The New Usual Care

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Key points

  • Current sepsis trials have not shown a benefit from protocolized early goal-directed care, as opposed to usual care.

  • Early recognition of sepsis, fluid resuscitation, appropriate antibiotic treatment, source control, and the application of multidiscipline evidence-based medicine are essential components of sepsis care.

  • Central venous pressure and continuous central venous saturation measurements, placement of central venous catheters, and routine blood transfusions are not necessary for all

Mortality in the era before early goal-directed therapy

In the roughly 35 years leading up to the introduction of the SSC, the overall mortality for patients with sepsis was 49.7%.11 Most publications over that time reported mortalities between 40% and 80%.11 Although there had been some improvements in mortality, the trend was small.11 Although it is easy to assume that this was the result of outdated treatments, the therapies delivered then were similar to modern interventions. Despite this, recent studies have suggested dramatic improvements in

Early goal-directed therapy

In 2001, Rivers and colleagues2 published a landmark article that challenged contemporary sepsis care. The investigators theorized that if patients could be treated in a timely and targeted manner to correct the imbalance between oxygen delivery and demand, the progression to multiorgan failure and death could be halted. They did this by targeting specific central hemodynamic end points during the initial 6 hours of treatment of severe sepsis (defined by the presence of 2 systemic inflammatory

A shift in sepsis care

After publication of the Rivers and colleagues2 trial, EGDT was viewed as cornerstone to successful sepsis management.15 In 2002, EGDT was suggested as a guideline for care by an expert sepsis panel.16 In 2004, the SSC, a committee composed of critical care and infectious disease experts representing 11 international organizations, recommended the following EGDT hemodynamic targets with grade B evidence: CVP of 8 to 12 mm Hg, MAP greater than or equal to 65 mm Hg, central venous or mixed venous

The ProCESS, ARISE, and ProMISe trials

Given the criticisms, 3 multicenter, randomized, independent but collaborative trials were conducted in the United States (ProCESS), Australia (ARISE), and United Kingdom (ProMISe) to evaluate the benefits of EGDT.8, 9, 10 Each trial used the definitions of severe sepsis and septic shock used in the original EGDT trial. However, the definition of refractory hypotension was changed from unresponsive to 20 to 30 mL/kg over 30 minutes (as in the original EGDT trial) to unresponsive to a 1-L fluid

What makes a difference?

The results of these 3 large trials provide a wealth of evidence to further refine current sepsis management. Importantly, strict adherence to the original goals of the initial EGDT trial and the methods implemented to reach central hemodynamic end points does not seem to result in a significant difference in patient outcomes. However, the mortality data from these 3 studies indicate a clear overall improvement in mortality compared with previous data and the original EGDT trial, which suggests

The new usual care

The use of continuous Scvo2 has now failed to show mortality benefit in 3 multicenter, randomized controlled trials when implemented in the routine care of patients with sepsis.8, 9, 10 Similarly the transfusion of red blood cells to target a hematocrit of 30%, either alone or with inotropic support with the goal of increasing oxygen delivery, is also unlikely to provide any additional benefit.8, 9, 10 Therefore, as with the use of continuous Scvo2, this practice is anticipated to become less

Summary

UC before the major EGDT trials2, 8, 9, 10 was characterized by a delayed response in the treatment of sepsis and septic shock. EGDT has evolved over the past 2 decades. Therapeutic modalities such as CVP and continuous Scvo2 measurements, placement of central venous catheters, routine blood transfusions, and inotropic support are no longer viewed as prerequisites in the treatment of sepsis. Notwithstanding, the current sepsis trials have established a culture of early recognition of sepsis,

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References (63)

  • P.C. Hébert et al.

    A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group

    N Engl J Med

    (1999)
  • D. Osman et al.

    Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge

    Crit Care Med

    (2007)
  • D.J. Kelm et al.

    Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death

    Shock

    (2015)
  • V.A. DePalo et al.

    The Rhode Island ICU collaborative: a model for reducing central line-associated bloodstream infection and ventilator-associated pneumonia statewide

    Qual Saf Health Care

    (2010)
  • ProCESS Investigators et al.

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

    N Engl J Med

    (2014)
  • ARISE Investigators et al.

    Goal-directed resuscitation for patients with early septic shock

    N Engl J Med

    (2014)
  • P.R. Mouncey et al.

    Trial of early, goal-directed resuscitation for septic shock

    N Engl J Med

    (2015)
  • G. Friedman et al.

    Has the mortality of septic shock changed with time

    Crit Care Med

    (1998)
  • R.P. Dellinger

    Cardiovascular management of septic shock

    Crit Care Med

    (2003)
  • K.-M. Kaukonen et al.

    Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012

    JAMA

    (2014)
  • M. Singer et al.

    The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

    JAMA

    (2016)
  • G.P. Patel et al.

    New treatment strategies for severe sepsis and septic shock

    Curr Opin Crit Care

    (2003)
  • J.-L. Vincent et al.

    Reducing mortality in sepsis: new directions

    Crit Care

    (2002)
  • L.B. Holst et al.

    Lower versus higher hemoglobin threshold for transfusion in septic shock

    N Engl J Med

    (2014)
  • A. Kumar et al.

    Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects

    Crit Care Med

    (2004)
  • S. Peake et al.

    Early goal-directed therapy of septic shock: we honestly remain skeptical

    Crit Care Med

    (2007)
  • A. Perel

    Bench-to-bedside review: the initial hemodynamic resuscitation of the septic patient according to Surviving Sepsis Campaign guidelines–does one size fit all?

    Crit Care

    (2008)
  • D.J. Carlbom et al.

    Barriers to implementing protocol-based sepsis resuscitation in the emergency department–results of a national survey

    Crit Care Med

    (2007)
  • A.E. Jones et al.

    Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial

    JAMA

    (2010)
  • A.E. Jones et al.

    Implementing early goal-directed therapy in the emergency setting: the challenges and experiences of translating research innovations into clinical reality in academic and community settings

    Acad Emerg Med

    (2007)
  • ProCESS/ARISE/ProMISe Methodology Writing Committee et al.

    Harmonizing international trials of early goal-directed resuscitation for severe sepsis and septic shock: methodology of ProCESS, ARISE, and ProMISe

    Intensive Care Med

    (2013)
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    Disclosures: The authors have nothing to disclose.

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