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Protocol-Based Care for Septic Shock

Protocol-Based Care for Septic Shock

Until recently, the hospital mortality of patients with severe sepsis and septic shock was 50%. In 2001, a single-center ED study found that mortality in patients with severe sepsis or septic shock was significantly lower among those treated according to a 6-hour protocol of early goal-directed therapy (EGDT) than for those receiving standard therapy. That study involved a specific protocol in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets. “Many wondered if all the EGDT steps were needed and if changes in critical illness care have since altered the impact of the catheter-guided sepsis care,” says Donald M. Yealy, MD. To address this question, Dr. Yealy and colleagues designed a multicenter trial comparing alternative resuscitation strategies in patients with septic shock. Published in the New England Journal of Medicine, the study tested whether protocol-based resuscitation was superior to usual care. They also tested whether a protocol with central hemodynamic monitoring to guide treatments was superior to a simpler protocol that used bedside exams to trigger care. “We wanted to see if we could achieve better outcomes by simply recognizing septic shock early and treating it aggressively with fluids and vasopressors absent a catheter-based algorithm,” says Dr. Yealy. Key Findings Conducted in 31 U.S. EDs and in 1,351 enrollees, Dr. Yealy and colleagues randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: 1. Protocol-based EGDT given by a dedicated two-person team. 2. Protocol-based standard therapy by the same team that did not require the placement of a central venous catheter, administration ofninotropes, or blood transfusions. 3....
Identifying Patients With Problematic Drug Use in the ED

Identifying Patients With Problematic Drug Use in the ED

According to the Drug Abuse Warning Network, 2.5 million of the 5.1 million drug-related ED visits nationwide in 2011 were directly related to the use of illicit substances, non-medical use of pharmaceuticals, or a combin-ation of the two. In 2008, researchers found that the total annual cost of illicit drug use was about $151.4 billion. Medical care costs alone account for $5.4 billion of that total annual cost, not including costs for substance use treatment. “Studies have shown that drug users are more likely to use the ED for their medical care and are more likely to require hospitalization than those who don’t use drugs,” says Wendy L. Macias-Konstantopoulos, MD, MPH. The American College of Emergency Physicians and other organizations have recommended using screening, brief intervention, and referral to treatment (SBIRT) in the ED for problematic alcohol use. Many studies have demonstrated the effectiveness of SBIRT for alcohol use, but its effectiveness in addressing problematic drug use may also be promising, especially if implemented in ED settings. The challenge with addressing drug use disorders in the ED is that these problems are often difficult to detect, says Dr. Macias-Konstantopoulos. “Patients tend to deny or underreport illicit drug use,” she says. “If we can improve our ability to identify patients with drug use problems, we have an opportunity to mitigate the subsequent health effects.” New Data In a study published in Annals of Emergency Medicine, Dr. Macias-Konstantopoulos and colleagues sought to identify characteristics that were associated with problematic drug use in ED patients who reported drug use during the past month. Using previously validated tests, investigators prescreened more than 15,000...
Protocols Mean No One Has to Think

Protocols Mean No One Has to Think

Let me say up front that I do not object to protocols in principle. I have been responsible for the development of several protocols, both for trauma and for critical care. At their best, protocols serve as guidelines and memory aides prompting us to do the right thing to help and protect our patients. They can be powerful reminders and guides for those who don’t often deal with a particular problem, or conversely, may keep those of us for whom certain critical interventions are routine from becoming complacent. I do object to protocols that take the place of critical thinking, especially when that is coupled with an electronic medical record that forces the physician to follow a checklist. Recently, this was brought home during an episode at my primary hospital. My patient was a 59-year-old man who had under gone a laparoscopic assisted right colectomy. He was a two pack a day smoker and had some modest high blood pressure. He did well with surgery and the initial postop period. On day 3 however, he became hypoxic (low oxygen saturation in the blood), had some tachycardia (rapid heart rate) and had a little confusion. This was enough to trigger a “sepsis alert.” Severe sepsis is an inflammatory response to severe infection. It is an exaggerated expression of the fever and normal inflammation that accompany an infection. It can cause a cascade of low blood pressure, fever, poor tissue perfusion and acidosis leading to organ failure and death. The sepsis initiative is designed to improve outcomes by identifying patients with early sepsis and providing physicians with a standard set of...
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