Treatment protocolOur EGDT protocol

Treatment protocolOur EGDT protocol inhibitor Imatinib Mesylate and the clinical impact of its implementation has been previously reported in detail [9]. In brief, our protocol was the similar to that of Rivers and colleagues [6] in that our early resuscitation targeted three physiologic endpoints: central venous pressure (CVP), mean arterial pressure (MAP) and central venous oxygen saturation (ScvO2) using various stepwise therapeutic interventions to achieve predefined values of each endpoint. Our protocol differed from that described by Rivers and colleagues in that: it was executed only by ED physicians and nurses that were providing clinical care to the patient; and it was initiated in the ED and care was subsequently transitioned to the ICU during the resuscitation period.

The use of serum lactate concentrations to screen for global hypoperfusion was encouraged but not mandated by the protocol. Because this quantitative resuscitation protocol was implemented relatively early after the original study (in 2005), no faculty or trainees at our hospital had prior experience with the use of a structured quantitative resuscitation protocol for sepsis.Study subjectsEligible subjects were identified by board-certified emergency physicians in the ED, and inclusion criteria were identical for both phases: age 18 years and older; suspected or confirmed infection; two or more systemic inflammatory response syndrome (SIRS) criteria [11] (heart rate >90 beats per minute, respiratory rate >20 breaths per minute, temperature >38 or <36��C, white blood cell count >12,000 or <4000 cells/mm3 or >10% bands); systolic blood pressure below 90 mmHg or MAP below 65 mmHg after a 20 ml/kg isotonic fluid bolus OR anticipated need for ICU care and a serum lactate concentration of 4.

0 mM or higher. Exclusion criteria were: age less than 18 years; need for immediate surgery with an anticipated departure to the operating room in less than six hours; absolute contraindication for a chest central venous catheter. As our intent was to measure the potential impact of the early resuscitation program, subjects who did not survive the first six hours of early resuscitation (e.g. care was withdrawn early or the subject dies prior to the initial six hours of resuscitation) were excluded post-hoc from both groups.The pre-implementation phase encompassed 13 months, from August 2004 to September 2005.

During this time emergency physicians identified candidates with the inclusion and exclusion criteria and entered patient data in real-time on a computer in Batimastat the ED using a secure web-based electronic collection form [12]. In this phase, care was provided by emergency physicians at their discretion and no formal protocol was utilized. The post-implementation phase encompassed two years, from November 2005 to October 2007.

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