title: Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED.
abstract: BACKGROUND
  Early goal-directed therapy (EGDT) in septic shock defined by Rivers et al was proven to reduce mortality and validated by observational studies. However, criticism is centered in particular on the early requirement of a central venous catheter (CVC) and on central venous pressure (CVP) as an indicator of volume responsiveness. The present study is a pivotal study to investigate the reliability of a less invasive approach, which uses inferior vena cava (IVC) and lung ultrasounds (US) to guide the infusion of fluids and lactate clearance to monitor tissue perfusion.
  
  
  METHODS
  We enrolled 51 patients with septic shock. As a marker of preload optimization, we measured IVC collapse in place of CVP and serum lactate clearance in place of central venous oxygen saturation as a marker of tissue perfusion. As outcomes, we considered the accomplishment of the noninvasive EGDT goals, the number of patients treated without the need of a CVC, the amount of fluids administered in the first 6 hours, the development of pulmonary edema, and the overall mortality rate.
  
  
  RESULTS
  Inferior vena cava US evaluation resulted feasible in 92% of patients. Lung US was performed in 100% of cases. In the first 6 hours, only 61.7% of patients received a CVC, an average of 5.5 L of crystalloids were administered, and only 4 patients developed clinical overt pulmonary edema. Mortality was 34% at 28 days and 38.3% at 60 days.
  
  
  CONCLUSIONS
  Our approach to resuscitation in septic shock appears feasible in the emergency department and needs further study with a randomized controlled trial.
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy. Electronic address: daniele.coen@ospedaleniguarda.it.
authors.forename: Daniele
authors.initials: D
authors.lastname: Coen
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Cortellaro
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Pasini
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Tombini
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
authors.forename: Angelica
authors.initials: A
authors.lastname: Vaccaro
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Montalbetti
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
authors.forename: Michela
authors.initials: M
authors.lastname: Cazzaniga
authors.affiliation: Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Boghi
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D001794:Blood Pressure / Q000502:physiology; D002405:Catheterization, Central Venous; D002985:Clinical Protocols; D000077324:Crystalloid Solutions; D004636:Emergency Service, Hospital; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007552:Isotonic Solutions / Q000627:therapeutic use; D007773:Lactates / Q000097:blood; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D010100:Oxygen / Q000097:blood; D012151:Resuscitation / Q000379:methods; D012772:Shock, Septic / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D014463:Ultrasonography; D014682:Vena Cava, Inferior / Q000503:physiopathology
chemical_list: D015415:Biomarkers; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions; D007773:Lactates; D010100:Oxygen