Early goal directed therapy: couldn′t be not fully denied

doi:10.3877/cma.j.jssn.2096-1537.2016.03.010

Abstract

Abstract:

Early goal-directed therapy had been doubted since it was reported 2001, and recently the trio of EGDT trials (ProCESS, ProMISe and ARISE) proved EDGT did not have positive effect and EGDT should not be recommended. However, the trio of EGDT trials themself had their own problem, they could not totally overthrow EGDT. Moreover, since EGDT was published and SSC bundle wide spread all over the world, it decreased the mortality of sepsis significantly. So we should understand EGDT correctly, knowing its core was the idea of early active resuscitated and updated its parameters, which could more conducive to patient with sepsis. EGDT should not be abandoned.

Key words: Sepsis, Infection, Shock

Luhao Wang, Bin Ouyang, Xiangdong Guan. Early goal directed therapy: couldn′t be not fully denied[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2016, 02(03): 184-188.

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URL: https://icu.cma-cmc.com.cn/EN/10.3877/cma.j.jssn.2096-1537.2016.03.010

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References 55

[1]	Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock[J]. N Engl J Med, 2001, 345(19):1368–1377.
[2]	Nguyen HB, Jaehne AK, Jayaprakash N, et al. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE[J]. Critical Care, 2016, 20(1):10.
[3]	Kaukonen KM, Bailey M, Suzuki S, et al. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012[J]. JAMA, 2014, 311(13):1308–1316.
[4]	Pro CI, Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock[J]. N Engl J Med, 2014, 370(18):1683–1693.
[5]	Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock[J]. N Engl J Med, 2015, 372(14):1301–1311.
[6]	Investigators A, Group ACT, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock[J]. N Engl J Med, 2014, 371(16):1496–1506.
[7]	Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)[J]. JAMA, 2016, 315(8):775–787.
[8]	Dombrovskiy VY, Martin AA, Sunderram J, et al. Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003[J]. Crit Care Med, 2007, 35(5):1244–1250.
[9]	Ani C, Farshidpanah S, Bellinghausen SA, et al. Variations in organism-specific severe sepsis mortality in the United States: 1999-2008[J]. Crit Care Med, 2015, 43(1):65–77.
[10]	Stevenson EK, Rubenstein AR, Radin GT, et al. Two decades of mortality trends among patients with severe sepsis: a comparative meta-analysis*[J]. Crit Care Med, 2014, 42(3):625–631.
[11]	Kumar G, Kumar N, Taneja A, et al. Nationwide trends of severe sepsis in the 21st century (2000-2007)[J]. Chest, 2011, 140(5):1223–1231.
[12]	Castellanos-Ortega A, Suberviola B, Garcia-Astudillo LA, et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study[J]. Crit Care Med, 2010, 38(4):1036–1043.
[13]	Laguna-Pérez A, Chilet-Rosell E, Delgado Lacosta M, et al. Clinical pathway intervention compliance and effectiveness when used in the treatment of patients with severe sepsis and septic shock at an intensive care unit in Spain[J]. Rev Lat Am Enfermagem, 2012, 20(4):635–643.
[14]	Memon JI, Rehmani RS, Alaithan AM, et al. Impact of 6-hour sepsis resuscitation bundle compliance on hospital mortality in a saudi hospital[J]. Crit Care Res Pract, 2012, 2012:273268.
[15]	Shiramizo SC, Marra AR, Durao MS, et al. Decreasing mortality in severe sepsis and septic shock patients by implementing a sepsis bundle in a hospital setting[J]. PLoS One, 2011, 6(11):e26790.
[16]	Hanzelka KM, Yeung SC, Chisholm G, et al. Implementation of modified early-goal directed therapy for sepsis in the emergency center of a comprehensive cancer center[J]. Support Care Cancer, 2013, 21(3):727–734.
[17]	Jeon K, Shin TG, Sim MS, et al. Improvements in compliance with resuscitation bundles and achievement of end points after an educational program on the management of severe sepsis and septic shock[J]. Shock, 2012, 37(5):463–467.
[18]	Kang MJ, Shin TG, Jo IJ, et al. Factors influencing compliance with early resuscitation bundle in the management of severe sepsis and septic shock[J]. Shock, 2012, 38(5):474–479.
[19]	Kortgen A, Niederprum P, Bauer M. Implementation of an evidence-based ʺstandard operating procedureʺ and outcome in septic shock[J]. Crit Care Med, 2006, 34(4):943–949.
[20]	Mikkelsen ME, Gaieski DF, Goyal M, et al. Factors associated with nonadherence to early goal-directed therapy in the ED[J]. Chest, 2010, 138(3):551–558.
[21]	Sivayoham N, Rhodes A, Jaiganesh T, et al. Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock: a 4-year observational cohort study[J]. Eur J Emerg Med, 2012, 19(4):235–240.
[22]	Thiel SW, Asghar MF, Micek ST, et al. Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis[J]. Crit Care Med, 2009, 37(3):819–824.
[23]	Tromp MB-RC, van Achterberg T, Kullberg BJ, et al. Internal medicine residents' knowledge about sepsis: effects of a teaching intervention[J]. Neth J Med, 2009, 67(9):312–315.
[24]	Trzeciak S, Dellinger RP, Abate NL, et al. Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department[J]. Chest, 2006, 129(2):225–232.
[25]	Wawrzeniak IC, Loss SH, Moraes MC, et al. Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting?[J] Indian J Crit Care Med, 2015, 19(3):159–165.
[26]	Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial[J]. JAMA, 2010, 303(8):739–746.
[27]	浙江省早期规范化液体复苏治疗协作组. 危重病严重脓毒症／脓毒性休克患者早期规范化液体复苏治疗——多中心、前瞻性、随机、对照研究[J]. 中国危重病急救医学, 2010, 22(6):331–334.
[28]	陈仲清,金英慧,陈辉,等. 早起目标指导治疗对多器官功能障碍综合征发病率、严重度及病死率的影响[J]. 南方医科大学学报, 2007, 27(12):1892–1895
[29]	何征宇, 皋源, 王祥瑞, 等. 早期目标导向治疗在感染性休克中应用的临床探讨[J]. 中国危重病急救医学, 2007, 19(1):14–16.
[30]	王晓芝, 吕长俊, 高福全, 等. 目标指导下治疗脓毒性休克的疗效观察[J]. 中国危重病急救医学, 2006, 18(11):661–664.
[31]	Lin SM, Huang CD, Lin HC, et al. A modified goal-directed protocol improves clinical outcomes in intensive care unit patients with septic shock: a randomized controlled trial[J]. Shock, 2006, 26(6):551–557.
[32]	Yan J, Cai G. A multicentre study on early goal-directed therapy of severe sepsis and septic shock patients in the ICU: collaborative study group on early goal-directed therapy in Zhejiang Province, China[J]. Critical Care, 2008, 12(Suppl 2):P417.
[33]	Padkin A, Goldfrad C, Brady AR, et al. Epidemiology of severe sepsis occurring in the first 24 hrs in intensive care units in England, Wales, and Northern Ireland[J]. Crit Care Med, 2003, 31(9):2332–2338.
[34]	Gao F, Melody T, Daniels DF, et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study[J]. Crit Care, 2005, 9(6):R764–770.
[35]	Reuben AD, Appelboam AV, Higginson I. The outcomes of severe sepsis and septic shock in the UK[J]. Crit Care, 2006, 10(4):417.
[36]	Melville J, Ranjan S, Morgan P. ICU mortality rates in patients with sepsis before and after the Surviving Sepsis Campaign[J]. Critical Care, 2015, 19(Suppl 1):P15.
[37]	Daniels R, Nutbeam T, McNamara G, et al. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study[J]. Emerg Med J, 2011, 28(6):507–512.
[38]	Finfer S, Bellomo R, Lipman J, et al. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units[J]. Intensive Care Med, 2004, 30(4):589–596.
[39]	van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients[J]. N Engl J Med, 2001, 345(19):1359–1367.
[40]	Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock[J]. Jama, 2002, 288(7):862–871.
[41]	Vincent JL. We should abandon randomized controlled trials in the intensive care unit[J]. Crit Care Med, 2010, 38(10 Suppl):S534–538.
[42]	Boulain T, Garot D, Vignon P, et al. Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients: a prospective multicentre study[J]. Crit Care, 2014, 18(6):609.
[43]	Tiruvoipati R, Ong K, Gangopadhyay H, et al. Hypothermia predicts mortality in critically ill elderly patients with sepsis[J]. BMC Geriatr, 2010, 10:70.
[44]	Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock[J]. Chest, 2009, 136(5):1237–1248.
[45]	Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit[J]. Crit Care Med, 2007, 35(6):1477–1483.
[46]	Lee SJ, Ramar K, Park JG, et al. Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study[J]. Chest, 2014, 146(4):908–915.
[47]	Liu VX, Morehouse JW, Marelich GP, et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values[J]. Am J Respir Crit Care Med, 2016, 193(11):1264–1270.
[48]	Samuel A, Marc S, Mike H, et al. Utilizing Electronic Alerts And IVC Ultrasound To Improve Outcomes For Sepsis Care In An Urban ED[A]. In: B37. QUALITY IMPROVEMENT IN PULMONARY AND CRITICAL CARE MEDICINE: American Thoracic Society, 2014: A2817–A2817.
[49]	Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study[J]. Intensive Care Med, 2014, 40(11):1623–1633.
[50]	Rhodes A, Phillips G, Beale R, et al. The surviving sepsis campaign bundles and outcome: results from the international multicentre prevalence study on sepsis (the IMPreSS study)[J]. Intensive Care Med, 2015, 41(9):1620–1628.
[51]	Marik PE. The demise of early goal-directed therapy for severe sepsis and septic shock[J]. Acta Anaesthesiol Scand, 2015, 59(5):561–567.
[52]	Sharif S, Owen JJ, Upadhye S. The end of early-goal directed therapy?[J] Am J Emerg Med, 2016, 34(2):292–294.
[53]	Shippy CR, Appel PL, Shoemaker WC. Reliability of clinical monitoring to assess blood volume in critically ill patients[J]. Crit Care Med, 1984, 12(2):107–112.
[54]	Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares[J]. Chest, 2008, 134(1):172–178.
[55]	Angus DC, Barnato AE, Bell D, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators[J]. Intensive Care Med, 2015, 41(9):1549–1560.

研究		研究年份	病死率（%）
研究		研究年份	研究前	研究后
Rivers EGDT^[1]		1997-2000	46.5	30.5
Shanker-hari等^[7]^☆		1993-2015	46.5	N/A
观察性研究^a
	Dombrovsky等^[8]^△	2001	40.3	N/A
	Ani等^[9]^△	1999-2008	40.0	27.8
	Stevenson等^[10]	1993-2009	46.9	29.2
	Kumar等^[11]^△	2003-2009	39.6	27.3
	Kumar等^[11]^☆	2000-2007	47.1	36.4
EGDT后续研究^b
	类似的系列研究^{[12,13,14,15]}	2001-2016	45.8	28.5
	回顾性研究^{[16,17,18,19,20,21,22,23,24,25]}	2001-2016	41.1	24.7
	RCT研究^{[1,4,5,6,26,27,28,29,30,31,32]}	2001-2016	31.3	26.2
	ProCESS研究^[4]	2008-2013	18.9	19～20
观察性研究^c
	Padkin等^[33]	1995-2000	47.0	N/A
	Gao等^[34]	2004-2005	55.0	29.0
	Reuben等^[35]	2004-2005	43.0	N/A
	Melvile等^[36]	2005-2008	51.9	41.3
	Danoels等^[37]	2007-2008	44.1	20.0
	ProMISe研究^[5]	2011-2014	25.6	24.6
观察性研究^d
	Finfer等^△^[38]	1999	37.5	N/A
	Kaukonen等^△^[3]	2000-2012	30.2	14.2
	Kaukonen等^☆^[3]	2000-2012	40.3	22.0
	ARISE^[6]	2008-2014	18.8	18.6

研究		研究年份	病死率（%）
研究		研究年份	研究前	研究后
Rivers EGDT^[1]		1997-2000	46.5	30.5
Shanker-hari等^[7]^☆		1993-2015	46.5	N/A
观察性研究^a
	Dombrovsky等^[8]^△	2001	40.3	N/A
	Ani等^[9]^△	1999-2008	40.0	27.8
	Stevenson等^[10]	1993-2009	46.9	29.2
	Kumar等^[11]^△	2003-2009	39.6	27.3
	Kumar等^[11]^☆	2000-2007	47.1	36.4
EGDT后续研究^b
	类似的系列研究^{[12,13,14,15]}	2001-2016	45.8	28.5
	回顾性研究^{[16,17,18,19,20,21,22,23,24,25]}	2001-2016	41.1	24.7
	RCT研究^{[1,4,5,6,26,27,28,29,30,31,32]}	2001-2016	31.3	26.2
	ProCESS研究^[4]	2008-2013	18.9	19～20
观察性研究^c
	Padkin等^[33]	1995-2000	47.0	N/A
	Gao等^[34]	2004-2005	55.0	29.0
	Reuben等^[35]	2004-2005	43.0	N/A
	Melvile等^[36]	2005-2008	51.9	41.3
	Danoels等^[37]	2007-2008	44.1	20.0
	ProMISe研究^[5]	2011-2014	25.6	24.6
观察性研究^d
	Finfer等^△^[38]	1999	37.5	N/A
	Kaukonen等^△^[3]	2000-2012	30.2	14.2
	Kaukonen等^☆^[3]	2000-2012	40.3	22.0
	ARISE^[6]	2008-2014	18.8	18.6

项目	ProCESS、ProMISe、ARISE	EGDT
基本监测和常规治疗	监测SIRS治疗	之前十年没有治疗标准
	容量治疗
	乳酸监测
	建议6 h内使用抗生素（ProCESS）
液体治疗	1 L	20～30 ml/kg
研究实施	急诊停留时间<3 h	在急诊实施急诊停留6～8 h
	主要在ICU内治疗
	高等级医院
	对照组超过50%使用CVP
	因病死率低减少病例数
机械通气	MV比较26%使用，有肺保护性策略	MV比例54%，没有肺保护性策略
病情严重程度	排除急性肺水肿、急性肺损伤	体温低、PaCO₂低、更多呼吸急促
血流动力学	正常ScvO₂和CVP	低ScvO₂、高乳酸、低CVP

项目	ProCESS、ProMISe、ARISE	EGDT
基本监测和常规治疗	监测SIRS治疗	之前十年没有治疗标准
	容量治疗
	乳酸监测
	建议6 h内使用抗生素（ProCESS）
液体治疗	1 L	20～30 ml/kg
研究实施	急诊停留时间<3 h	在急诊实施急诊停留6～8 h
	主要在ICU内治疗
	高等级医院
	对照组超过50%使用CVP
	因病死率低减少病例数
机械通气	MV比较26%使用，有肺保护性策略	MV比例54%，没有肺保护性策略
病情严重程度	排除急性肺水肿、急性肺损伤	体温低、PaCO₂低、更多呼吸急促
血流动力学	正常ScvO₂和CVP	低ScvO₂、高乳酸、低CVP

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