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Implementation of early goal-directed therapy in Finland
Critical Care volume 11, Article number: P69 (2007)
The early recognition and rapid start of goal-directed treatment (EGDT) are important elements for better outcome in severe sepsis. These actions should take place in the emergency department (ED) before admission to the ICU. The aim of our study was to determine how the EGDT was performed and to evaluate the impact of EGDT principles on mortality in septic shock in Finland. Our study was conducted before national guidelines for severe sepsis were published.
A prospective observational study of patients with severe sepsis and septic shock admitted to 21 ICUs in Finland from 1 November 2004 to 28 February 2005 (Finnsepsis). Only patients with community-acquired sepsis, who fulfilled the criteria of septic shock and were admitted directly from the ED to the ICU, were included. The following treatment targets were evaluated: (1) measurement of lactate during the first 6 hours from admission to the ED; (2) obtaining the blood cultures before antibiotics; (3) starting the antibiotics within 3 hours from admission; and reaching the (4) mean arterial pressure over 65 mmHg, (5) central venous pressure over 8 mmHg and (6) central venous oxygen saturation over 70% or mixed venous oxygen saturation over 65% during the first 6 hours with fluids and vasopressors.
Sixty-three patients were included. The median age was 57 years (IQR 18.5) and the median APACHE II score was 28 (IQR 10). The ICU, hospital and 1-year mortality rates were 25%, 38% and 52%, respectively. Only five (8%) patients reached all treatment targets and 24 patients (38%) reached four or more targets (group A).
The hospital mortality of group A was 29% (95% CI 15–49%) compared with 44% (95% CI 29–59%) of those who reached only three or less targets (group B) (P = 0.3). The median delay from ED arrival to ICU admission in group A and group B was 1.1 and 3.7 hours (P < 0.001), and the median SOFA score for the first day was 10 and 11 (P = 0.4), respectively. The median APACHE II score was 28 in both groups (P = 0.9). In multivariate analysis including all separate targets, delay for ICU admission and APACHE II score, the APACHE II value and measurement of lactate were independent predictors of mortality (P = 0.001 and 0.02). Only 18% of patients had serum lactate measured during the ED stay. The 1-year mortality of group A was 42% (95% CI 24–61%) and of group B was 59% (95% CI 43–73%) (P = 0.2).
The adoption of EGDT protocol was poor in Finnish hospitals. The impaired early recognition of sepsis may lead to a delay in ICU admission. The rate of reached EGDT targets reflected mortality. In this study the most critical EGDT target was the measurement of lactate during first 6 hours after arrival in the ED. A forthcoming follow-up study will evaluate the impact of guidelines to treatment and outcome of septic shock in Finland.
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Varpula, M. Implementation of early goal-directed therapy in Finland. Crit Care 11, P69 (2007). https://0-doi-org.brum.beds.ac.uk/10.1186/cc5229
- Emergency Department
- Septic Shock
- Severe Sepsis
- Central Venous Pressure
- Sofa Score