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The Journal of Emergency Medicine, Vol. 54, No. 2, pp.

244–248, 2018
Ó 2017 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

Letters
to the Editor
, EARLY GOAL-DIRECTED ings for estimating volume status and has been largely
THERAPY IS STANDARD replaced by other methods, such as bedside focused
THERAPY FOR SEPTIC SHOCK point-of-care ultrasound and the passive leg raise test,
but there is still some merit in measurement of central
, To the Editor: venous blood saturation in addition to lactate. Central
venous blood saturation rapidly changes in response to
I read with much interest the American Academy of oxygen supply and utilization while lactate may be
Emergency Medicine Clinical Practice paper by Winters initially normal and only slowly rise with circulatory
et al. on the care of patients with septic shock (1). The au- shock (5). The central point that has been missed is,
thors should be congratulated on the efforts to clarify this “What is the standard of care for septic shock currently
important topic, and although I agree with much of their compared to so-called early goal-directed therapy
conclusions, I would like to comment. The title is slightly (EGDT)?” I would suggest that the reason that there
misleading because it states patients with “septic shock,” was not a significant difference in mortality between
but the abstract and manuscript discuss patients with both the EGDT group and the so-called “usual care” group
“severe sepsis and septic shock,” thus potentially in the 3 studies quoteddProCESS, ARISE, and
confusing the reader because these are different entities ProMISedis that there has been such penetrance of the
with distinct treatment approaches. Septic shock by defi- basic tenets of EGDT that there was not much actual dif-
nition includes hypotension resistant to intravenous (IV) ference between the care delivered to patients in the 2
fluid challenge, thereby requiring vasopressor infusion groups studied. There was a large difference in mortality
(2). Central venous catheters (CVCs) are indicated for in Dr. River’s original study, with a 16% absolute reduc-
administration of all vasopressors (but not all vasoactive tion in the EGDT group. More than a decade later, when
medications, such as the inotropes dobutamine and milri- these 3 studies were conducted, the mortality of septic
none) because of concerns over tissue necrosis if any shock is lower because of the acceptance of the basic te-
extravasation occurs, and interruption of the infusion if nets of the identification of septic shock as well as early
any problems occur with the peripheral IV. Using a aggressive resuscitation with targeted goals, and these
reasonably reliable antecubital peripheral IV for the were simply lacking previously. The “usual care” for sep-
initial resuscitation of a patient with septic shock is tic shock in the 1990s was certainly very different than it
acceptable, but it is still standard of care that a CVC is now, and it only slowly became so after Dr. River’s
would be placed if vasopressor infusion is ongoing for 2001 publication; it had previously consisted of the
more than a few hours (3,4). Direct arterial blood following: 1) give IV fluids and call the intensive care
pressure monitoring is recommended “as soon as unit, 2) give more IV fluids, and 3) only start a vaso-
practical to place” for all critically ill patients requiring pressor when the blood pressure continues to fall. There-
vasoactive therapy (2). If it is clearly still recommended, fore, I am in total agreement with the authors’ statement
for patients with septic shock, to place a CVC and arterial that the decline in mortality of septic shock and severe
line early, whether in the emergency department or inten- sepsis found in the 3 studies can be attributed to the
sive care unit, I do not think the authors’ comments on acceptance of the basic approach put forth by Dr. Rivers.
“need for invasive procedures” or “forgoing the need We would also like to encourage the American
for placement of invasive catheters” are supported. Academy of Emergency Medicine going forward to
When Dr. River’s article was published in 2001, the include emergency physicians who are fellowship
recommendation for measuring and trending a central trained in and practicing critical care medicine in the
venous pressure was one of the only methods in common review of clinical practice statements involving emer-
practice for attempting to determine intravascular volume gency medicine (EM)–critical care medicine topics,
status. Central venous pressure certainly has shortcom- just as the review of practice statements of pediatric–

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The Journal of Emergency Medicine 245

EM topics include emergency physicians with pediatric administration. Recent evidence shows that vasopressor
training and clinical expertise. medications can be safely administered for short durations
through an appropriate peripheral intravenous catheter
Joseph Shiber, MD, FAAEM, FACP, FCCM placed proximal to the antecubital or popliteal fossa (5).
Department of Emergency Medicine We concur with Dr. Shiber that a central venous catheter
University of Florida College of Medicine – Jacksonville should be placed when clinically feasible for the prolonged
Jacksonville, Florida administration of vasopressor medications in the manage-
ment of critically ill patients. In addition, we also agree
http://dx.doi.org/10.1016/j.jemermed.2017.04.040
that an intra-arterial line be placed when clinically feasible
in patients receiving vasoactive therapy. Notwithstanding,
REFERENCES Dr. Shiber makes reference to comments within the paper
on the “need for invasive procedures” and “forgoing the
1. Winters ME, Sherwin R, Vilke GM, Wardi G. Does early
goal-directed therapy decrease mortality compared with placement of invasive catheters.” It is important to note
standard care in patients with septic shock? J Emerg Med 2017;52: that these comments are not recommendations of our
379–84. paper. Rather, these comments pertain to literature that
2. Rhodes MB, Evans LE, Alhazzani W, et al. Surviving sepsis
campaign: international guidelines for management of sepsis and described the variability in sepsis management, along
septic shock: 2016. Crit Care Med 2017;45:486–552. with commonly cited concerns with implementation of
3. Ricard JD, Salomon L, Boyer A, et al. Central or peripheral catheters the specific EDGT protocol by Rivers et al. (6).
for initial venous access of ICU patients: a randomized controlled
trial. Crit Care Med 2013;41:2108–15. In our conclusion, we write: “the current literature
4. Brewer JM, Puskarich MA, Jones AE. Can vasopressors safely be does not support the mandatory use of central hemody-
administered through peripheral intravenous catheters compared namic monitoring in the routine management of emer-
with cenral venous catheters? Ann Emerg Med 2015;66:629–31.
5. Ducrocq N, Kimmoun A, Levy B. Lactate or ScvO2 as an endpoint gency department patients with severe sepsis or septic
in resuscitation of shock states? Minerva Anestesiol 2013;79: shock.” We appreciate the opportunity to clarify that
1049–58. this statement specifically references the use of central
venous pressure (CVP) as a method to monitor volume
, REPLY responsiveness, and central venous oxygen saturation
(ScvO2) as a method to monitor oxygen delivery. There
, To the Editor: are numerous factors that impact the reliability of CVP
measurements, including valvular disease, dysrhythmias,
We thank Dr. Shiber for his thoughtful comments increased intrathoracic pressure, pericardial disease, right
regarding our paper, “Does early goal-directed therapy ventricular dysfunction, and even the reference level of
decrease mortality compared with standard care in pa- the pressure transducer (7). In fact, current guidelines
tients with septic shock?” He raises several important for the management of sepsis and septic shock no longer
points regarding the paper and the resuscitation of recommend CVP alone to guide fluid resuscitation (8).
patients with septic shock that warrant clarification. Rather, these guidelines suggest the use of dynamic vari-
Dr. Shiber correctly highlights the differences between ables to predict fluid responsiveness (i.e., respirophasic
the title, abstract, and manuscript with respect to the use changes in the inferior vena cava diameter, passive leg
of the terms septic shock and severe sepsis. We agree that raise, and pulse pressure variation) (8). The use of
these terms describe different sets of patients along the ScvO2 as a method to monitor resuscitation remains
continuum of sepsis severity, and acknowledge that debatable. While we do acknowledge that there may be
including the term severe sepsis in the abstract and manu- a select group of patients with septic shock who have a
script may be confusing to the reader. Though the original normal serum lactate and a low ScvO2, the incidence of
early goal-directed therapy (EGDT) trial included this scenario is reportedly low (7,9). In addition, a
patients with both severe sepsis and septic shock, more recent study by Lee et al. showed that ScvO2 provided
recent randomized trials included in our analysis (e.g., additional information only in patients in whom lactate
ProCESS, ARISE, and ProMISe) compared EGDT to failed to normalize after resuscitation (10). The decision
usual care in patients with septic shock (1–4). Because to use ScvO2 in addition to serum lactate trends should be
these large trials constitute the majority of current based on the individual patient. Current evidence does not
evidence comparing EGDT to usual care, we focused support its use as a component of usual care for all emer-
the paper on the patient with septic shock. We gency department patients with septic shock (2–4,11,12).
appreciate the opportunity to clarify this for the reader. Finally, we would like to reiterate Dr. Shiber’s points
As Dr. Shiber notes, septic shock is defined by comparing usual care at the time of the original EGDT
persistent hypotension that is resistant to intravenous trial with current usual care in ProCESS, ARISE, and
fluid resuscitation and, therefore, requires vasopressor ProMISe. Undoubtedly, “usual care” has dramatically