Anthony Delaney examines the evidence for usefulness of goal directed therapy in the septic patient.

1. Goal-directed therapy:
where are the goal posts
Anthony Delaney MBBS MSc FACEM FCICM
Staff Specialist Malcolm Fisher Intensive Care Unit, Royal North
Shore Hospital
Senior Lecturer, Northern Clinical School, Sydney Medical School,
University of Sydney

2. A few points to consider
 What are the goals of early goal directed
therapy?
 Should all patients have the same goals?
 How do you achieve the goals?
 Does it matter if you score?

3. So……
 What is Early Goal Directed Therapy?
 O2 saturation
 Central Venous Pressure
 Mean Arterial Pressure
 ScvO2

8. Should all patients have the
same goals?

20. Sepsis is a disease of sick
people
 Patients with sepsis have comorbidity that will
need to be considered when setting resuscitation
goals
 But keep in mind….

25. How do we achieve the goals?
 SaO2 ≥ 93%

Oxygen, PEEP, mechanical ventilation
 CVP ≥ 8-12 mmHg

Fluids
 MAP 60-90 mmHg

Vasopressors

(vasodilators)
 ScvO2 ≥ 70%

Blood

Dobutamine

26. Oxygen saturation
 text

27. Oxygen saturation
 655 patients randomised to ketamine or
etomidate
 16% patients had sepsis
 2.5% had a cardiac arrest at induction

28. Central Venous Pressure
 Determinants:

Fluid status

Vascular tone

Cardiac function

Intra-thoracic and intra-abdominal pressure

30. Positive fluid balance and
elevated CVP in septic shock
 Retrospective analysis of data from VASST
 778 patients
 Analysis stratified by quartiles using cox
proportional hazards models

Age, APACHE II score, dose of noradrenaline

31. Positive fluid balance and
elevated CVP in septic shock

32. Positive fluid balance and
elevated CVP in septic shock

33.  1000 patients with acute lung injury randomised
to conservative or liberal fluid balance
 Pneumonia and sepsis most common cause
 7 day fluid balance
 -136 ml +/- 491 conservative

34.  Nosignificant difference in mortality

25.5% v 28.4%
 Increased ventilator free days

14.6 v 12.1
 Days out of ICU

13.4 v 11.2
 No difference in other organ dysfnction

35. Maintaining CVP with fluids
 Certainly the potential for mortality and
morbidity associated with excessive fluid
administration

39. Central Venous Oxygen
Saturation
 Surrogate for mixed venous oxygen saturation
(SvO2)
 Marker of global adequacy of oxygen delivery

Assuming normal microcirculation, tissue oxygen
extraction
 DO2 = [1.39 x Hb x SaO2 + dissolved O2] x
CO

40. Blood transfusion

41.  30 day mortality 18.7% v 23.3%, p=0.11

42.  Estimate of OR for
mortality OR= 1.47

95% CI 0.98-2.21

P=0.06

43. So,
 Patients with sepsis may have comorbidity that
may make achievement of physiological
resuscitation goals difficult or undesirable
 The treatments required to achieve the
physiological resuscitation goals all have
significant potential adverse effects
 Do we need to achieve the physiological goals
to obtain the mortality benefit from early goal
directed therapy?

45.  “Before and After”
 854 patients with sepsis before
 1465 patients after
 247 patients 1 year later

46.  Intervention

Institutional support

Local champion

Muliti-disciplinary team

Multi-facted education campaign based on the SSC
guidelines
 Powerpoint
 Posters
 Pocket cards

47.  I

51.  15,775 participants from 252 sites
 Complicated QI project
 Compliance
 “goal was achieved within 6 hours”
 Intervention

Sites volunteered for the project

Website with educational materials

Meetings

Email list server

Newsletter

52.  Jan 2005 to March 2008

Hospital mortality 37.0% to 30.8%

55. So………

56. Conclusion
 Be careful about choosing rigid targets for
resuscitating septic patients
 Early Goal Directed Therapy is a complex
intervention, and involves more than simply
following a resuscitation recipe
 Wait a little longer for further high quality
evidence to guide practice in this area

57. Questions??