Early goal-directed resuscitation of patients with septic shock: current evidence and future directions

Abstract

Severe sepsis and septic shock are among the leading causes of mortality in the intensive care unit. Over a decade ago, early goal-directed therapy (EGDT) emerged as a novel approach for reducing sepsis mortality and was incorporated into guidelines published by the international Surviving Sepsis Campaign. In addition to requiring early detection of sepsis and prompt initiation of antibiotics, the EGDT protocol requires invasive patient monitoring to guide resuscitation with intravenous fluids, vasopressors, red cell transfusions, and inotropes. The effect of these measures on patient outcomes, however, remains controversial. Recently, three large randomized trials were undertaken to re-examine the effect of EGDT on morbidity and mortality: the ProCESS trial in the United States, the ARISE trial in Australia and New Zealand, and the ProMISe trial in England. These trials showed that EGDT did not significantly decrease mortality in patients with septic shock compared with usual care. In particular, whereas early administration of antibiotics appeared to increase survival, tailoring resuscitation to static measurements of central venous pressure and central venous oxygen saturation did not confer survival benefit to most patients. In the following review, we examine these findings as well as other evidence from recent randomized trials of goal-directed resuscitation. We also discuss future areas of research and emerging paradigms in sepsis trials.

14-Year Survey in a Swedish County Reveals a Pronounced Increase in Bloodstream Infections (BSI). Comorbidity - An Independent Risk Factor for Both BSI and Mortality

“…In contrast, the study by Ammerlaan et al, mainly conducted in European hospitals and using basically the same BSI definitions as in our study, showed that nosocomial BSIs due to antibiotic-resistant bacteria increased [21]. Similar findings have been reported from a large study in the US [5, 4]. Sweden has one of Europe’s lowest outpatient antibiotic consumption [43].…”

Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

“…The Surviving Sepsis Campaign (SSC) guidelines proclaimed some components of EGDT as the standard treatment for patients with sepsis and septic shock (2,9). However, the beneficial effect of EGDT has been challenged by several large trials (10,11), which will be discussed in the following sections.…”

The Sepsis Early Recognition and Response Initiative (SERRI)

“…31–34 SERRI’s second responders use standardized protocols, but, for most sites, the adequacy and timing of their implementation must be obtained by means of laborious chart review (time elapsed between a positive screen [T 0 ] and notification of a second responder; time elapsed between T 0 and the arrival of the second responder; time elapsed between T 0 and the orders for fluid resuscitation, cultures, lactic acid measurement, and antibiotics). The difficulty of getting these data means that it is possible to establish compliance with the sepsis care protocols (analogous to a “pill count” in a drug study) only for a sample of SERRI patients.…”