Early, goal-directed resuscitation for septic shock

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.