Septic Shock Management

[triemal04]

Unfortunately, medicine is not nearly as evidence based as we often like to profess. There are many interesting situations. Think about "coma cocktails," tissue plasminogen activator for ischaemic stroke and others that are based on evidence that is perhaps not as robust as we would like.

Fortunately, we can have dialogue and discuss some of these issues. With that, I still believe general guidelines are still generally good and can act as a starting point or a place to run back home to mom when we are completely lost. They also help to put everybody on the same page in critical situations. However, sometimes our care may not be in perfect alignment with guidelines and guidelines can also change.

It's so important to look at the evidence as we are doing here. It's also possible for two very qualified people to come of with different conclusions and that discourse is interesting, relevant and hopefully, productive to discuss.

Agreed. The problem with protocols is when they are no longer looked at as guidelines of what should be considered, but rather as a concrete set of rules that you will follow...or else. I think when that happens not only are people less likely to take the risk of going against them (especially when there is some evidence that the protocol works) but that the protocol starts to be seen as the only way to do things...so nobody takes a deeper look at it and really questions how appropriate it is.

If you look at how many studies have been published in the last couple years that directly refute previous ones and the current way of treating people (and many of these studies have a larger enrollment and better analysis than the previous ones), it's rather amazing. EGDT...tPA...beta-blockers in STEMI...hypothermia post ROSC...field hypothermia...concussion guidelines (probably)...it's just another reminder that, as we better understand the body, and better understand what the treatments actually do, medicine will change.

I still think that the take home message from all this is that early recognition, aggressive treatment individualized to the patient, and actually treating the pathology behind the illness and symptoms will be what makes a difference.

I can't take credit for this quote, but it sums it up rather nicely. Simply switch EGDT with another protocol, and sepsis with another problem.

I think most of us looking back on the Rivers' study recognized that EGDT was a concept desperately needed at the time, and got everyone thinking about being more vigilant about bird-dogging sepsis and also much more aggressive in resuscitation. Those were the real "take-away" messages when the dust all settled following the study IMHO - the "big change" that occurred in the collective consciousness of people treating sepsis. And this is the biggest reason why I think Rivers got significant differences THEN and you simply won't see significant difference between EGDT and "usual care" now. Everyone "gets it" - the idea, the concept - so it doesn't surprise me at all.

[Just Plain Ruff]

I am all in favor of evidenced based medicine (EBM), the problem I have is in the true research of what is legit and what is not. There are several articles citing where bogus pay-offs to endorse EBM. Of course large fines have been set but ... the millions of dollars and opening of potential law suits because physicians follow set guidelines only to later find out they were falsified.

I have worked professionally in research and development, I have seen and understand the importance of rigid standards and ethics... and I also have seen the opposite to be published and some set as standards without questions.

Here is a link to an interesting article.

http://gaia-health.com/gaia-blog/2011-12-09/evidence-based-medicine-is-a-fraud-heres-why/

R/r 911

Try building the evidence based medicine requirements into an EMR system. Many times the EMR system that you are using does not support the functionality that the EBM is requiring. Often we have to do workarounds and build the system to do what we want it to rather than the system being designed to follow the EBM.

[BushyFromOz]

We had lecture about this few weeks ago and when asked if the RIvers study had made a significant difference to the Management of sepsis patients in our states largest hospital the answer came back that despite the Rivers being interesting time the survival rate in this hospital was already slightly lower than the Rivers EGDT group. The doc then followed his up with something like "we didn't know a lot about sepsis then, what we did now is that the patient was hypovolaemic, so we filled them up and used pressors if that didn't work."

gotta run, bbl...

[Levi]

The process trial just showed that strict endpoint targets are not important, but recognizing sepsis, giving abx early, giving IV fluids and pressors etc. are what matters. Also you have to realize that the people in the 'placebo' arm of that trial are aware of EGDT and were probably still resuscitating to similar end points.

As to people complaining about getting antibiotics in early, well there is research to support that (8% increase mortality for every hour), but even without research it makes logical sense that it matters. So if your hospital has a policy of getting those antibiotics in early, I'm all for that. If you have trouble doing that because you have sicker patients to attend to, then of course you triage your resources but something should be fixed so that doesn't happen.