An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock.
BACKGROUND
Septic shock is highly lethal. We recently implemented an algorithm (advanced resuscitation algorithm for septic shock, ARAS 1) with a global survival of 67%, but with a very high mortality (72%) in severe cases [norepinephrine (NE) requirements >0.3 microg/kg/min for mean arterial pressure > or =70 mmHg]. As new therapies with different levels of evidence were proposed [steroids, drotrecogin alpha, high-volume hemofiltration (HVHF)], we incorporated them according to severity (NE requirements; algorithm ARAS-2), and constructed a multidisciplinary team to manage these patients from the emergency room (ER) to the ICU. The aim of this study was to compare the outcome of severe septic shock patients under both protocols.


METHODS
Adult patients with severe septic shock were enrolled consecutively and managed prospectively with ARAS-1 (1999-2001), and ARAS-2 (2002-05). ARAS-2 incorporates HVHF for intractable shock.


RESULTS
Thirty-three patients were managed with each protocol, without statistical differences in baseline demographics, APACHE II (22.2 vs 23.8), SOFA (11.4 vs 12.7) and NE peak levels (0.62 vs 0.8 microg/kg/min). The 28-day mortality and epinephrine use were higher with ARAS-1 (72.7% vs 48.5%; 87.9% vs 18.2 %); and low-dose steroids (35.9% vs 72.7%), drotrecogin (0 vs 15 %) and HVHF use (3.0% vs 39.4%) were higher for ARAS-2 (P<0.05 for all).


CONCLUSIONS
Management of severe septic shock with a multidisciplinary team and an updated protocol (according to the best current evidence), with precise entry criteria for every intervention at different stages of severity, may improve survival in these patients. Multidisciplinary management, rationalization of the use of vasoactives and rescue therapy based on HVHF instead of epinephrine may have contributed to these


RESULTS
Management of severe septic shock with these kinds of algorithms is feasible and should be encouraged.
Castro
R
R
Department of Intensive Care Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
Regueira
T
T
Aguirre
M L
ML
Llanos
O P
OP
Bruhn
A
A
Bugedo
G
G
Dougnac
A
A
Castillo
L
L
Andresen
M
M
Hernández
G
G
D000465:Algorithms; D004638:Emergency Treatment; D019317:Evidence-Based Medicine; D006801:Humans; D007362:Intensive Care Units; D008875:Middle Aged; D011446:Prospective Studies; D012772:Shock, Septic / Q000401:mortality* / Q000628:therapy*; D015996:Survival Rate