The Journal of Emergency Medicine, Vol. 54, No. 2, pp.
244–248, 2018
Letters
to the Editor
, EARLY GOAL-DIRECTED
THERAPY IS STANDARD
THERAPY FOR SEPTIC SHOCK
, To the Editor:
I read with much interest the American Academy of
Emergency Medicine Clinical Practice paper by Winters
et al. on the care of patients with septic shock (1). The au-
thors should be congratulated on the efforts to clarify this
important topic, and although I agree with much of their
conclusions, I would like to comment. The title is slightly
misleading because it states patients with “septic shock,”
but the abstract and manuscript discuss patients with both
“severe sepsis and septic shock,” thus potentially
confusing the reader because these are different entities
with distinct treatment approaches. Septic shock by defi-
nition includes hypotension resistant to intravenous (IV)
fluid challenge, thereby requiring vasopressor infusion
(2). Central venous catheters (CVCs) are indicated for
administration of all vasopressors (but not all vasoactive
medications, such as the inotropes dobutamine and milri-
none) because of concerns over tissue necrosis if any
extravasation occurs, and interruption of the infusion if
any problems occur with the peripheral IV. Using a
reasonably reliable antecubital peripheral IV for the
initial resuscitation of a patient with septic shock is
acceptable, but it is still standard of care that a CVC
would be placed if vasopressor infusion is ongoing for
more than a few hours (3,4). Direct arterial blood
pressure monitoring is recommended “as soon as
practical to place” for all critically ill patients requiring
vasoactive therapy (2). If it is clearly still recommended,
for patients with septic shock, to place a CVC and arterial
line early, whether in the emergency department or inten-
sive care unit, I do not think the authors’ comments on
“need for invasive procedures” or “forgoing the need
for placement of invasive catheters” are supported.
When Dr. River’s article was published in 2001, the
recommendation for measuring and trending a central
venous pressure was one of the only methods in common
practice for attempting to determine intravascular volume
status. Central venous pressure certainly has shortcom-
244
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ings for estimating volume status and has been largely
replaced by other methods, such as bedside focused
point-of-care ultrasound and the passive leg raise test,
but there is still some merit in measurement of central
venous blood saturation in addition to lactate. Central
venous blood saturation rapidly changes in response to
oxygen supply and utilization while lactate may be
initially normal and only slowly rise with circulatory
shock (5). The central point that has been missed is,
“What is the standard of care for septic shock currently
compared to so-called early goal-directed therapy
(EGDT)?” I would suggest that the reason that there
was not a significant difference in mortality between
the EGDT group and the so-called “usual care” group
in the 3 studies quoteddProCESS, ARISE, and
ProMISedis that there has been such penetrance of the
basic tenets of EGDT that there was not much actual dif-
ference between the care delivered to patients in the 2
groups studied. There was a large difference in mortality
in Dr. River’s original study, with a 16% absolute reduc-
tion in the EGDT group. More than a decade later, when
these 3 studies were conducted, the mortality of septic
shock is lower because of the acceptance of the basic te-
nets of the identification of septic shock as well as early
aggressive resuscitation with targeted goals, and these
were simply lacking previously. The “usual care” for sep-
tic shock in the 1990s was certainly very different than it
is now, and it only slowly became so after Dr. River’s
2001 publication; it had previously consisted of the
following: 1) give IV fluids and call the intensive care
unit, 2) give more IV fluids, and 3) only start a vaso-
pressor when the blood pressure continues to fall. There-
fore, I am in total agreement with the authors’ statement
that the decline in mortality of septic shock and severe
sepsis found in the 3 studies can be attributed to the
acceptance of the basic approach put forth by Dr. Rivers.
We would also like to encourage the American
Academy of Emergency Medicine going forward to
include emergency physicians who are fellowship
trained in and practicing critical care medicine in the
review of clinical practice statements involving emer-
gency medicine (EM)–critical care medicine topics,
just as the review of practice statements of pediatric–
The Journal of Emergency Medicine
EM topics include emergency physicians with pediatric
training and clinical expertise.
Joseph Shiber, MD, FAAEM, FACP, FCCM
Department of Emergency Medicine
University of Florida College of Medicine – Jacksonville
Jacksonville, Florida
http://dx.doi.org/10.1016/j.jemermed.2017.04.040
REFERENCES
1. Winters ME, Sherwin R, Vilke GM, Wardi G. Does early
goal-directed therapy decrease mortality compared with
standard care in patients with septic shock? J Emerg Med 2017;52:
379–84.
2. Rhodes MB, Evans LE, Alhazzani W, et al. Surviving sepsis
campaign: international guidelines for management of sepsis and
septic shock: 2016. Crit Care Med 2017;45:486–552.
3. Ricard JD, Salomon L, Boyer A, et al. Central or peripheral catheters
for initial venous access of ICU patients: a randomized controlled
trial. Crit Care Med 2013;41:2108–15.
4. Brewer JM, Puskarich MA, Jones AE. Can vasopressors safely be
administered through peripheral intravenous catheters compared
with cenral venous catheters? Ann Emerg Med 2015;66:629–31.
5. Ducrocq N, Kimmoun A, Levy B. Lactate or ScvO2 as an endpoint
in resuscitation of shock states? Minerva Anestesiol 2013;79:
1049–58.
, REPLY
, To the Editor:
We thank Dr. Shiber for his thoughtful comments
regarding our paper, “Does early goal-directed therapy
decrease mortality compared with standard care in pa-
tients with septic shock?” He raises several important
points regarding the paper and the resuscitation of
patients with septic shock that warrant clarification.
Dr. Shiber correctly highlights the differences between
the title, abstract, and manuscript with respect to the use
of the terms septic shock and severe sepsis. We agree that
these terms describe different sets of patients along the
continuum of sepsis severity, and acknowledge that
including the term severe sepsis in the abstract and manu-
script may be confusing to the reader. Though the original
early goal-directed therapy (EGDT) trial included
patients with both severe sepsis and septic shock, more
recent randomized trials included in our analysis (e.g.,
ProCESS, ARISE, and ProMISe) compared EGDT to
usual care in patients with septic shock (1–4). Because
these large trials constitute the majority of current
evidence comparing EGDT to usual care, we focused
the paper on the patient with septic shock. We
appreciate the opportunity to clarify this for the reader.
As Dr. Shiber notes, septic shock is defined by
persistent hypotension that is resistant to intravenous
fluid resuscitation and, therefore, requires vasopressor
245
administration. Recent evidence shows that vasopressor
medications can be safely administered for short durations
through an appropriate peripheral intravenous catheter
placed proximal to the antecubital or popliteal fossa (5).
We concur with Dr. Shiber that a central venous catheter
should be placed when clinically feasible for the prolonged
administration of vasopressor medications in the manage-
ment of critically ill patients. In addition, we also agree
that an intra-arterial line be placed when clinically feasible
in patients receiving vasoactive therapy. Notwithstanding,
Dr. Shiber makes reference to comments within the paper
on the “need for invasive procedures” and “forgoing the
placement of invasive catheters.” It is important to note
that these comments are not recommendations of our
paper. Rather, these comments pertain to literature that
described the variability in sepsis management, along
with commonly cited concerns with implementation of
the specific EDGT protocol by Rivers et al. (6).
In our conclusion, we write: “the current literature
does not support the mandatory use of central hemody-
namic monitoring in the routine management of emer-
gency department patients with severe sepsis or septic
shock.” We appreciate the opportunity to clarify that
this statement specifically references the use of central
venous pressure (CVP) as a method to monitor volume
responsiveness, and central venous oxygen saturation
(ScvO2) as a method to monitor oxygen delivery. There
are numerous factors that impact the reliability of CVP
measurements, including valvular disease, dysrhythmias,
increased intrathoracic pressure, pericardial disease, right
ventricular dysfunction, and even the reference level of
the pressure transducer (7). In fact, current guidelines
for the management of sepsis and septic shock no longer
recommend CVP alone to guide fluid resuscitation (8).
Rather, these guidelines suggest the use of dynamic vari-
ables to predict fluid responsiveness (i.e., respirophasic
changes in the inferior vena cava diameter, passive leg
raise, and pulse pressure variation) (8). The use of
ScvO2 as a method to monitor resuscitation remains
debatable. While we do acknowledge that there may be
a select group of patients with septic shock who have a
normal serum lactate and a low ScvO2, the incidence of
this scenario is reportedly low (7,9). In addition, a
recent study by Lee et al. showed that ScvO2 provided
additional information only in patients in whom lactate
failed to normalize after resuscitation (10). The decision
to use ScvO2 in addition to serum lactate trends should be
based on the individual patient. Current evidence does not
support its use as a component of usual care for all emer-
gency department patients with septic shock (2–4,11,12).
Finally, we would like to reiterate Dr. Shiber’s points
comparing usual care at the time of the original EGDT
trial with current usual care in ProCESS, ARISE, and
ProMISe. Undoubtedly, “usual care” has dramatically