0
Correspondence |

Response FREE TO VIEW

Gregory A. Schmidt, MD, FCCP
Author and Funding Information

From the Division of Pulmonary Diseases, Critical Care, and Occupational Medicine; Department of Internal Medicine, University of Iowa.

Correspondence to: Gregory A. Schmidt, MD, FCCP, University of Iowa, 200 Hawkins Dr, C33-GH, Iowa City, IA 52242; e-mail: gregory-a-schmidt@uiowa.edu


Financial/nonfinancial disclosures: The author has 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):727. doi:10.1378/chest.10-2863
Text Size: A A A
Published online

To the Editor:

I appreciate the added perspective of Coen and colleagues regarding my recent counterpoint editorial in CHEST (September 2010)1 of yet another group reporting difficulty adhering to an early goal-directed therapy (EGDT) protocol despite extensive efforts. Using a novel approach, these authors are studying a dynamic fluid responsiveness predictor (vena caval collapsibility on hand-carried ultrasound examination) in place of the central venous pressure (CVP). This tactic addresses a major failing in conventional EGDT: CVP simply fails to distinguish patients who will respond to fluids from those who will not. For example, in one large study of volume challenges in septic subjects, the positive predictive value of CVP <8 mm Hg for identifying those who respond was only 47%.2 The impact of this is that many patients who could respond to further fluids despite a CVP >8 will be treated with inappropriate blood transfusion or vasoactive therapy. At the same time, many patients who are fluid unresponsive, despite a CVP <8, will be driven to receive yet more ineffective fluid. These findings mirror those of many other studies published over the past 2 decades showing the physiologic unsuitability of CVP for guiding fluid resuscitation.3

In addition to using ultrasound to replace CVP, these investigators then turn the probe on the lungs in an attempt to identify those patients who already have pulmonary edema.4 A complete goal-oriented ultrasound examination (vena cava plus both lungs) can probably be completed in 3 min, certainly in less time than required for insertion and calibration of a central venous catheter.

Even these possible improvements on EGDT will not lead to superior outcomes if the whole concept of EGDT is flawed. The unusually high mortality in the control group of that study5 casts doubt on both the adequacy of control group care and the generalizability of these results to other patients. Finally, a Bayesian analysis of the original trial shows that even a mildly skeptical clinician will conclude that the EGDT trial failed to show benefit.6

For many reasons, pending the results of larger, multicenter trials, EGDT should not be considered the standard of care. Meanwhile, creative attempts to meld the commonsense approach of urgent treatment with state-of-the-art knowledge of circulatory physiology will lay the foundation for the future of sepsis resuscitation.

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]
 
Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;351:64-68. [CrossRef] [PubMed]
 
Durairaj L, Schmidt GA. Fluid therapy in resuscitated sepsis: less is more. Chest. 2008;1331:252-263. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;1341:117-125. [CrossRef] [PubMed]
 
Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group Early Goal-Directed Therapy Collaborative Group Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;34519:1368-1377. [CrossRef] [PubMed]
 
Kalil AC, Sun J. Why are clinicians not embracing the results from pivotal clinical trials in severe sepsis? A Bayesian analysis. PLoS ONE. 2008;35:e2291. [CrossRef] [PubMed]
 

Figures

Tables

References

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]
 
Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;351:64-68. [CrossRef] [PubMed]
 
Durairaj L, Schmidt GA. Fluid therapy in resuscitated sepsis: less is more. Chest. 2008;1331:252-263. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;1341:117-125. [CrossRef] [PubMed]
 
Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group Early Goal-Directed Therapy Collaborative Group Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;34519:1368-1377. [CrossRef] [PubMed]
 
Kalil AC, Sun J. Why are clinicians not embracing the results from pivotal clinical trials in severe sepsis? A Bayesian analysis. PLoS ONE. 2008;35:e2291. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543