early goal directed theraphy2

8/13/2019 Early Goal Directed Theraphy2

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EARLY GOAL DIRECTEDTHERAPHY

(EGDT)


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Definition

usually referring to the specificresuscitation of severely septic

patients, or patients in septic shock,

immediately at presentation to thehospital.


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Components

1. Early recognition2. Early and adequate antibiotic therapy

3. Source control

4. Early hemodynamic resuscitation and

continued support

Corticosteroids

Tight glycemic control

Surgical treatmentProper ventilator management with low tidal

volume in patients with acute respiratory distresssyndrome (ARDS)


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Respiratory support: Supplementaloxygen 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 over30 minutescentral venous pressure

(CVP) goal between 8 and 12 mmHg Urine output (UOP) 30-50 mL/h

Administration of colloid


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Antimicrobial therapy: broadspectrum, covering gram-positive,

gram-negative, and anaerobic

bacteria. Metabolic support: hyperglycemia

and electrolyte abnormalities

(hypokalemia, hypomagnesemia, andhypophosphatemia)


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Correction of anemia andcoagulopathy: Hemoglobin as low as

8 g/dL, thrombocytopenia and

coagulopathy Nutritional support: high protein and

energy requirements, the enteral route

is preferred, glutamine administration


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Principles OF EGDT

The first step: crystalloid fluid administration toCVP by initial administering 500-mL boluses (8

and 12 mm Hg)

The second step: vasopressors administration to

attain a mean arterial pressure (MAP) greater than65 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


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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 ofvolume 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))


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Inotropic Therapy andAugmented Oxygen Delivery

Dobutamine: recommended if

ScvO2< 70 mm Hg after CVP,

MAP, and hematocrit goals have

been met.


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Surgical Treatment: infected foci,soft-tissue abscess, superficial

abscess, deep abscess or suspected

necrotizing fasciitis.


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Management of Acute RespiratoryDistress Syndrome

A major complication of sepsis and septic

shock. Primarily supportive

General supportive management : antibiotics

Appropriate fluid management Hemodynamic monitoring.


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Long-Term Monitoring

Admission to the hospital.

Patientsrespond to EGDT in the ED

and show no evidence of end-organ

hypoperfusion : a general hospital unit.

Patientsdo notrespond to initial ED

treatment: ICU / advanced life support

monitoring to another hospital


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GOAL of EGDT

Decreases these components of care:1. Mortality by 16-20%

2. Components of inflammatory response

3. Morbidity of organ dysfunction4. Need for vasopressor therapy

5. Need for mechanical ventilation

6. Sudden cardiopulmonary complications in the

first 24 hours7. Length of hospital stay

8. Health care resource consumption


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Thank you for your kind attention

early goal directed theraphy2

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