130 Hist Control YES
Barnes Micek 120 Prosp obs YES
Carolinas Jones 157 Prosp obs YES
River et al. NEJM 2001; Trzeciak et al. Chest 2006.
Shapiro CCM 2006; Micek CCM. 2007;
Jones et al. Chest 2007
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Fluids - InitialL
iter
s
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Vasopressor Use
0
10
20
30
40
50
60
70
80
90
100
Henry
Ford
Cooper BIDMC Barnes-
Jewish
Carolina
Standard
Protocol
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Time to Antibiotics
0
20
40
60
80
100
120
140
160
180
Henry
Ford
Cooper BIDMC Barnes-
Jewish
Carolina
Standard
Control
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Mortality
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EGDT Validation
Chen C, Kollef MH. Conservative fluid therapy in septic shock: an example of targeted
therapeutic minimization. Critical care (London, England). 2014;18(4):481.
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• ProCESS (United States)
• ARISE (Australia)
• ProMISe (England)
3 EGDT Validation Trials
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ProCESS
.
ProMISeARISE
PROCESS Investigators. New England Journal of Medicine. 2014;370(18):1683-93
Mouncey PR,, et al. New England Journal of Medicine. 2015.
ARISE Investigators New England Journal of Medicine. 2014;371(16):1496-506.
3 EGDT Validation Trials
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Intravenous Fluids in Triad Trials
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Vasopressor Administration
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Other Processes of Care
PROCESS Investigators, A randomized trial of protocol-based care for early septic shock.
New England Journal of Medicine. 2014;370(18):1683-93
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All Fluids Over 72 hours
2.6 2.5 2.1 2.3 2.0 2.0
1.7 2.0 2.32.8
1.8 2.0
4.4 4.3 4.44.5
4.0 3.6
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
ARISE -UsualCare
ARISE -EGDT
ProCESS -UsualCare
ProCESS -EGDT
Promise -UsualCare
Promise -UsualCare
6-72 hr fluids
0-6 fluids
pre-fluids
8.7 8.8 8.79.5
7.87.6
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Mortality Rates for EGDT Trials
47%
31%
19%
21%
15% 16%
25% 26%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Rivers ProCESS ARISE Promise
UsualCareEGDT
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Implications of EGDT triad trialsBackdrop: All patients received
– Early Identification
– Aggressive Fluid Resuscitation (about 4-5 liters in first 6 hours)
– Early antibiotics (>97% all groups)
– Other care elements provided
1. A team based EGDT protocol or empiric structured protocol was not beneficial compared to usual care in 2009 - 2013
2. Systematic Screening and Aggressive treatment is needed to reproduce these findings
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What EGDT does not tell us:
“How much fluids should I give to a septic patient?”
…..While EGDT trials used fluids, they were not fluids trials
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The Pendulum is Swinging
Too Much
Fluid
Too Little
Fluid
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Each Has Theoretical AdvantagesLiberal Fluids Restrictive Fluids
Augment preload to increase CO and organ perfusion
Reduce overall fluids and positive fluid balance
Decrease vasopressor use and its detrimental effects
Early vasopressors to treat vasodilation
?Increase Microcirculatory Flow Prevent worsening of pathologic edema(due to sepsis-induced barrier dysfunction)
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Negative Fluid Balance is Associated with Better Outcomes
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Pre-EGDT = Conservative
Post EGDT = Liberal
Era(s) of Fluid Management
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Fluids in Usual Care Pre- and Post- Rivers
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Henry Ford Cooper BIDMC Barnes-Jewish
Carolina ARISE ProCESS ProMISE
Standard
Standard
Pre-Rivers Post-Rivers
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Mortality in Usual Care Pre- and Post- Rivers
46%44%
29%
48%
27%
16%
19%
25%
0%
10%
20%
30%
40%
50%
60%
Henry Ford Cooper BIDMC Barnes-Jewish
Carolina ARISE ProCESS ProMISE
Standard
Standard
Pre-Rivers Post-Rivers
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How much fluids should we give a patient before moving on to
vasopressors?
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Crystalloid Liberal Or Vasopressors Early Resuscitation in Sepsis
(CLOVERS)
PETAL Network
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Hypothesis
“Conservative”(Vasopressors for followed by rescue fluids)
Versus
“Liberal”(Fluids followed by rescue vasopressors)
Will reduce 90-day in-hospital mortality in Sepsis induced hypotension
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Methods
• Multicenter, randomized prospective phase 3 trial
• Sepsis induced hypotension
• Intervention 24-hour fluid titration strategies
• 2,320 patients planned enrollment
• 50 PETAL network hospitals
• Primary outcome: 90-day inpatient mortality
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What is the correct “dose” and
“timing” intravenous fluids in
sepsis-induced hypotension?
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Questions?
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Inclusion Criteria
• A suspected or confirmed infection
• SBP< 100 mmHg or MAP < 65 mmHg after a minimum of at least 1 liter of fluid
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Exclusion Criteria (abbreviated)
• Age < 18 years
• Patient already received 3 liters of fluid
• >4 hours elapsed since meeting criteria
• Blood pressure is at known baseline
• Pulmonary edema or signs of new fluid overload
• Physician unwilling to randomize to one of the arms
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Vasopressor First(Fluid Conservative)
Norepinephrine Drip –Titrate to MAP > 65
Rescue Fluids Criteria or
Norepi >20 mcg/min
Intervention Needed?
Increase Vasopressors/ add second vasopressor
500ml fluid bolus
No
Intervention Needed?
•SBP < 90 mmHG or MAP <65mmHG
Rescue Fluids Criteria
Yes
• SBP <70 mmHG) • Refractory hypotension (MAP <65) despite
norepi at 20 mcg/min• Persistent lactate > 4 mmol/l and rising• Sinus heart rate > 120 for >15 minutes• Echo/Ultra evidence of extreme
hypovolemia • Suspected central (e.g. bowel) or peripheral
ischemia or mottling
Restrictive Arm
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Fluids First(Liberal Fluids)
2000 ml IVF crystalloid bolus
Rescue VP CriteriaOr 5 liter administered
Intervention Needed?
500ml fluid bolus
Norepinephrine DripTitrate to SBP > 90
No
Intervention Needed?
• MAP <65mmHG• persistent lactate > 4 mmol/l• sinus heart rate > 110• Any clinical or measured assessment of
volume status or volume responsiveness (e.g. echo, IVC measurement, CVP, etc) suggesting benefit from additional fluid
Rescue Vasopressor Criteria
• SBP < 70 mmHG• Persistent and rising lactate >
4mmol/liter• Signs of fluid overload• Suspected Central or peripheral
ischemia or mottling
Yes
Liberal Arm (draft)