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Correspondence |

Toward a Noninvasive Approach to Early Goal-Directed Therapy FREE TO VIEW

Daniele Coen, MD; Angelica Vaccaro, MD; Michela Cazzaniga, MD; Francesca Cortellaro, MD; Gianpaola Monti, MD, PhD; Valeria Tombini, MD
Author and Funding Information

From the Emergency Department, Ospedale Niguarda Ca’Granda.

Correspondence to: Daniele Coen, MD, Ospedale Niguarda Ca’Granda, P Osp Maggiore, Milano, MI 20162, Italy; e-mail: daniele.coen@ospedaleniguarda.it


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(3):726-727. doi:10.1378/chest.10-2632
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To the Editor:

Although early goal-directed therapy (EGDT) has been a landmark in guiding the approach to patients with sepsis in the ED, few institutions seem willing and able to adopt it for all eligible patients.1 The complexity and invasiveness of the protocol are the most frequently cited barriers. In particular, it has been underlined that many clinicians would not feel comfortable with inserting a central venous catheter (CVC) as a guide to treatment when, for various reasons, they believe that their patients could be treated adequately with a noninvasive approach.

In his counterpoint editorial in a recent issue of CHEST (September 2010), Schmidt2 maintained that the development of alternative goal-directed therapy/resuscitation protocols that are simpler and noninvasive may facilitate implementation. At our institution, we experienced difficulties similar to those described by Mikkelsen et al3 since, even after extensive educational interventions in the year 2007, <50% of eligible patients were treated in accordance to the EGDT protocol, in most cases because a CVC was not placed in the patient in the ED. These patients received an inadequate amount of fluids within the first 6 h, probably because when central venous pressure was not measured, only clinical signs were used as a guide to fluid replacement. We are now enrolling patients to a noninvasive protocol that uses inferior vena cava collapsibility >30% and the absence of B lines at lung ultrasound as a guide for fluid challenge.4 CVC placement is reserved for patients who need noradrenaline infusion. A lactate clearance >10% rather than adequate central venous oxygenation values is used as a sign of improving tissue perfusion.5 To date, we have enrolled 27 patients with sepsis whose eligibility was defined as a serum lactate level of ≥4 mmol/L (seven patients) or systolic BP <90 mm Hg after volume resuscitation (20 patients). Average fluid infusion was 4,120 ±1,473 mL. A CVC needed to be inserted for the administration of vasoactive drugs in only 44% of cases. Mortality was 44.4% in patients with hypotension and 14.3% in normotensive patients with high lactate levels. Both values are comparable with those published by Rivers6 in his original study. In conclusion, we believe that given the increasing diffusion of clinical ultrasound in the ED, a noninvasive approach such as the one we are using could prove helpful in overcoming many difficulties inherent in the classic EGDT protocol and could favor its well-deserved diffusion.

Carlbom DJ, Rubenfeld GD. Barriers to implementing protocol-based sepsis resuscitation in the emergency department—results of a national survey. Crit Care Med. 2007;3511:2525-2532. [CrossRef] [PubMed]
 
Schmidt GA. Counterpoint: adherence to early goal-directed therapy: does it really matter? No. Both risks and benefits require further study. Chest. 2010;1383:480-483. [CrossRef] [PubMed]
 
Mikkelsen ME, Gaieski DF, Goyal M, et al. Factors associated with nonadherence to early goal-directed therapy in the ED. Chest. 2010;1383:551-558. [CrossRef] [PubMed]
 
Charron C, Caille V, Jardin F, Vieillard-Baron A. Echocardiographic measurement of fluid responsiveness. Curr Opin Crit Care. 2006;123:249-254. [CrossRef] [PubMed]
 
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Emergency Medicine Shock Research Network (EMShockNet) Investigators Emergency Medicine Shock Research Network (EMShockNet) Investigators Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;3038:739-746. [CrossRef] [PubMed]
 
Rivers EP. Point: adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest. 2010;1383:476-480. [CrossRef] [PubMed]
 

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References

Carlbom DJ, Rubenfeld GD. Barriers to implementing protocol-based sepsis resuscitation in the emergency department—results of a national survey. Crit Care Med. 2007;3511:2525-2532. [CrossRef] [PubMed]
 
Schmidt GA. Counterpoint: adherence to early goal-directed therapy: does it really matter? No. Both risks and benefits require further study. Chest. 2010;1383:480-483. [CrossRef] [PubMed]
 
Mikkelsen ME, Gaieski DF, Goyal M, et al. Factors associated with nonadherence to early goal-directed therapy in the ED. Chest. 2010;1383:551-558. [CrossRef] [PubMed]
 
Charron C, Caille V, Jardin F, Vieillard-Baron A. Echocardiographic measurement of fluid responsiveness. Curr Opin Crit Care. 2006;123:249-254. [CrossRef] [PubMed]
 
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Emergency Medicine Shock Research Network (EMShockNet) Investigators Emergency Medicine Shock Research Network (EMShockNet) Investigators Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;3038:739-746. [CrossRef] [PubMed]
 
Rivers EP. Point: adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest. 2010;1383:476-480. [CrossRef] [PubMed]
 
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