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EMCrit 134 – ARISE has arisen; now where do we stand on Severe Sepsis in 2014

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SMACC-Final-Sepsis1

So the Arise Study (Australasian Resuscitation In Sepsis Evaluation) just dropped. The amazing guys at the Bottom Line did a summary (saving me a bunch of work)

Baseline Characteristics

baseline characteristics

Table S5-Therapies in the first 6 hours and 3 days

table-S5

Videos from a Prime Author

Hear from Sandra Peake

Recognition-Find em' Early

SIRS+

Lactate or Persistent Hypotension (Arise used 1 liter)

I would use STOP Sepsis Campaign Modification of SIRS Critieria, so you don't need to wait for cbc

SNAG-0016

Treatment-Treat the Source/Perfuse the Tissues

sepsis priorities

Antibiotics

Another trial showing early abx are associated with goodness

If a patient is sick and you don't know what is going on, just give them appropriate spectrum abx. If a patient is persistently hypotensive and you don't know why–give them abx.

A very cute antibiotic summary

Source Control

Early, early, early

Don't box 'em with the tube

See the Hemodynamic Kills Lecture

The Right Amount of Fluid

Use whatever method you want, but you should probably give between 3-4 liters

Early Vasopressors

Give them peripherally to get them in fast and then you should probably put in a line

If you have given 3-4 liters, the patient probably deserves pressors for venous squeeze before giving more fluid

Check Your Work

Serial lactates?

Put them in a Monitored Setting

b/c of the way septic patients die

Other Stuff

Blood

No role for blood, except in niche cases, until Hb < 7 from the recent TRISS Trial (PMID 25270275)

Fewer pts got blood in EGDT group of either ProCESS or ARISE than the original EGDT study

Dobutamine

who the hell knows

Want to Hear from the Primary Investigator?

Oli Flower did a podcast in which Anthony Delaney addresses many comments from this post. Here's Oli:

Thanks Scott for your insights on ARISE and the state of play of sepsis management in 2014.

These open discussions that your podcast stimulates are incredibly important and essential for translating research findings into practice, and getting the important messages and critical interpretation of the data to as many people as possible!

Yesterday I interviewed the ARISE PI Anthony Delaney to hear his take, now he’s allowed to finally talk about the results, and I went through a lot of your listener’s comments to get an answer from the horse’s mouth.

The interview is here:
http://intensivecarenetwork.com/delaney-arise-study-emcrit-dogmalysis/

Cheers,
Oli

What do you think? Let me know below.

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Scott Weingart, MD FCCM
Latest posts by Scott Weingart, MD FCCM (see all)

Cite this post as:

Scott Weingart, MD FCCM. EMCrit 134 – ARISE has arisen; now where do we stand on Severe Sepsis in 2014. EMCrit Blog. Published on October 3, 2014. Accessed on January 17th 2025. Available at [https://emcrit.org/emcrit/arise-trial-sepsis-2014/ ].

Financial Disclosures:

The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.

CME Review

Original Release: October 3, 2014
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027

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Chris Nickson
Chris Nickson
10 years ago

Hi Scott Great commentary and summary of cutting-edge sepsis care. It looks like everyone in the world has moved towards a more fluid restrictive strategy since 2001 for severe sepsis/ septic shock. Obviously. we think this is good. However, regarding the ‘the right amount of fluid’: I’m not sure that it holds that we ‘should probably give between 3-4 liters’. These studies (ProCESS and ARISE) show that 3-4 L is what we are giving, but we don’t know if it would be better to give even less fluids (e.g. 2L) before starting vasopressors – for reasons you suggest at the… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago

You blokes could have done it with this one. They already received 2.5 liters before randomization. I’m surprised from that point on, they were not kept bone dry. Fully expected big differences in the amounts of time 0 fluid admin. Guess you folks are just like us.

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Chris Nickson
Chris Nickson
10 years ago
Reply to  Scott Weingart, MD FCCM

The solution is clearly to have a John Myburgh in every resus room 🙂
C

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Chris Nickson

though remember after my SMACC sepsis talk, I pitched him a nice slow pitch and said in any septic pt, by the time we reach 3 or 4 liters, they should be on a vasopressor and asked him what he thought. He disagreed entirely and said some patients will need a bunch more fluid.

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Chris Nickson
Chris Nickson
10 years ago
Reply to  Scott Weingart, MD FCCM

Sure – it needs to be tailored to the patient.
If the patient has had severe diarrhoea and no oral intake as part of the sepsis prodrome, he/she may need more fluid than another patient who isn’t so fluid deplete.
I suspect Prof Myburgh is reluctant to make a blanket statement because he knows that good care is tailored to the individual needs of the patient.
Figuring out who needs what is perhaps more art than science.
Having said that, I suspect at 2-3 L of fluid we may be starting to split hairs…
C

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Chris Nickson

not sure that follows. not saying give 3 liters and then stop giving fluids and go to pressors in all patients. Saying if you gave 3-4 liters, put on low dose pressor before giving more. Ostensibly even in that diarrhea patient with severe sepsis, after 4 liters, going on low dose vasopressors would give you a more accurate picture of how much additional fluid they need from that point.

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Steven Moore
Steven Moore
10 years ago

Another well intentioned study that was done 10 years to late to truly compare EGDT to so called “usual care”. Process and arise needed done before EGDT had permeated the thinking, textbooks, and hospital implemented resuscitation bundles. To pretend that the seminal paper that is the most cited in medicine in the last decade did not effect usual care is to lie to yourself. These studies change nothing in my mind expect to reinforce how much farther we need to go in lowering septic shock mortality. I do not think de-escalation of therapy and a trend towards doing less is… Read more »

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Chris Nickson
Chris Nickson
10 years ago
Reply to  Steven Moore

Hi Steven EDGT has never been followed in ANZ, and we do not not use the SSC guidelines for that reason The point is not that usual care does not involves goals, just that the exact goals (and monitoring devices) suggested by EGDT do not appear to confer a benefit – so why not use the least costly, easiest to perform approach that gets the best outcomes? ARISE validates the non-use of Rivers-style EGDT in ANZ – however the presumed importance of early antibiotics, source control, close observation and considered use of fluids and vasopressors are just as important in… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Chris Nickson

Must go with Chris with this one. If you want an objective, goal based strategy then use the hybrid protocol from ProCESS–objective, but still less invasive with same (if not better) outcomes.

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The Bottom Line (@WICSBottomLine)
The Bottom Line (@WICSBottomLine)
10 years ago

Scott Fantastic commentary and podcast. Thank you so much for including TBL Wondering what the thoughts are on the baseline ScvO2 in the patients in the Rivers’ paper compared with the more recent studies. Rivers astonishingly low at 50% and ProCESS much higher (can’t remember exact). I couldn’t find the baseline data from the supplementary appendix in ARISE although am sure they will have it. Within 1 hour it was >70%. In the context of sepsis, I’ve never seen ScvO2 as low as River’s patients unless there was associated significant myocardial depression. APACHE scores were the same in Rivers &… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  The Bottom Line (@WICSBottomLine)

At my old shop we would get ScvO2s that low on occasion; almost always in people that would not come to the hospital until near dead. Phenomenon in catchment areas with illegal immigrants. Having visited Dr. River’s shop, his patient population is some of the sickest folks I’ve seen. Not sure there is generalizability with regular populations just as you say

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Kapil Dev Soni
Kapil Dev Soni
10 years ago

Kapil Dev Soni,Asstt.Prof.Critical Care,AIIMS(New Delhi) Hi Scott,Great talk as usual.love listening to you and your thundering voice.However,i still not convinced about the take home message of 3 to 4 liters within 6 hour empirically in septic shock.It’s early days that we are just beginning to understand fluids more closely than ever before.The type of fluids,rate of administration and the amount perhaps have major bearing than the total amount alone.Yes,we do need to fill up the patients but how much and what rate still remains enigma.Do we need boluses within span of few minutes?not sure.We need to time our fluid therapy… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Kapil Dev Soni

fantastic point! to be clear, if the pt has already been in-house receiving therapies and becomes septic, we can’t extrapolate anything about empiric fluids from ProCESS or ARISE.

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Niklas Jonsson
Niklas Jonsson
10 years ago

Hi Scott, thanks for a great summary. In the context of dobutamine’s place; what do you think about the phenomenon septic cardiomyopathy? In my experience it only unmasks itself properly after you restored the SVR with vasopressors. With that in mind it is important to repeat the focused echo. A combination of MAPSE, TAPSE and eyeballing is what I do. Where I work we tend to use levosimendan or milrinone to treat in this setting. What we don’t know is if we are affecting outcome at all. Would love to hear your and your listeners opinion on this. Best regards,… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Niklas Jonsson

agree, you need to correct the vasodilation and then you see it. I use dobutamine or epi in these cases.

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Jens Michelsen
Jens Michelsen
10 years ago
Reply to  Scott Weingart, MD FCCM

Hi Scott and Niklas Thanks for a very nice podcast as always. I think that you have a good point, Niklas. The septic cardiomyopathy is there from the start. The ejection fraction of a hypovolemic heart with no afterload is fantastic, but it is only when hypovolemia is corrected and afterload is increased with norepi or epi that you can see that the heart is not pumping properly. That’s why I’m a bit concerned with using epinephrine instead of dobutamine or milrinone since it drastically increases afterload. The problem with dobutamine and milrinone on the other hand is that it… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Jens Michelsen

mind you this is all anecdotal… the way the STC cticu used epi was purely as an inotrope (the way us yanks use that word, not the Aussies). Doses of 0.01 to 0.08 mcg/kg (quite low doses). I did not see a sig. increase in afterload or lactate at these low doses. It would be great if someone studied this.

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Luciano Pilla
Luciano Pilla
10 years ago

Hello, guys! Great discussion! The great question for me is how to guide our fluid administration after the first six hours of resus. We can give some liters of fluids in the first six hours ,that is fine, no problem. But what to do after that, when we know that less (fluid) is more? How much is less? How much is too much? Beyond SVV and Delta PP, that can be applied to a very restrict subset of patients, what can we use to guide the amount of fluids we are going to offer after the first 6 hours? Just… Read more »

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David Bedford-Lee
David Bedford-Lee
10 years ago

A no stage has there been any mention about the temperature of the patient (warm or cold sepsis) and the temperature of the fluid administered. Most hospitals use fluid that is room temperature, approx 22 degrees Celsius. In the pre-hospital environment the temperature of the fluid administered is generally the same as the ambient temperature of the ambulance. This can range from one degree Celsius to 30 degrees Celsius in various parts of southern Australia. What is the physiological effect of this on a patient that has an elevated set point temperature of 40 degrees Celsius, know that it takes… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  David Bedford-Lee

great ?s. I have no idea.

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Eric Einstein
Eric Einstein
10 years ago

Ok, so I am a henry ford resident who works under Dr. Rivers. So know I may be biased. However, one big issue I have with this paper (and process) is that they have a skewed definition of septic shock. The early goal directed therapy study defines septic shock as refractory hypotension after 30 cc/kg fluid bolus, while process and ARISE chose 1 L. For many patients this is even less than 20 cc/kg!!! Thus, I believe to discount EGDT is unacceptable as these patients are NOT AS SICK as the ones deemed in septic shock in Rivers’ trial. We’re… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Eric Einstein

process started at 30 cc/kg and dropped later to 20 cc. Pure hypotensive patients without lactate elevations are a much less sick group in general and are not the crux of EGDT. Arise had a surprisingly high number of patients with surprisingly high lactates. These are the patient’s Manny has always stated get the most benefit from EGDT.

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Eric Einstein
Eric Einstein
10 years ago
Reply to  Scott Weingart, MD FCCM

Understood. Will this paper change your practice? For example – you’ve got a toxic patient with some sort of sepsis. They are not hypotensive but their lactate comes back at 10. At this point they don’t need pressors. Are you now going to forego a central line?

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Eric Einstein

Eric, not sure what you mean. Central line has nothing to do with it; CVP, ScvO2 and lots of blood transfusions are what ARISE and ProCESS dispensed with.

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Craig Rosebrock
Craig Rosebrock
10 years ago

Scott and Eric are getting into something that I think is very important. First off, We seem to forget something sometimes in medicine …. something are pediatric friends have not forgotten. Wt and size of the patient. I have not delved into the Rivers study since I was a fellow several years ago and have not had the time yet to look through the new data from our aussie brothers. Second….variable variable variables…. the medical literature gurus worst nightmare…lol I tend to think that using 1 liter or 4 liters in a few hours is sooooooo dependent on too many… Read more »

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David Bedford-Lee
David Bedford-Lee
10 years ago
Reply to  Craig Rosebrock

I agree Graig, “It is what it is”, BUT can we do better ? What studies have been done on temperature regulation in both warm and cold sepsis and if so what temperature are they regulating to ? Should we be looking at the temperature of the fluid that we are giving ? The inflammatory response and release of mediators in both SIRS and CARS must be a big player in sepsis. Rather than just fluid and pressors should we be looking at “controlling” the effects of these inflammatory mediators or maybe they are too difficult to identify and/or control… Read more »

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Craig Rosebrock
Craig Rosebrock
10 years ago
Reply to  David Bedford-Lee

David, “The inflammatory response and release of mediators in both SIRS and CARS must be a big player in sepsis. ” When I was a fellow and UNC Chapel Hill, I spent a good part of my fellowship looking at burn inhalation injury in the burn ICU. I spent an enormous amount of my nights reading the literature about inhalation injury and why these patients develops a SIRS type (similar to septic shock) response to their injury a few days if not hours after the lung was subjected to a large amount of hot gas coupled with the waste products… Read more »

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Oliver Flower
Oliver Flower
10 years ago

Thanks Scott for your insights on ARISE and the state of play of sepsis management in 2014.

These open discussions that your podcast stimulates are incredibly important and essential for translating research findings into practice, and getting the important messages and critical interpretation of the data to as many people as possible!

Yesterday I interviewed the ARISE PI Anthony Delaney to hear his take, now he’s allowed to finally talk about the results, and I went through a lot of your listener’s comments to get an answer from the horse’s mouth.

The interview is here:
http://intensivecarenetwork.com/delaney-arise-study-emcrit-dogmalysis/

Cheers,
Oli

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Francesco Savelli
Francesco Savelli
10 years ago

Looking at the survival rate of the control group of River’s study compared to the more recent trials, it’s evident how the surviving sepsis campaign have changed our attitude towards this pathophysiological condition, as outlined by Steven Moore. Higher attention for the diagnosis, early antibiotics and cultural specimens, source control, attempt to haemodynamic stabilization as early as possible, have become part of our way of thinking and nobody can put in discussion the usefulness of these measures. So honor to Rivers who has positively changed our behavior. But if I have to learn a lesson from these recent trials, it… Read more »

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FRANCESCO SAVELLI
FRANCESCO SAVELLI
10 years ago

I’ve realized not to have correctly interpreted the article, since a CVC has been inserted early also in the majority of the control group (the 62% of the controls vs the 90% of the EGDT, only 220 patients haven’t been managed with a CVC) and, looking at the supplementary appendix, along the six hours of treatment the value of CVP reported was quite similar between the two groups. Despite the ScvO2 hasn’t been used to guide therapy, it’s hard not to think that all the other elements of the EGDT have not played an important influence also on the management… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  FRANCESCO SAVELLI

yep!

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Greg Press, MD, RDMS, FACEP, FACEM
Greg Press, MD, RDMS, FACEP, FACEM
10 years ago

ARISE demonstrates the most effective way to decrease mortality in sepsis trials (and it’s not EGDT): Don’t enroll dying patients. Sure, first we should focus on the conclusion that EGDT is unnecessary. But next we should turn our attention to the impressively low mortality rate, 15%. It’s been suggested this is due to ANZ providing the best sepsis care in the world: http://medicalxpress.com/news/2014-10-sepsis-survival-aussies-kiwis.html As an EP who has practiced in NZ and the US, I can tell you it would be silly to think ANZ care is more aggressive, more timely, the antibiotics stronger, the fluid wetter, the pressors stronger,… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Greg Press, MD, RDMS, FACEP, FACEM

could not agree more!

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Adam Drenzla
Adam Drenzla
10 years ago

Many thanks again Scott for more excellent listening. Some points for discussion I also posted on ICN: So routine ScVO2 monitoring is not beneficial – but what conclusions can be drawn for it’s use at the coalface? The unexplained (?unexplainable) large discrepancy in initial ScVO2 values between current trials ( 70-75%) and the Rivers trial (<50%) makes it difficult to exclude a beneficial effect of EGDT in low ScVO2 patients (however small that group may currently be). Though in Oz we don’t use ScVO2 catheters, intermittent blood gas sampling is not uncommon and neither is change in therapeutic trajectory if… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Adam Drenzla

Adam in regards to your first set of statements: see the recent wee. I would almost buy it if EGDT actually did anything with the ScvO2 numbers. But it doesn’t unless you believe in transfusing 7-10 g/dl range of Hbs.

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Francesco Savelli
Francesco Savelli
10 years ago

Have a look to this review article of the great heretic of the EGDT, Paul Marik, who since the beginning has always criticized protocols based on CVP, pointing the importance of direct measurement of cardiac output. At the end of all, also ScvO2 it’s only an indirect way to have an idea of the adequacy of DO2 and so of CO.

Early management of severe sepsis: concepts and controversies.
Chest. 2014 Jun;145(6):1407-18. doi: 10.1378/chest.13-2104.

Here is a link where it’s possible to download free the article:
http://www.uvm.edu/medicine/mededucation/weeklywire/2014/documents/ED_marik.pdf

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Lawrence Lynn
Lawrence Lynn
10 years ago

Excellent talk Scott. I always look forward to them. It may be time to bring and end to these simplistic static threshold defined trials. This is a beautiful trial but it (and all large sepsis trials) are based on 1980s threshold science which is fatally oversimplified. Pathogens have extended phenotypes as defined by the host so sepsis actually comprises a hybrid phenotype of host state and response and the pathogen’s extended phenotype. Think about the complexity of the cases you see. The patient with emphysema, dynamic hyperinflation and pneumoccocal bacteremia. The 18 year old with beta strep toxic shock. The… Read more »

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Craig Rosebrock
Craig Rosebrock
10 years ago
Reply to  Lawrence Lynn

WOW somebody that thinks like I do…never knew…

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lawrencelynn
lawrencelynn
10 years ago
Reply to  Craig Rosebrock

Of course there are many who think like this but they have not had a voice except in obscure journals. Note that non of the trails ever say, “One of the limitations of this trial is that we used guessed thresholds as gold standards and static cutoffs of single parameters to define treatment”. Why is that? My goodness doctors, static cutoffs levels do not even work to define something as straightforward as insulin treatment of blood sugar in severe infection. The statistics are also embellishments of profound oversimplifications. We call these “p values of fragments in space and time” as… Read more »

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Richard Gordon
Richard Gordon
10 years ago

First I want to say thanks you for all you do here, The information you post here is nothing short of fantastic and has open my mind as a Paramedic to how and what to do to improve the outcomes of my severely ill pt’s. Thank You! I practice in Orange County, Florida and in the pre-hospital determination “Sepsis Alert” and along with your Modified SIRS Criteria we also use ETCO2 monitoring. It is quick, inexpensive and easy to use. I feel that we have had good success in helping to identify sepsis Pt’s using ETCO2 monitoring in conjunction with… Read more »

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Adam
Adam
10 years ago

Scott,
Do you have a reference for the “STOP Sepsis Campaign Modification of SIRS Critieria?” I am trying to implement better screening at my shop for sepsis and would like some backing for these criteria for the admin people. Thanks!

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Matthew Mitchell
Matthew Mitchell
10 years ago

As an EM-CCM fellow who previously worked in the community EDs, I think it is important to make a clarification on all of these studies. I know Dr. Rivers very well and I have the utmost respect for him and what he has done for Sepsis Mortality in the past several years. No one is more dedicated to the field of sepsis research than him. However, I feel that the focus of his landmark paper continues to be CVP and ScVO2, and we sometimes fail to evaluate the entire picture. Prior to EGDT, septic patients would sit in the ED… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Matthew Mitchell

agree with all of that!

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Kyle, Gunnerson, MD, EM/IM/Critical Care
Kyle, Gunnerson, MD, EM/IM/Critical Care
10 years ago
Reply to  Matthew Mitchell

Very well written Matthew. After reading these recent trials and being part of the EGDT team at Ford in the 90’s with Manny, I have come to the conclusion that if I have severe sepsis or septic shock, take me to one of these centers that were in the trial. They received excellent training prior to enrolling and were pretty darn good to begin with. If the 90 day mortality doesn’t go much above 20% in any of their patients, I think that is more of a reflection of how good their teams are. Some of the early criticism EGDT… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Kyle, Gunnerson, MD, EM/IM/Critical Care

Kyle. If you were asked to consult at one of these community hospitals and they wanted you to write a protocol to avoid issues with vairable care, would it look like ProCESS hybrid or would you alter that in some way?
s

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Kyle, Gunnerson, MD, EM/IM/Critical Care
Kyle, Gunnerson, MD, EM/IM/Critical Care
10 years ago
Reply to  Scott Weingart, MD FCCM

Good question Scott. Of course that’s the million dollar question. We know not everyone needs the full EGDT protocol, but how do we know who does without checking DO2/VO2 inadequacy. It would have been nice if everyone received central lines and ScvO2 were recorded, but blinded to the control groups. In the non-EGDT arms, I think almost 60% still received central lines. So I’d agree that the hybrid would be a good start, however, if a central line was placed, check an ScvO2, if it was still low after 2-3 liters of fluid, there is nothing that supports an overt… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Kyle, Gunnerson, MD, EM/IM/Critical Care

Agree with all of that, brother. But let’s really acid test this bad boy. You see an ScvO2 of 60% after 3 liters on your intubated pt. The Hb is 9–are you still going to give blood? Then you throw on the probe–heart is slamming and CI is great–are you giving dobutamine? If the answer to both of these is no, what has canonical EGDT brought to the table. If the ? is does ScvO2 still have a role, my answer is definitely yes. EGDT unfortunately no longer gives me the solution to oxygen debt problems though. I think we… Read more »

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Kyle Gunnerson
Kyle Gunnerson
10 years ago
Reply to  Scott Weingart, MD FCCM

Well….not that easy Scott. This will be a hybrid response (after reading Lawrence’s post right after this). Not a fan of speaking in hyotheticals. Not sure your acid test really is that. But for the sake of argument, I’ll rebut that if you would have checked serial ScvO2 and noticed it dropped from 60% to 45% then I’m going to do something, starting with a good head-to-toe reassessment and going through the whole exercise again. Point being is that a single measurement isn’t as helpful as a trend. I know you believe this too, just restating it. I think you’re… Read more »

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Scott Weingart, MD FCCM
Author
Scott Weingart, MD FCCM
10 years ago
Reply to  Kyle Gunnerson

Think we are on the same page. I would much rather someone with the knowledge and experience to individualize patient care have access to ScvO2 values than someone who is going to follow the canonical EGDT protocol.

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Lawrence Lynn
Lawrence Lynn
10 years ago
Reply to  Scott Weingart, MD FCCM

This says it all Scott. I know from our talks that you get this but I will summarize for the blog spot. Understanding SVO2 is complex. When 21st century sepsis trialists talk, it is about the trials not pathophysiology. They discuss nuances of their failed trials as if we can really draw any meaning from such speculation. They do not speculate about whether the guessed thresholds or failure to provide sufficient flexibility and therapy options in their simple” if X then Y” protocol to engage the nascent changes in actual pathophysiology might be the problem. The recent review of sepsis… Read more »

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Lawrence Lynn
Lawrence Lynn
10 years ago
Reply to  Kyle Gunnerson

This article predicted the failure of PROcess and ARISE. It also shows while the fall in mortality in septic shock may be artifactual as a function of loading the denominator up with less sick through the progressive increase in use of broad simple static guessed sepsis and septic shock threshold definitions which were made gold standards without a drop of science by a few well meaning thought leaders. We predicted failure and showed why it was inevitable. Don’t miss the article that shows why pontificating on and on about utterly simplistic threshold based protocols and trials of sepsis is an… Read more »

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lawrencelynn
lawrencelynn
10 years ago
Reply to  Kyle, Gunnerson, MD, EM/IM/Critical Care

Excellent points but remember Rivers EGDT was simply a hybrid of the failed SupraNormal values protocols of the 1980s which used the PA catheter to determine VO2 and pushed large volumes of fluid, PRBC, and Dobutamine to increase DO2 to supranormal values. Academics focused on treating the unique individual phenotypes of sepsis and who lived through the supranormal value era have long awaited the demise of EGDT which we considered an oversimplified “made for clinical trial” protocol. A hybrid of a hybrid will fail as well. There is no substitute for learning the pathophysiology and treating each case as it… Read more »

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We are the EMCrit Project, a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM.

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