title: Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department.
abstract: OBJECTIVE
  To describe our experience with early goal-directed therapy (EGDT), corticosteroid administration, and recombinant human activated protein C (rhAPC) administration in patients with severe sepsis or septic shock and an Acute Physiology and Chronic Health Evaluation (APACHE) II score > or =25 in the emergency department (ED).
  
  
  METHODS
  This was a retrospective case series of a prospectively maintained ED sepsis registry. Data are presented as median (25th, 75th percentile). The setting was an academic tertiary ED with approximately 60,000 annual patient visits. Patients with severe sepsis or septic shock and an APACHE II score > or =25 entered in an ED sepsis registry over a four-month period were included. Patients who received rhAPC in the intensive care unit were excluded. Central venous catheterization for central venous pressure and central venous oxygen saturation monitoring, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, inotropes, corticosteroids, and rhAPC were initiated by the emergency physicians and continued in the intensive care unit by intensivists.
  
  
  RESULTS
  Twenty-four patients were enrolled. Patient characteristics were as follows: age, 79.5 (68.0, 83.5) years; APACHE II score, 31.5 (29.8, 36.0); ED length of stay, 6.5 (4.0, 10.5) hours; predicted mortality, 76.7% (71.9, 86.4); and in-hospital mortality, 45.8%. All patients received broad-spectrum antibiotics, 54.2% completed EGDT, 33.3% received corticosteroids, and 33.3% received rhAPC. Time of antibiotic administration was 1.5 (1.0, 2.0) hours, time of central venous pressure/central venous oxygen saturation monitoring was 1.0 (0.5, 2.5) hour, and time of rhAPC administration was 9.5 (6.8, 10.5) hours after patients met criteria for severe sepsis or septic shock. In-hospital mortality of patients who received rhAPC in addition to other therapies was 25.0%.
  
  
  CONCLUSIONS
  EGDT, corticosteroid administration, and rhAPC administration are feasible in the ED setting. While these evidence-based therapies individually have been shown to improve outcomes for patients with severe sepsis or septic shock, further studies are needed to examine their combined effectiveness during the early stages of this disease.
authors.affiliation: Department of Emergency Medicine, Loma Linda, Loma Linda, CA 92354, USA. hbnguyen@ahs.llumc.edu
authors.forename: H Bryant
authors.initials: HB
authors.lastname: Nguyen
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Corbett
authors.forename: Kevin
authors.initials: K
authors.lastname: Menes
authors.forename: Thomas
authors.initials: T
authors.lastname: Cho
authors.forename: Jennifer
authors.initials: J
authors.lastname: Daugharthy
authors.forename: Walter
authors.initials: W
authors.lastname: Klein
authors.forename: William A
authors.initials: WA
authors.lastname: Wittlake
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use*; D002140:California; D003131:Combined Modality Therapy / Q000379:methods; D004635:Emergency Medicine / Q000379:methods*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care; D011486:Protein C / Q000627:therapeutic use*; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis / Q000628:therapy*; D012772:Shock, Septic / Q000175:diagnosis / Q000628:therapy; D016019:Survival Analysis
chemical_list: D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents; D000925:Anticoagulants; D011486:Protein C