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Early, goal-directed resuscitation for septic shock


Auinger, Katja; Maggiorini, Marco (2015). Early, goal-directed resuscitation for septic shock. New England Journal of Medicine, 373(6):576.

Abstract

The Protocolised Management in Sepsis (ProMISe) trial (April 2 issue) completes a trio of studies that question the further application of early, goal-directed therapy (EGDT) as suggested by Rivers et al. In particular, these trials consistently show no survival benefit with regard to the mandated use of central venous oxygen saturation (ScvO$_2$) monitoring. However, it remains questionable whether the results of the three trials support this claim. According to the EGDT protocol, an ScvO$_2$ value of less than 70% is a trigger for hemodynamic intervention. Unlike in the study by Rivers et al., the reported mean values at baseline in all three trials do not require any intervention. Whether the reported survival benefit in the study by Rivers et al. is based on the treatment of patients with initially extremely low ScvO$_2$ values and determines the targeted patient population that benefits from EGDT remains, therefore, unanswered. Pope et al. reported increased mortality when ScvO$_2$ values were initially low (<70%) or high (>80%). Unless subgroup analyses and further studies that focus on these high-risk patients do not rule out a survival benefit, the final conclusion of the three trials cannot be supported.

Abstract

The Protocolised Management in Sepsis (ProMISe) trial (April 2 issue) completes a trio of studies that question the further application of early, goal-directed therapy (EGDT) as suggested by Rivers et al. In particular, these trials consistently show no survival benefit with regard to the mandated use of central venous oxygen saturation (ScvO$_2$) monitoring. However, it remains questionable whether the results of the three trials support this claim. According to the EGDT protocol, an ScvO$_2$ value of less than 70% is a trigger for hemodynamic intervention. Unlike in the study by Rivers et al., the reported mean values at baseline in all three trials do not require any intervention. Whether the reported survival benefit in the study by Rivers et al. is based on the treatment of patients with initially extremely low ScvO$_2$ values and determines the targeted patient population that benefits from EGDT remains, therefore, unanswered. Pope et al. reported increased mortality when ScvO$_2$ values were initially low (<70%) or high (>80%). Unless subgroup analyses and further studies that focus on these high-risk patients do not rule out a survival benefit, the final conclusion of the three trials cannot be supported.

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Additional indexing

Item Type:Journal Article, refereed, further contribution
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Division of Surgical Intensive Care Medicine
Dewey Decimal Classification:610 Medicine & health
Language:English
Date:6 August 2015
Deposited On:19 Feb 2016 09:07
Last Modified:05 Apr 2016 20:07
Publisher:Massachusetts Medical Society
ISSN:0028-4793
Additional Information:From N Engl J Med 2015; 373:576-578. Copyright © 2015 Massachusetts Medical Society. Reprinted with permission.
Free access at:Publisher DOI. An embargo period may apply.
Publisher DOI:https://doi.org/10.1056/NEJMc1506514#SA1
PubMed ID:26244315

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