And so the EGDT trilogy is complete. The results of the ProMISe trial was published, after we’ve recently had the results from the ARISE and ProCESS trials. They all compared EGDT (Early Goal-Directed Therapy) to “standard care”. And they were all agreeing: Standard care is as good as EGDT. But who has practices orthodox EGDT this last decade? Not anyone I’ve spoken to. And what is “standard care” – it’s mostly a tweaked version of EGDT. So as far as we’re concerned, not much new here, and the legacy of EGDT is still very much alive and kicking.
When Rivers came along with EGDT in the 2001, he revolutionised sepsis therapy. He made sepsis treatment more aggressive and sexy, and saved lots of of lives in the process. It became the gold standard of sepsis care. And few treatment regiments have had such impact on management and has lasted as long as EGDT. Today, 14 years later, it’s still very much part of our sepsis treatment. But it’s changed along the way. As new evidence emerged in other areas, EGDT therapy was tweaked and adapted to these new ways of thinking.
EGDT as strict guideline or a concept?
If you’re an orthodox EBM believer and only accept that what the original Rivers study showed is true if you stricly adhere to exactly what they did in their study – and if you’re very orthodox and strict and literal of your understanding of EGDT – then, yes, EGDT is dead for you. If you view EGDT more as a concept that has evolved, then EGDT is still very much alive and kicking.
Like the CVP goals in EGDT. Very few people believe CVP measurements in the middle ranges are meaningful anymore. Not just in sepsis, but in general ICU management. So we’ve generally stopped following the CVP>8 goal from EGDT. But what was the purpose of having a CVP>8? CVP above 8 is not meaningful in itself. It was, of course, to judge volume status. CVP>8 was merely a marker. So when we felt we had better volume status markers, we switched from CVP to other markers: PPV (Pulse Pressure Variation), PiCCO, ultrasound, leg raise tests etc. I don’t see this as scrapping EGDT, I see it as evolving it. Same with SvO2 largely being replaced by lactate as a measure of hypoperfusion.
Again, the heart of EGDT was, in my mind, early antibiotics and early, aggressive fluid therapy (to optimise circulation and oxygen delivery). Those are still at heart. And just as our understanding of CVP has changed, other things, like our general understanding of fluid therapy, has changed. As we’re giving less fluids in the OR and ICU in general, and starting pressors earlier, this has naturally also made its way into our understanding of EGDT and sepsis treatment. We still give fluids aggressivly, but we also acknowledge the importance of not overdoing it, and therefore start pressors earlier.
Much of this can also be read in the numbers from the ProMISe trial: even in “standard care” group, more than half still got a central line and an art line – so called EGDT interventions. Or, in other words: basic, good critical care management of really sick patients.
EGDT could be viewed as many of the on paper very strict standard operating procedures we have – they’re usually used as a guide. If you’re new and unfamiliar to it, you’ll often adhere strictly to it. But once you get lots of experience with that patient population and its management and procedures, you’ll start going more by clinical judgement and feel. Knowing when to adhere strictly to protocol, and when it’s better to make different calls. From that point of view, EGDT has been internalised, and is being tweaked and individualised by clinicians to suit each patient (and doctor).
In that sense, ARISE, ProCESS and ProMISe can be viewed as a trials telling us good clinical judgement and experience, based on good evidence, training and proper guidelines, lead to good outcomes.
I know there are various discussion points to ARISE, ProCESS and ProMISe on one side, and the original EGDT trial by Rivers on the other – like the severity av sepsis in these trials compared to the original Rivers study. The Rivers Study seemed to have sicker patients. So the sickest sepsis patients might benefit from more invasive management – and I think that’s what they usually get. Anyway, there’s already been written loads of good posts on these trials. I’ll point you to some of them below. In addition, unsurprisingly, the selection criteria of SIRS might not be so helpful – and so patient intervention differences seen in standard care might be based much on good old clinical judgement. More here:
The Bottom Line Reviews:
- ProMISe: Trial of Early, Goal-Directed Resuscitation for Septic Shock
- ARISE: Australasian Resuscitation In Sepsis Evaluation Randomised Controlled Trial
- ProCESS Investigators: A Randomized Trial of Protocol-Based Care forEarly Septic Shock
EMlit of Note: