Early goal-directed therapy vs usual care in the treatment of severe sepsis and septic shock: a systematic review and meta-analysis

Abstract

Sepsis is a common and high-burden healthcare problem with a mortality exceeding 20 % in severe sepsis and nearly 50 % when septic shock is present. Early goal-directed therapy (EGDT) is recommended by sepsis guidelines as the standard of care following a landmark study by Rivers et al. alongside other observational studies. Three recent randomized controlled trials have questioned the Rivers' results. The objective of our systematic review was to assess the effectiveness of EGDT in reducing the mortality of severe sepsis or septic shock. Relevant primary studies were identified by searching the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Clinical Trials to identify randomized controlled trials assessing the effectiveness of EGDT for sepsis. Data from all trials were combined and analyzed using a random effects model. Five studies, enrolling a total of 4033 patients, were included in the meta-analysis. In-hospital mortality did not differ between the two treatment groups (RR 0.93, 95 % CI 0.77-1.11, P = 0.42), although moderate heterogeneity between studies was noted (I (2) = 48 %). A non-significant trend toward reduction in 60-day mortality in the EGDT group was noted (RR 0.93, 95 % CI 0.82-1.05, P = 0.22, I (2) = 24 %). Heterogeneity between trials precludes a definitive conclusion on the utility of EGDT in severe sepsis. Until further evidence is available, it is reasonable to consider EGDT in the care of patients with severe sepsis and septic shock.

Pulmonary Artery/Central Venous Pressure Monitoring in Adults

“…11 The addition of CVP monitoring to guided therapy is not associated with improved outcomes in patients with severe sepsis and septic shock. [12][13][14][15][16] The PAOP and CVP are not accurate for identifying which patients will respond to a fluid bolus with an increase in stroke volume, and alternative methods such as functional and implement preventive actions to decrease risk for catheter-induced pulmonary artery rupture or infarction. [ include presence of a left bundle branch block (risk for complete heart failure), right-sided cardiac mass, tricuspid or pulmonic valve endocarditis, or presence of a mechanical tricuspid or pulmonic valve.…”

Effect of early goal directed therapy in the treatment of severe sepsis and/or septic shock

“…While in these published studies, only five RCTs were included in three meta-analysis (Rusconi et al, 2015;H. Yu et al, 2016;Zhang et al, 2015), and one RCT was inappropriately selected in Lu(2015) study (Andrews et al, 2014); in Chelkeba(2015) study, 9 RCTs were included, while three of which were inappropriately selected (Andrews et al, 2014;He et al, 2007;Lin et al, 2006).…”

“…Ever since the publication of the ProCESS study (Pro et al, 2014), which showed no survival benefit of EGDT over usual care, several meta-analysis were published to address this issue (Angus et al, 2015;Chelkeba, Ahmadi, Abdollahi, Najafi, & Mojtahedzadeh, 2015;Jun Lu, 2016;Rusconi et al, 2015;H. Yu, Chi, Wang, & Liu, 2016;Zhang, Zhu, Han, & Fu, 2015).…”

Early goal-directed therapy for severe sepsis and septic shock: A living systematic review

“…Data abstraction and risk of bias assessment A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT 5 We assessed trials with the Cochrane Risk of Bias Tool (16). We added the following criteria:…”