Goal-directed resuscitation for patients with early septic shock.
The Australasian Resuscitation in Sepsis Evaluation (ARISE) was a multicentre randomised study comparing early goal-directed therapy (EGDT) according to the protocol proposed by Rivers et al. (N Engl J Med 2001;345:1368-77) versus usual care in 1588 patients (792 patients in the EGDT group) during the first 6 hours of admission to the emergency department for septic shock. As in the recently published ProCESS study (N Engl J Med 2014;370:1683-93, the authors did not observe any difference in mortality at 90 days (18.6 versus 18.8%). Mortality was also similar in all predefined subgroups (country, age, APACHE II score, mechanical ventilation, signs of hypoperfusion, refractory hypotension, amount of fluid received before randomisation).
Although the results of this study are considered negative (no difference in mortality between the two groups), it is interesting to note several positive points with regard to early management of patients with septic shock when one compares usual care in this and previous studies. The amount of fluid infused during the first 6 hours was greatly reduced (1713 versus 3499 mL in the study by Rivers et al.), which probably contributed to reducing the side effects associated with hydration. In addition, in-hospital mortality has been greatly reduced since the study by Rivers et al. (15.7 vs. 46.5% in the control groups).
This study shows that the care of patients with septic shock has improved (whether protocolised or not), resulting in decreased mortality. Time is tissue!
– Michael Piagnerelli
Discuss this article on the Nataonline forum