Part I of Dr. Rivers' talk on Severe Sepsis
Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.
I broke the ~1 hour lecture into 3 parts. In Part I, Dr. Rivers discusses:
- Prehospital Antibiotics
- Comparison between the original EGDT Study and the Jones study (showing the non-inferiority of the non-invasive approach).
- Alactemic Septic Shock
Find Part II and Part III for more fun
Here is a pdf of Dr. Rivers' Slides
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Scott Weingart
An ED Intensivist from NY. No conflicts of interest (coi).
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Any chance we can get an audio-only version. Thanks.
it is now up
Hi Scott,
Any reason Rivers’s talk on sepsis is not downloadable as an “mp3” ?
Its in a mpeg4 movie format.
Regards and Salams
Big thank you to Dr Rivers and yourself Scott for this podcast. It is excellent
with the aeromedical retrieval work we do in RFDS we use prehospital antibiotics a lot as transport times are long. So it’s not unheard of. But Dr Rivers raises a salient point that doing so can cause harm if inappropriately given.
Absolutely
The EGDT trial always seems to be misrepresented. What is often ignored is that the control gr0up got very good care, and innovations to improve sepsis care are often about improving existing levels of care given to that given in the control group. The Australian experience in studies related to the ARISE trial showed that existing outcomes showed a mortality of under 25%, i.e. what was achieved by the EGDT protocol, despite the EGDT protocol not being used. The issue down here is how can EGDT improve on existing care? I’ve asked at many conferences, but no-one has been able to explain why the intervention group got more fluids than was given to the control group despite the treatment goals in the control group aiming for the same CVP and BP. The next step of EGDT to target HtCT and ScvO2 was only required in 15%. What directed increased fluids in the other 85% – was it based on ScvO2, or if not why didn’t the CVP and BP targets result in similar fluid volumes being given?
Brendon,
The biggest difference between the two groups was one that was barely mentioned in the study publication: the EGDT arm had a specially trained resident come in from home and only deal with the one patient. This is probably why the EGDT arm got the fluids and aggressive therapies in the proper amount at the proper time. I have always considered the original paper to be proof of the value of ED crit care with dedicated staff more than anything else.
Thanks for the audio.
great post there.
Thanks to you for your great work Scott.
Keep the great work up.
Regards
HI Scott
One point confused me a bit – inappropriate vs appropriate antibiotics – it seemed like a bad thing to give the wrong ABs – increased mortality etc.
What is the definition for inappropriate antibiotics? Is it based on the empirical choice? Or have I misunderstood?
Casey
In the context of these studies, appropriate refers to antibiotics that the eventually discovered bacteria was susceptible to and inappropriate refers to antibiotics that did not cover the bug. This is why sepsis antibiotic regimens have become broad enough to cover EVERY POSSIBLE bug, rather than adding on later.
Thanks for the wonderful talk and the free downloads. I have posted a blog post (http://emergencymedic.blogspot.com/2011/09/sever-sepsis-talk-by-emmanuel-rivers.html) featuring Part 1 of this talk and a link back to EMCrit, encouraging my readers to subscribe to your RSS feeds.
[…] If you haven’t already, check out Part I. […]
[…] you haven’t already, check out Part I and Part […]
[…] you haven’t already, check out Part I and Part […]
Hi, this was a great lecture. I had some reserve tough about antibiotics in prehospital care. How would we be able to step down antibiotics when we don’t have a positive culture? Will it increase antibiotic resistance which is already a big problem? For what benefice?
Jeff
It would have to be in community acquired infections only, that would be an easy screen. And with the new lit just published a few months ago in crit care med, it probably should only be in hypotensive patients. In this group there could be a fairly impressive mortality drop if abx were given 1 hr earlier.
Hi Scott, Jeff and other listeners / readers.
I am a Paramedic Intern with Wellington Free Ambulance. Our current Clinical Patrice Guidelines have a Pre-hospital septic shock protocol for the patient population Scott mentions above. See p60 – 61 of http://www.ambo.com.au/download/wfa_guidelines_2011.pdf
Great lecture series, and Podcast Scott and contributors, Im a big fan of your work!
Regards,
Mike
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