A randomized trial of protocol-based care for early septic shock.

Yealy DM, Kellum JA, Huang DT, et al.
N Engl J Med 2014;370:1683-1693.
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Review by : M. Piagnerelli
NATA Review

This multicentre study, which enrolled 1341 septic shock patients admitted to the emergency department, compared 1) resuscitation based on early goal-directed therapy (EGDT) guided by mean arterial pressure, central venous pressure, ScvO2 and haematocrit, and thus requiring invasive monitoring, as proposed by Rivers et al. (N Engl J Med 2001;345:1368-77), 2) protocol-based standard therapy without central catheter, and 3) usual care. The authors found no significant advantage, with respect to mortality or morbidity, of protocol-based resuscitation over bedside care that was provided according to the treating physician’s judgment. They also found no significant benefit of the mandated use of central venous catheterization and central haemodynamic monitoring in all patients. Changes during the past decade in the care of critically ill patients, including the use of lower haemoglobin levels as a threshold for transfusion, the implementation of lung-protection strategies, and the use of tighter control of blood sugar, may have helped lower the overall mortality (approximatively 20% in this study compared to 30.5% and 46.5% in the two study groups in the Rivers study) and may have reduced the marginal benefit of alternative resuscitation strategies. Moreover, patients were different in the two studies with more seriously ill patients in the study by Rivers et al. (lower ScvO2, older patients, higher rate of preexisting heart and liver diseases, higher lactate level at admission). Other multicentre trials on EGDT are being conducted and may offer additional insight.

– Michael Piagnerelli

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