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EARLY GOAL DIRECTED THERAPHY

(EGDT)

Definition
usually referring to the specific resuscitation of severely septic patients, or patients in septic shock, immediately at presentation to the hospital.

Components
1. 2. 3. 4.

Early recognition Early and adequate antibiotic therapy Source control Early hemodynamic resuscitation and continued support
Corticosteroids Tight glycemic control Surgical treatment Proper ventilator management with low tidal volume in patients with acute respiratory distress syndrome (ARDS)

Respiratory support: Supplemental oxygen with early intubation and mechanical ventilation
Circulatory support/ FLUID RESUSCITATION:
initial crystalloid fluid challenge of 20-30 mL/kg (1-2 L) over 30-60 minutes 1 L over 30 minutes central venous pressure (CVP) goal between 8 and 12 mmHg Urine output (UOP) 30-50 mL/h Administration of colloid

Antimicrobial therapy: broad spectrum, covering gram-positive, gram-negative, and anaerobic bacteria. Metabolic support: hyperglycemia and electrolyte abnormalities (hypokalemia, hypomagnesemia, and hypophosphatemia)

Correction of anemia and coagulopathy: Hemoglobin as low as 8 g/dL, thrombocytopenia and coagulopathy Nutritional support: high protein and energy requirements, the enteral route is preferred, glutamine administration

Principles OF EGDT

The first step: crystalloid fluid administration to CVP by initial administering 500-mL boluses (8 and 12 mm Hg) The second step: vasopressors administration to attain a mean arterial pressure (MAP) greater than 65 mm Hg. The third step: evaluation the central venous oxygen saturation (ScvO2), which is measured from the central venous line in the superior vena cava (65-70%). Dobutamine: 10.3 mcg/kg/min

Vasopressor Therapy: if the patient does not respond to several liters of volume infusion with isotonic crystalloid solution (usually 4 L or more) or evidence of volume overload.
Persistent hypotension: SBP < 90 mmHg, or MAP < 65 mmHg.

Norepinephrine: 5-20 mcg/min (0.2-1.5 g/kg/min - 3.3 g/kg/min) Dopamine: 5-10 g/kg/min IV - 20 g/kg/min. Epinephrine Phenylephrine Vasopressin (antidiuretic hormone (ADH))

Inotropic

Therapy and Augmented Oxygen Delivery Dobutamine: recommended if ScvO2 < 70 mm Hg after CVP, MAP, and hematocrit goals have been met.

Surgical Treatment: infected foci, soft-tissue abscess, superficial abscess, deep abscess or suspected necrotizing fasciitis.

Management of Acute Respiratory Distress Syndrome A major complication of sepsis and septic shock. Primarily supportive
General supportive management : antibiotics Appropriate fluid management Hemodynamic monitoring.

Long-Term Monitoring

Admission to the hospital. Patients respond to EGDT in the ED and show no evidence of end-organ hypoperfusion : a general hospital unit. Patients do not respond to initial ED treatment: ICU / advanced life support monitoring to another hospital

GOAL of EGDT
Decreases these components of care:
1. 2. 3. 4. 5. 6. Mortality by 16-20% Components of inflammatory response Morbidity of organ dysfunction Need for vasopressor therapy Need for mechanical ventilation Sudden cardiopulmonary complications in the first 24 hours 7. Length of hospital stay 8. Health care resource consumption

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