Is the Sun Setting on Goal-Directed Resuscitation for Septic Shock?

Since the landmark 2001 trial by Rivers et al, early goal-directed therapy (EGDT) for septic shock has been endorsed as the standard of care. The multicenter Australasian Resuscitation in Sepsis Evaluation (ARISE) trial was designed to test the hypothesis that EGDT, as compared with usual care, would reduce all-cause mortality at 90 days among patients presenting to the emergency department with early septic shock. The study was a prospective, randomized, parallel-group trial hosted in 51 tertiary care and nontertiary care hospitals in Australia, New Zealand, Finland, Hong Kong, and Ireland.

The authors concluded that EGDT does not offer a survival advantage in patients presenting to the emergency department with early septic shock. This work represents the second published study in a triad of trials. The Protocolised Management in Sepsis (ProMISe) trial has yet to be published; the results of the Protocolized Care for Early Septic Shock (ProCESS) trial were published earlier this year. Strengths of the ARISE trial include an appropriate sample size, the multicenter nature of the study and high compliance with the intervention. However, early resuscitation and antibiotic administration likely are now regarded as “usual care,” and this may have had a significant impact before randomization. A meta-analysis of all three trials is planned when the ProMISe trial is completed. This meta-analysis — which could have greater power than any individual study — may demonstrate benefits of EGDT in certain patient populations.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

The Surviving Sepsis Campaign recently released an updated statement regarding hemodynamic and oximetric monitoring. This statement is in response to the ProCESS and ARISE trials. The statement highlights recently released data from the Surviving Sepsis Campaign, which confirms that “adherence to quality improvement measures in severe sepsis and septic shock is associated with mortality decline.”

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2 thoughts on “Is the Sun Setting on Goal-Directed Resuscitation for Septic Shock?

  1. Carole Cahaney

    Thank you for the timely update on the SS Guidelines. I am able to share them with our ED physicians and
    continue our endeavors against Sepsis.

  2. Lawrence Lynn

    None of the studies identify the limitation of using criteria sepsis/septic shock which were simply guessed (expert opinion-Grade D) . The concept that there is a unifying phenotype of sepsis which can be treated by a unified protocol is a 1980s myth.

    If the SCCM chooses to continue to promulgate the unified phenotype of sepsis they should inform the reader that this concept is no longer universally held and is based on expert opinion from the 20th century. The trials should have (and now should) include the following statement “One important limitation of this trial was that the “true state” of sepsis/septic shock was defined by set of simple static criteria which were simply derived from expert opinion” (REF 1) . “Another limitation is the use of statistical methods which do not engage the dimension of time.” (REF 2)

    Reference
    1. The diagnosis of sepsis revisited – a challenge for young medical scientists in the 21st century.
    Lynn LA. Patient Saf Surg. 2014 Jan 2;8(1):1.

    2. Dynamic diagnostic relationism: a new diagnostic paradigm for complex rapidly changing clinical conditions. Lynn LA. Patient Saf Surg. 2014 May 7;8:21.

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