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It seems to me that EGDT still provides the framework for an easily implemented protocol in institutions that have greater than average sepsis mortality. Since we still are not clear on which part of “intuitive care” is truly bending the curve for these patients, is there harm in using it as a guideline? Correct me if I am wrong but it seems the average treatment for septic patients varies little (i.e. the 170 ml difference you cite between “liberal” and “judicious” fluid administration) in the studied groups with similar outcomes and in your ARISE podcast you state that it may have been EGDT that brought the standard of care to this point. Are there significant differences that I am missing that could result in adverse outcomes?

Dr Rivers is one of my all time heroes for many reasons. For me as an emergency physician he made me realize that I needed to be good a critical care, be scientific in my approach to sick patients and care about sepsis. Without his genius we would not be able to have this debate. All these studies stand on his shoulders. If I could give this guy hug, and buy him a pint I would! But things have moved on, as they do in medicine, which is one of the most exciting and also frustrating parts of EM! What is it that EGDT therapy adds to the sicker patients? CVP? Really? Surely not? Then transfusion? TRICC in the 1999 looked at this and now there is more evidence on transfusion thresholds in septic patients. So we are left with ScvO2 as a surrogate marker for cardiac output, but now most EM docs can echo, and use other non invasive measures of cardiac output. So I don’t see what the benefit is in terms of measuring pathophysiology, patient survival, patient safety, cost, and time at the bedside. If you want to reduce the mortality of septic patients why not apply… Read more »

I see this whole thing as a bit of an artificial argument. First of all, most of us who aren’t literalists or have some financial stake in the game never bought into the precise details of EGDT in the first place. To paraphrase what Pinsky said at SCCM a few years ago, ‘the purpose of EDGT was to give non-intensivists a framework for taking care of septic patients in the middle of the night’. Do I give blood? Sometimes, not often. SvO2? Usually not. Central line? Usually. Etc. Just as most of us never believed that it was imperative to keep blood glucose between 80-120 or give every single patient in the OR a dose of beta blocker, I always viewed EGDT as a model for resuscitation, not an absolute. I also liked your comment that EGDT has never been shown to be an inferior way to practice, so if sepsis isn’t your thing, maybe the EGDT algorithm holds some value. The real genius of Manny Rivers, I think, was to refocus sepsis from being an ICU disease to being more of an ED condition. Standard of care right now is essentially de facto EGDT, sans some of the details.… Read more »