Treatment according to the early and later stages of sepsis

The cornerstone of emergency management of sepsis is early, goal directed therapy, plus lung protective ventilation, broad spectrum antibiotics, and possibly activated protein C (Table 2). A randomized controlled trial was conducted in which patients with severe sepsis and septic shock received early, goal directed, protocol guided therapy during the first 6 hours after enrollment or the usual therapy. In the group receiving early, goal directed therapy, central venous oxygen saturation was monitored continuously with the use of a central venous catheter. The level of central venous oxygen saturation served to trigger further interventions recommended in the protocol. Crystalloids were administered to maintain central venous pressure at 8 to 12 mm Hg. Vasopressors were added if the mean arterial pressure was less than 65 mm Hg; if central venous oxygen saturation was less than 70%, erythrocytes were transfused to maintain a hematocrit of more than 30%. Dobutamine was added if the central venous pressure, mean arterial pressure, and hematocrit were optimized yet venous oxygen saturation remained below 70%. Early, goal directed therapy in that study decreased mortality at 28 and 60 days as well as the duration of hospitalization. Patients in the early, goal directed therapy group received more fluids, transfusions, and dobutamine in the first 6 hours; whereas control subjects received more fluids and more control subjects received vasopressors, transfusion, and mechanical ventilation for a period of 7 to 72 hours. The mechanisms of the benefit of early, goal directed therapy are unknown but may include reversal of tissue hypoxia and a decrease in inflammation and coagulation defects.