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In the Treatment of
Severe Sepsis and Septic Shock
E Rivers et al
NEJM 2001;345:1368-1377
REVIEWED BY D
BIMA
PURWAAMIDJAJA,DR
SIRS -- self limited
- severe sepsis & shoc
k septik.
-Random
-Pasien-2 di ruang emergensi dengan severe
sepsis, shock sepsis/ sindrom sepsis
-Maret 1997 – 2000
-Informed consent
Kriteria Inklusi :
-Memenuhi 2 dari 4 kriteria SIRS
-Sistolik < 90 mmHg ( setelah kristaloid 20 – 30
cc/ kgBB > 30 menit )
- Laktat darah 4 mmol.
Kriteria eksklusi :
- Umur < 18 th
- Hamil
- Gangguan pembuluh darah serebral akut, sindro
m koroner akut, edema paru akut, status asmatiku
s, disritmia, terdapat kontraindikasi CVC, perdara
han GI, kejang, overdosis obat, luka bakar, trauma,
membutuhkan operasi segera, kanker, immunosupr
esi ok transplantasi organ atau penyakit sistemik,
Status dnr.
SIRS criteria & systolic
Blood pressure < 90 mmHg
Or lactate >4 mmol/liter
Assessment
&
Consent
ScvO2 > 70 %
Hospital
admission
Cardiac index
Did not complete 6 hr Did not complete 6 hr
( n=14 ) Follow up ( n=13 ) VO2
Supplement O2
Endotracheal intubation,
Mechanical ventilation
Sedation, Paralysis
( if intubated ), or Both
< 8 mmHg
Crystalloid
CVP
Colloid
8 – 12 mmHg
< 65 mmHg
Inotropic agents
70 %
No
Goal achieved
Yes
Hospital admission
Rivers, E. et al. N Engl J Med 2001;345:1368-1377
• Kristaloid 500 cc bolustiap 30 mnt ---> CVP 8 - 12
mmHg
• Student t-test
• Chi-square test
• p < 0,04 ---> significance
HASIL
Data Karakteristik
• 288 ps : 8,7 % -- > eksklusi
• 263 random : standard terapi & EGDT
• Ps standard terapi tinggal lebih pendek di r
emergensi drpd EGDT ---> 6,3 + 3,2 : 8,0 + 2,1 ( p
< 0,001 )
• Data lain tidak ada perbedaan bermakna (
penggunaan antibiotik, tanda vital, resusitasi, organ
disfunction score & test koagulasi )
Vital Signs & Resuscitation End Points
Periode awal 6 jam setelah terapi
• Tidak ada perbedaan bermakna : HR rata-2 & CVP
• MAP Standard terapi < EGDT ---> p < 0,001
• SCVO2 > 70 % -- > ST : EGDT = 60,2 % : 94,9 %
(p<0,001)
• Base defisit ST > EGDT ( p=0,006 )
• Laktat ( p=0,62 ), pH ( p=0,26 )
Periode jam 7 - 72 setelah start terapi
AIM :
EVALUATE THE EFFICACY OF EGDT
PT SEV SEPSIS AND SEPTIC SHOCK
PRIOR TO INTENSIVE CARE UNIT ADMISSION
METHODS
ELIGIBILITY
THE CRITERIA INCLUSION WERE FULFILLMENT OF TWO
OR FOUR CRITERIA FOR SIRS, AND
A SYSTOLIC BLOOD PRESSURE < 90
BLOOD LACTATE CONC>/= 4 MMOL/L
TREATMENT
PT RANDOMIZED : STANDAR TH - EGDT
RESULTS
1. THERE WERE NO SIG DIFF IN BASELINE
CHARACTERISTICS BETWEEN THE TWO GROUPS
CONCLUSION :
WHEN EARLY GOAL DIRECTED THERAPY IS APPLIED
IN THE EMERGENCY ROOM
SURVIVAL PT SEPSIS IMPROVED
COMMENTARY
RECOMMENDATION