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

Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GM - Crit Care (2015)

Bottom Line: 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.The effect of these measures on patient outcomes, however, remains controversial.

View Article: PubMed Central - PubMed

Affiliation: Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA. guptar4@vcu.edu.

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.

No MeSH data available.


Related in: MedlinePlus

Early goal-directed therapy. During the first 6 hours of septic shock, the early goal-directed therapy protocol requires the placement of a central venous catheter with an oximetric port for continuous monitoring of central venous pressure (CVP) and central venous oxygen saturation (ScvO2). Resuscitation with intravenous fluids, vasopressors, and packed red blood cells is titrated to specific end-points, including CVP of 8 to 12 mm Hg, mean arterial pressure (MAP) of at least 65 mm Hg, and ScvO2 of at least 70 %. Inotropic therapy is recommended in patients with low cardiac output despite adequate volume and MAP. Recent controlled clinical trials have challenged the efficacy of this approach for reducing mortality among patients with septic shock. HCT hematocrit
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC4552276&req=5

Fig2: Early goal-directed therapy. During the first 6 hours of septic shock, the early goal-directed therapy protocol requires the placement of a central venous catheter with an oximetric port for continuous monitoring of central venous pressure (CVP) and central venous oxygen saturation (ScvO2). Resuscitation with intravenous fluids, vasopressors, and packed red blood cells is titrated to specific end-points, including CVP of 8 to 12 mm Hg, mean arterial pressure (MAP) of at least 65 mm Hg, and ScvO2 of at least 70 %. Inotropic therapy is recommended in patients with low cardiac output despite adequate volume and MAP. Recent controlled clinical trials have challenged the efficacy of this approach for reducing mortality among patients with septic shock. HCT hematocrit

Mentions: Guidelines from the SSC published in 2013 also recommend goal-directed resuscitation during the first 6 hours of septic shock (Fig. 2). In this approach, treatment with intravenous fluids is titrated to specific endpoints, including CVP of 8 to 12 mm Hg and ScvO2 of at least 70 %. The SSC recommends placing a central venous catheter to monitor these variables and using a minimum of 30 ml per kg of fluids during initial resuscitation. Other goals of resuscitation include the use of vasopressor therapy to achieve an MAP of at least 65 mm Hg in patients with refractory hypotension as well as inotropic therapy in patients with low cardiac output. In patients with ScvO2 persistently below 70 % during the first 6 hours, the SSC advocates the use of packed red blood cell transfusions with a target hematocrit of at least 30 %.Fig. 2


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

Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GM - Crit Care (2015)

Early goal-directed therapy. During the first 6 hours of septic shock, the early goal-directed therapy protocol requires the placement of a central venous catheter with an oximetric port for continuous monitoring of central venous pressure (CVP) and central venous oxygen saturation (ScvO2). Resuscitation with intravenous fluids, vasopressors, and packed red blood cells is titrated to specific end-points, including CVP of 8 to 12 mm Hg, mean arterial pressure (MAP) of at least 65 mm Hg, and ScvO2 of at least 70 %. Inotropic therapy is recommended in patients with low cardiac output despite adequate volume and MAP. Recent controlled clinical trials have challenged the efficacy of this approach for reducing mortality among patients with septic shock. HCT hematocrit
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4552276&req=5

Fig2: Early goal-directed therapy. During the first 6 hours of septic shock, the early goal-directed therapy protocol requires the placement of a central venous catheter with an oximetric port for continuous monitoring of central venous pressure (CVP) and central venous oxygen saturation (ScvO2). Resuscitation with intravenous fluids, vasopressors, and packed red blood cells is titrated to specific end-points, including CVP of 8 to 12 mm Hg, mean arterial pressure (MAP) of at least 65 mm Hg, and ScvO2 of at least 70 %. Inotropic therapy is recommended in patients with low cardiac output despite adequate volume and MAP. Recent controlled clinical trials have challenged the efficacy of this approach for reducing mortality among patients with septic shock. HCT hematocrit
Mentions: Guidelines from the SSC published in 2013 also recommend goal-directed resuscitation during the first 6 hours of septic shock (Fig. 2). In this approach, treatment with intravenous fluids is titrated to specific endpoints, including CVP of 8 to 12 mm Hg and ScvO2 of at least 70 %. The SSC recommends placing a central venous catheter to monitor these variables and using a minimum of 30 ml per kg of fluids during initial resuscitation. Other goals of resuscitation include the use of vasopressor therapy to achieve an MAP of at least 65 mm Hg in patients with refractory hypotension as well as inotropic therapy in patients with low cardiac output. In patients with ScvO2 persistently below 70 % during the first 6 hours, the SSC advocates the use of packed red blood cell transfusions with a target hematocrit of at least 30 %.Fig. 2

Bottom Line: 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.The effect of these measures on patient outcomes, however, remains controversial.

View Article: PubMed Central - PubMed

Affiliation: Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA. guptar4@vcu.edu.

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.

No MeSH data available.


Related in: MedlinePlus