PURPOSE: Early goal-directed therapy (EGDT) decreases mortality in patients with septic shock. Concern exists over allocating these resources to those with advanced age, limiting chronic illnesses, and high risk of death. We aimed to study the relationship between patient characteristics in those treated with EGDT and survival.
METHODS: Patients were treated with EGDT after placement of a Presept catheter (Edwards Lifescience, Irvine, Ca.) using pre-printed order sets. Baseline characteristics: age, organ dysfunction (AOD), severity-of-illness (APACHEII), comorbidities and resource consumption: duration of vasopressors (pres-d) in hours and mechanical ventilation (vent-d) in days, and length-of-stay in the intensive care unit (ICU-LOS) and hospital (hosp-LOS) in days were compared retrospectively between survivors (S) and non-survivors (NS).
RESULTS: 98 patients were included, S=54, NS=44. 29/44 (66%) NS were withdrawn. NS were older (74+13v. 68+17yrs., p=0.03), had more AOD (4.8+1.9 v. 3.6+1.8, p<0.001), and higher APACHEII scores (24+8 v. 21+7, p=0.01). However, age, AOD, and APACHEII score were poorly predictive of death by ROC analysis (AUC=0.61, 0.69, and 0.64 respectively). Proportions of patients with heart, lung, and kidney disease, and diabetes were similar among groups. NS tended to have shorter vent-d (4.5+9.2, 2.9+3.3, p=0.2) and overall hosp-LOS (11.8+13, 7.7+7, p=0.05). There was no difference between patients who were withdrawn versus those who died and were not.
CONCLUSION: Available patient characteristics at presentation are unhelpful in deciding who will benefit from EGDT. Thus, standard candidacy criteria should apply irrespective of age and comorbidities. NS tended to use fewer resources than S likely resulting from timely withdrawal of care in a large number of patients.
CLINICAL IMPLICATIONS: The notion that EGDT in patients at high risk of death based on age or comorbid disease is wasteful is unfounded. Because best outcomes in septic shock occur when patients are identified and resuscitated early, EGDT should be applied to all patients when code status cannot be immediately determined. Patients not responding after 24 hours of treatment had a 2/3 chance of being withdrawn and, in the end, consume fewer resources.
DISCLOSURE: Nathan Lidsky, None.