Chad M. Cannon, MD, FACEP
Department of Emergency Medicine, University of Kansas Hospital
Kansas City, Kansas
It was George Washington Carver who said "excellence is performing common things in uncommon places." What was known to be best practice for stroke, acute myocardial infarction and trauma was applied to septic emergency department patients resulting in the 2001 New England Journal of Medicine publication "Early Goal-Directed Therapy in Severe Sepsis and Septic Shock (EGDT)". After seven years and multiple replications of its results in peer reviewed medical literature, a non-peer review business article brought EGDT into question and characterized it as a "new therapy".
A quick review of the literature finds ample data demonstrating the contrary. A recent review found 11 peer-reviewed publications totaling 1569 patients, and 28 abstracts totaling 4,429 patients, demonstrating a mean absolute risk reduction of 20% which exceeds the original study. The concepts of EGDT have been recommended by expert opinion as far back as 32 years ago.[3, 4] Dr. Rivers and many others have been applying this concept to several other shock states for years prior to the EGDT study quietly and without fanfare.[5-9] Simply, instead of waiting until a patient was admitted to the intensive care unit (ICU) which may take many hours to a full day, definitive treatment was initiated in the ED.
Of available sepsis treatments, EGDT has had the greatest impact on mortality reduction in the last 20 years. Although unclear why such an abundance of data was not reported in this non-peer review business article, it is a serious warning nevertheless to those who may interface with the media and rely on it as an information source. Additionally, it is perfect timing for the meta-analysis by Alan Jones et al followed by this summary and commentary by Dr. Tiffany Osborn. In Emergency Medicine, our practice is based on best evidence and peer-review. In the case of EGDT, the evidence is clear and the peer review unquestionable.
Early Goal Directed Therapy for Sepsis: Show Me the Data!
Meta-analysis of randomized sepsis trials showed mortality benefit with early goal-directed, therapy.
About the Author:
Dr. Cannon practices emergency medicine, and is the assistant medical director of the emergency department at the University of Kansas Hospital in Kansas City, Kansas. He is the vice president of the Kansas Chapter of ACEP. Dr. Cannon resides in Overland Park, Kansas.