Implementation of Early Goal-Directed Therapy for Severe Sepsis and Septic Shock: A Decision...
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Abstracts e IMPLEMENTATION OF EARLY GOAL-DIRECTED THERAPY FOR SEVERE SEPSIS AND SEPTIC SHOCK: A DECISION ANALYSIS. Huang DT, Clermont G, Dremsizov TT, et al. Crit Care Med 2007;35:2090 –100. This study from the University of Pittsburgh used a decision model to evaluate the clinical and economic consequences of early goal-directed therapy (EGDT) using data generated from previous human trials. The authors devised a simulation of an average United States Emergency Department (ED) and inves- tigated the potential costs and consequences of implementing EGDT in this simulated ED. There were three ways in which EGDT was simulated to begin: a) ED-based, b) mobile inten- sive care unit (ICU) team, and c) ICU-based (after ED transfer). The simulation estimated 91 annual cases of severe sepsis and septic shock with start-up costs of the implementation ranging from $12,973 (ICU based) to $26,952 (ED based), with an annual cost of $100,113 thereafter. It was estimated that EGDT reduced net hospital costs by approximately 22.9%, principally by decreasing hospital length of stay. Simulated EGDT imple- mentation was determined to have a 99.4 –99.8% probability of saving lives and reducing costs from $2749 (ICU based) to $7019 (ED based) per quality-adjusted life-year. The ICU- based treatment arm was the least expensive but also the least effective, thought secondary to a potential delay in EGDT implementation. The authors conclude that although EGDT may have significant start-up costs and not-insignificant deliv- ery costs, it is cost-saving to the hospital with decreased patient length of stay and may have favorable lifetime cost-effective- ness projections with overall decreased mortality. [Elijah Edwards, MD, Denver Health Medical Center, Denver, CO] Editor’s Comment: The findings of this study are dependent on the validity of its many assumptions needed to generate the simulation. Nonetheless, the model demonstrated potential hos- pital and societal financial gains by implementing EGDT, es- pecially in the ED setting. The ED implementation of EGDT in patients with severe sepsis and septic shock has been shown to be effective in reducing patient mortality and also may be more cost-effective for the hospital and society overall. e DOES CORONARY ANGIOPLASTY AFTER TIMELY THROMBOLYSIS IMPROVE MICROVASCULAR PER- FUSION AND LEFT VENTRICULAR FUNCTION AFTER ACUTE MYOCARDIAL INFARCTION? Agati L, Funaro S, Madonna M, et al. Am Heart J 2007;154:151–7. This study from Italy randomized 96 consecutive patients with their first ST-segment elevation myocardial infarction, presenting within 3 h of onset of symptoms, into three treat- ment groups: primary percutaneous coronary intervention (PCI), thrombolysis followed within 24 h by PCI (thromboly- sis/PCI), and thrombolysis alone. All patients initially received aspirin and subcutaneous enoxaparin. Patients in the two PCI groups received infarct-related artery stenting with abciximab administered just before the procedure, and for 12 h afterwards, as well as a 6-month course of clopidigrel and daily aspirin indefinitely. Those in the thrombolysis groups received tenect- eplase. The primary endpoint of the study was to assess the effect of early PCI after thrombolysis on the extent of residual microvascular damage, quantified with myocardial contrast echocardiography. Left ventricular function was also assessed with two-dimensional echocardiography on hospital day 2, pre-discharge, and at 3 months. The thrombolysis-only group had a significantly higher degree of microvascular damage, larger infarct size, and poorer left ventricular function, both after treatment and on follow-up, than those in the PCI and thrombolysis/PCI groups. There was not a statistically signifi- cant difference in outcomes for the primary PCI and thrombol- ysis/PCI groups. The authors conclude that PCI within 24 h of thrombolysis is superior to thrombolysis alone, and similar to primary PCI. This information may be helpful in planning treatment for patients who present to institutions where primary PCI is not available. [Emily Johnston, MD, Denver Health Medical Center, Denver, CO] Editor’s Comment: This study confirms others previously published and suggests that thrombolysis alone is less effective than thrombolysis combined with early PCI or PCI alone at reducing infarct size. The study does not address whether this disease-oriented outcome is clinically relevant. e OUTCOME IN PATIENTS WITH SUBARACHNOID HEMORRHAGE TREATED WITH ANTIEPILEPTIC DRUGS. Rosengart AJ, Dezheng H, Tolentino J, et al. J Neu- rosurg 2007;107:253– 60. This prospective, multi-center study evaluated the preva- lence of anti-epileptic drug use (AED) and the impact of AED on in-hospital complications and outcomes in patients with subarachnoid hemorrhage (SAH). The authors examined data collected on 3552 patients with SAH from 162 neurosurgical centers in 21 countries between 1991 and 1997. AEDs were used in 65.1% of patients with SAH, with phenytoin being the most frequently prescribed drug 52.8% of the time. Using conditional logistic regression, the authors found AED treat- ment varied dramatically according to study country (interclass The Journal of Emergency Medicine, Vol. 34, No. 1, pp. 111–115, 2008 Copyright © 2008 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/08 $–see front matter 111
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Transcript of Implementation of Early Goal-Directed Therapy for Severe Sepsis and Septic Shock: A Decision...
Abstracts
e IMPLEMENTATION OF EARLY GOAL-DIRECTEDTHERAPY FOR SEVERE SEPSIS AND SEPTICSHOCK: A DECISION ANALYSIS. Huang DT, ClermontG, Dremsizov TT, et al. Crit Care Med 2007;35:2090–100.
This study from the University of Pittsburgh used a decisionmodel to evaluate the clinical and economic consequences ofearly goal-directed therapy (EGDT) using data generated fromprevious human trials. The authors devised a simulation of anaverage United States Emergency Department (ED) and inves-tigated the potential costs and consequences of implementingEGDT in this simulated ED. There were three ways in whichEGDT was simulated to begin: a) ED-based, b) mobile inten-sive care unit (ICU) team, and c) ICU-based (after ED transfer).The simulation estimated 91 annual cases of severe sepsis andseptic shock with start-up costs of the implementation rangingfrom $12,973 (ICU based) to $26,952 (ED based), with anannual cost of $100,113 thereafter. It was estimated that EGDTreduced net hospital costs by approximately 22.9%, principallyby decreasing hospital length of stay. Simulated EGDT imple-mentation was determined to have a 99.4–99.8% probability ofsaving lives and reducing costs from $2749 (ICU based) to$7019 (ED based) per quality-adjusted life-year. The ICU-based treatment arm was the least expensive but also the leasteffective, thought secondary to a potential delay in EGDTimplementation. The authors conclude that although EGDTmay have significant start-up costs and not-insignificant deliv-ery costs, it is cost-saving to the hospital with decreased patientlength of stay and may have favorable lifetime cost-effective-ness projections with overall decreased mortality.
[Elijah Edwards, MD,
Denver Health Medical Center, Denver, CO]
Editor’s Comment: The findings of this study are dependenton the validity of its many assumptions needed to generate thesimulation. Nonetheless, the model demonstrated potential hos-pital and societal financial gains by implementing EGDT, es-pecially in the ED setting. The ED implementation of EGDT inpatients with severe sepsis and septic shock has been shown tobe effective in reducing patient mortality and also may be morecost-effective for the hospital and society overall.
e DOES CORONARY ANGIOPLASTY AFTER TIMELYTHROMBOLYSIS IMPROVE MICROVASCULAR PER-FUSION AND LEFT VENTRICULAR FUNCTION AFTERACUTE MYOCARDIAL INFARCTION? Agati L, Funaro S,Madonna M, et al. Am Heart J 2007;154:151–7.
This study from Italy randomized 96 consecutive patientswith their first ST-segment elevation myocardial infarction,
presenting within 3 h of onset of symptoms, into three treat-ment groups: primary percutaneous coronary intervention(PCI), thrombolysis followed within 24 h by PCI (thromboly-sis/PCI), and thrombolysis alone. All patients initially receivedaspirin and subcutaneous enoxaparin. Patients in the two PCIgroups received infarct-related artery stenting with abciximabadministered just before the procedure, and for 12 h afterwards,as well as a 6-month course of clopidigrel and daily aspirinindefinitely. Those in the thrombolysis groups received tenect-eplase. The primary endpoint of the study was to assess theeffect of early PCI after thrombolysis on the extent of residualmicrovascular damage, quantified with myocardial contrastechocardiography. Left ventricular function was also assessedwith two-dimensional echocardiography on hospital day 2,pre-discharge, and at 3 months. The thrombolysis-only grouphad a significantly higher degree of microvascular damage,larger infarct size, and poorer left ventricular function, bothafter treatment and on follow-up, than those in the PCI andthrombolysis/PCI groups. There was not a statistically signifi-cant difference in outcomes for the primary PCI and thrombol-ysis/PCI groups. The authors conclude that PCI within 24 h ofthrombolysis is superior to thrombolysis alone, and similar toprimary PCI. This information may be helpful in planningtreatment for patients who present to institutions where primaryPCI is not available.
[Emily Johnston, MD,
Denver Health Medical Center, Denver, CO]
Editor’s Comment: This study confirms others previouslypublished and suggests that thrombolysis alone is less effectivethan thrombolysis combined with early PCI or PCI alone atreducing infarct size. The study does not address whether thisdisease-oriented outcome is clinically relevant.
e OUTCOME IN PATIENTS WITH SUBARACHNOIDHEMORRHAGE TREATED WITH ANTIEPILEPTICDRUGS. Rosengart AJ, Dezheng H, Tolentino J, et al. J Neu-rosurg 2007;107:253–60.
This prospective, multi-center study evaluated the preva-lence of anti-epileptic drug use (AED) and the impact of AEDon in-hospital complications and outcomes in patients withsubarachnoid hemorrhage (SAH). The authors examined datacollected on 3552 patients with SAH from 162 neurosurgicalcenters in 21 countries between 1991 and 1997. AEDs wereused in 65.1% of patients with SAH, with phenytoin being themost frequently prescribed drug 52.8% of the time. Usingconditional logistic regression, the authors found AED treat-ment varied dramatically according to study country (interclass
The Journal of Emergency Medicine, Vol. 34, No. 1, pp. 111–115, 2008Copyright © 2008 Elsevier Inc.
Printed in the USA. All rights reserved0736-4679/08 $–see front matter
111
