Open Access Emergency Medicine
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O r i g i n a l Re s ea r c h
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Success of applying early goal-directed therapy for septic shock patients in the emergency department This article was published in the following Dove Press journal: Open Access Emergency Medicine 14 January 2016 Number of times this article has been viewed
Panita Worapratya 1 Apisit Wanjaroenchaisuk 2 Jutharat Joraluck 3 Prasit Wuthisuthimethawee 1 Department of Emergency Medicine, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Songkhla, 2Emergency Department, Samitivej Thonburi Hospital, Bangkok, 3 Emergency Department, Hatyai Hospital, Hatyai, Songkhla, Thailand 1
Background: Since early goal-directed therapy (EGDT) became standard care in severe sepsis and septic shock patients in intensive care units many years ago, we suppose that the survival rate of severe sepsis and septic shock patients improves if the resuscitative procedure is quickly implemented and is initiated in the emergency room. Objective: We aimed at recording emergency department time to improve our patient care system as well as determine the rate at which EGDT goals can be achieved. The second analysis is to find out how much we can improve the survival rate. Methods: This was a prospective observational study in an emergency room setting at a tertiary care facility where EGDT was applied for resuscitation of severe sepsis and septic shock patients. The data recorded were the initial vital signs, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, SAP II (Simplified Acute Physiology II) score, SOFA (Sequential Organ Failure Assessment) score, time at which EGDT goals were achieved (central venous oxygen saturation [Scvo2] .70%), initial and final diagnosis, and outcome of treatment. The t-test and Mann–Whitney U-test were used to compare between the achieved goal and nonachieved goal groups. Results: There were 63 cases of severe sepsis in the study period. Only 55 patients submitted a signed consent form and had central line insertion. Twenty-eight (50.9%) cases were male. Thirty-nine (70.9%) patients achieved the goal, and the mean SAP II score was 8. There were no statistically significant differences between the two groups (P-value =0.097). Thirty of the 39 patients (70.9%) survived in the achieved goal group, which was a statistically significant improvement of the survival rate when compared with only one of 16 patients (6.3%) surviving in the nonachieved goal group (P,0.001). Keywords: sepsis, septic shock, early goal-directed therapy, emergency room
Background
Correspondence: Panita Worapratya Department of Emergency Medicine, Songklanagarind Hospital, Prince of Songkla University, 15 Karnjanavanich Road, Hat Yai, Songkhla 90110, Thailand Tel +66 74 45 1705 Fax +66 74 45 1704 Email [email protected]
The original article by Rivers et al1 published in 2001 showed the huge benefit of a lower mortality rate in severe sepsis and septic shock patients from 46.5% to 30.5%. Early goal-directed therapy (EGDT) is a sepsis cardiovascular support protocol aimed at early hemodynamic optimization, which became standard treatment for severe sepsis and septic shock patients according to the Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock in 2004.2 The original research was conducted in a critical care unit; however, the principles are to bring blood circulation back to normal as soon as possible. In practice, septic shock patients present commonly in the emergency room. Therefore, the implementation of EGDT in the emergency room is essential. Recent studies show that the implementation of EGDT in the emergency room can be achieved and that it has benefits.3,4 1
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Open Access Emergency Medicine 2016:8 1–6
Dovepress
© 2016 Worapratya et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php
http://dx.doi.org/10.2147/OAEM.S86129
Dovepress
Worapratya et al
Songklanagarind Hospital is a tertiary care and referral center in southern Thailand. There are more than 42,000 cases each year. in the emergency room. EGDT was implemented in the emergency room of Songklanagarind Hospital in 2010. This study was conducted to determine the success rate of applying EGDT in the emergency room. The primary outcome is to achieve the EGDT goals, which are defined as central venous pressure (CVP) $8 mmHg, mean arterial pressure (MAP) $65 mmHg, and central venous oxygen saturation (Scvo2) $70%. The secondary outcome is to determine to what extent the survival rates can improve.
laboratory tests, initial and final diagnoses, severity scores (Sequential Organ Failure Assessment [SOFA], Simplified Acute Physiology II [SAP II], and Acute Physiology and Chronic Health Evaluation [APACHE II]), time to reach the goals (CVP $8 mmHg, MAP $65 mmHg, and Scvo2 $70%), and the results of treatment (death or improved). Only the cases of those patients or authorized representatives who signed a written consent form and had complete medical research charts were enrolled into the study. All others were excluded. As soon as the patient was diagnosed as having septic shock, the severe sepsis and septic shock campaign guideline of 2008 (Figure 1)5 was followed and parameters were recorded. Volume resuscitation, central venous catheter insertion (subclavian vein or internal jugular vein), and isotonic crystalloid were used to achieve a CVP of 8–12 mmHg. Vasopressors were added if necessary to reach the target MAP of 65 mmHg. Packed red blood cells and/or dobutamine were given when needed to reach the target Scvo2 of $70%. The times to reach the goals were also recorded. After the time to reach the goals was recorded, the patients were divided into two groups: achieved goal group and nonachieved goal group. The achieved goal
Methods This was a prospective observational study held in the emergency department between April 1 and September 30, 2013. The study was approved by the research quality and safety control committee of Prince of Songkla University. Only newly diagnosed septic shock patients who were of age $18 years, received EGDT, and submitted signed written consent forms were enrolled. The recorded data included the chief compliant, initial vital signs, past medical history,
SBP
Dovepress open access to scientific and medical research
O r i g i n a l Re s ea r c h
Open Access Full Text Article
Success of applying early goal-directed therapy for septic shock patients in the emergency department This article was published in the following Dove Press journal: Open Access Emergency Medicine 14 January 2016 Number of times this article has been viewed
Panita Worapratya 1 Apisit Wanjaroenchaisuk 2 Jutharat Joraluck 3 Prasit Wuthisuthimethawee 1 Department of Emergency Medicine, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Songkhla, 2Emergency Department, Samitivej Thonburi Hospital, Bangkok, 3 Emergency Department, Hatyai Hospital, Hatyai, Songkhla, Thailand 1
Background: Since early goal-directed therapy (EGDT) became standard care in severe sepsis and septic shock patients in intensive care units many years ago, we suppose that the survival rate of severe sepsis and septic shock patients improves if the resuscitative procedure is quickly implemented and is initiated in the emergency room. Objective: We aimed at recording emergency department time to improve our patient care system as well as determine the rate at which EGDT goals can be achieved. The second analysis is to find out how much we can improve the survival rate. Methods: This was a prospective observational study in an emergency room setting at a tertiary care facility where EGDT was applied for resuscitation of severe sepsis and septic shock patients. The data recorded were the initial vital signs, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, SAP II (Simplified Acute Physiology II) score, SOFA (Sequential Organ Failure Assessment) score, time at which EGDT goals were achieved (central venous oxygen saturation [Scvo2] .70%), initial and final diagnosis, and outcome of treatment. The t-test and Mann–Whitney U-test were used to compare between the achieved goal and nonachieved goal groups. Results: There were 63 cases of severe sepsis in the study period. Only 55 patients submitted a signed consent form and had central line insertion. Twenty-eight (50.9%) cases were male. Thirty-nine (70.9%) patients achieved the goal, and the mean SAP II score was 8. There were no statistically significant differences between the two groups (P-value =0.097). Thirty of the 39 patients (70.9%) survived in the achieved goal group, which was a statistically significant improvement of the survival rate when compared with only one of 16 patients (6.3%) surviving in the nonachieved goal group (P,0.001). Keywords: sepsis, septic shock, early goal-directed therapy, emergency room
Background
Correspondence: Panita Worapratya Department of Emergency Medicine, Songklanagarind Hospital, Prince of Songkla University, 15 Karnjanavanich Road, Hat Yai, Songkhla 90110, Thailand Tel +66 74 45 1705 Fax +66 74 45 1704 Email [email protected]
The original article by Rivers et al1 published in 2001 showed the huge benefit of a lower mortality rate in severe sepsis and septic shock patients from 46.5% to 30.5%. Early goal-directed therapy (EGDT) is a sepsis cardiovascular support protocol aimed at early hemodynamic optimization, which became standard treatment for severe sepsis and septic shock patients according to the Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock in 2004.2 The original research was conducted in a critical care unit; however, the principles are to bring blood circulation back to normal as soon as possible. In practice, septic shock patients present commonly in the emergency room. Therefore, the implementation of EGDT in the emergency room is essential. Recent studies show that the implementation of EGDT in the emergency room can be achieved and that it has benefits.3,4 1
submit your manuscript | www.dovepress.com
Open Access Emergency Medicine 2016:8 1–6
Dovepress
© 2016 Worapratya et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php
http://dx.doi.org/10.2147/OAEM.S86129
Dovepress
Worapratya et al
Songklanagarind Hospital is a tertiary care and referral center in southern Thailand. There are more than 42,000 cases each year. in the emergency room. EGDT was implemented in the emergency room of Songklanagarind Hospital in 2010. This study was conducted to determine the success rate of applying EGDT in the emergency room. The primary outcome is to achieve the EGDT goals, which are defined as central venous pressure (CVP) $8 mmHg, mean arterial pressure (MAP) $65 mmHg, and central venous oxygen saturation (Scvo2) $70%. The secondary outcome is to determine to what extent the survival rates can improve.
laboratory tests, initial and final diagnoses, severity scores (Sequential Organ Failure Assessment [SOFA], Simplified Acute Physiology II [SAP II], and Acute Physiology and Chronic Health Evaluation [APACHE II]), time to reach the goals (CVP $8 mmHg, MAP $65 mmHg, and Scvo2 $70%), and the results of treatment (death or improved). Only the cases of those patients or authorized representatives who signed a written consent form and had complete medical research charts were enrolled into the study. All others were excluded. As soon as the patient was diagnosed as having septic shock, the severe sepsis and septic shock campaign guideline of 2008 (Figure 1)5 was followed and parameters were recorded. Volume resuscitation, central venous catheter insertion (subclavian vein or internal jugular vein), and isotonic crystalloid were used to achieve a CVP of 8–12 mmHg. Vasopressors were added if necessary to reach the target MAP of 65 mmHg. Packed red blood cells and/or dobutamine were given when needed to reach the target Scvo2 of $70%. The times to reach the goals were also recorded. After the time to reach the goals was recorded, the patients were divided into two groups: achieved goal group and nonachieved goal group. The achieved goal
Methods This was a prospective observational study held in the emergency department between April 1 and September 30, 2013. The study was approved by the research quality and safety control committee of Prince of Songkla University. Only newly diagnosed septic shock patients who were of age $18 years, received EGDT, and submitted signed written consent forms were enrolled. The recorded data included the chief compliant, initial vital signs, past medical history,
SBP
