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Emergency Medicine

Answer 2
  1. EGDT. This patient has severe sepsis. Sepsis is defined by the presence of an infection and the systemic inflammatory response syndrome (eg, hyper/hypothermia, heart rate > 90 bpm, tachypnea, altered mental status, leukocytosis/leukopenia/bandemia, or elevated C-reactive protein or procalcitonin levels).² Severe sepsis is sepsis plus the presence of organ dysfunction or evidence of tissue hypoperfusion (serum lactate > 4 mmol/L). EGDT consists of administering IV fluids, vasopressors, packed red blood cells, and inotropic agents to target a central venous pressure of 8 to 12 mm Hg, a mean arterial pressure of 65 to 90 mm Hg, and a central venous oxygen saturation of greater than 70% within 6 hours of identification.³ EGDT reduced absolute mortality by 16.5% in patients with severe sepsis or septic shock compared with standard therapy in a single-center randomized trial.&sup4; Similar mortality reductions have been found in other studies using historical controls or comparing actual mortality with predicted mortality using APACHE II scores.&sup5; Corticosteroids have been shown to reduce mortality in patients with vasopressor-dependent septic shock, in those requiring mechanical ventilation, and in those who fail a cosyntropin stimulation test. However, this finding has recently been disputed in a large trial not yet published. Recombinant-activated protein C, an endogenous anticoagulant with anti-inflammatory properties, has been shown to reduce mortality in patients with an APACHE II score of 25 or more, sepsis-induced multiorgan failure, septic shock, or sepsis-induced acute respiratory distress syndrome who have no absolute contraindication related to bleeding risk (including a hemorrhagic stroke within 3 months, as in this patient). Elevated procalcitonin levels may be sensitive markers of bacterial sepsis, but procalcitonin has no therapeutic role. Protective ventilation strategies using low tidal volumes (6 mL/kg) have been associated with a reduction in mortality.

2. Levy MM, Fink MP, Marshall JC, et al; SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31:12506

3. Dellinger RP, Carlet JM, Masur H, et al; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock [published errata appear in Crit Care Med 2004;32:1448 and 2004;32:216970]. Crit Care Med 2004;32: 85873.

4. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:136877.

5. Otero RM, Nguyen HB, Huang DT, et al. Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings. Chest 2006;130:157995.

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