Therapeutic goal achievements during severe sepsis and septic shock resuscitation and their association with patients' outcomes

Chairat Permpikul, Phirawat Sringam, Surat Tongyoo
Journal of the Medical Association of Thailand 2014, 97 Suppl 3: S176-83

BACKGROUND: Severe sepsis and septic shock are associated with high mortality. "Early goal-directed therapy" (EGDT) has been shown to improve survival. The authors report here the goal achievements in the protocol and their association with patients' outcomes.

MATERIAL AND METHOD: A prospective cohort study of patients with severe sepsis and septic shock who were admitted from the Emergency Department from April 2011 to September 2012. All underwent the resuscitation protocol aimed to achieve hemodynamic goals within 6 hours after diagnosis. These goals included: 1) mean arterial > 65 mmHg, 2) urine output > 0.5 ml/kg/hour and 3) superior vena cava O2 saturation > 70% or serum lactate clearance > 10%. The primary outcome was 28-day mortality

RESULTS: Of the 175 enrolled patients, 23 (13.1%) achieved all 3 goals at 6 hour while 75 (42.8%) achieved 2 goals and 52 (29.8%) achieved only 1 goal. The 28-day mortality of these patients was 8.7%, 16% and 35.5%, respectively while 44% of those who did not achieve any goal died. A central venous catheter was placed in 79 patients, 46 of whom had it inserted during the first 6 hours, and 42 of whom had a CVP of 8-12 mmHg. Only 13 patients had their ScvO2 measured. Mean arterial pressure target was achieved in 129 patients, who had lower initial APACHE II score, lower initial lactate level and higher initial blood pressures than those who did not. These patients received less fluid at 6 hours, at 24 hours and at 3 days, respectively; they also received less norepinephrine. This group had lower mortality (28-day mortality 19.4% vs. 34.86%, p = 0.043). Of 119 patients who had achieved the urine output goal, 21 reached this goal alone and their survival was better than those who did not achieve any target goal. Serum lactate was monitored in 51 patients and a clearance of > 10% was noted in 23 of them. These patients were divided into 3 groups.: group 1 consisted of patients with initial lactate < 2; group 2 were patients with initial lactate > 2, which decreased during resuscitation; group 3 consisted of patients with initial lactate > 2, which increased after wards. The mortalities were 7.7%, 14.3% and 43.6%, respectively, p = 0.011.

CONCLUSION: The achievement of therapeutic targets at 6 hours after sepsis/septic shock resuscitation was associated with improved survival, especially when more goals were reached. Although the achievement of adequate tissue oxygenation was proved beneficial, only one-third of the patients were monitored.

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