title: Early goal-directed resuscitation of patients with septic shock: current evidence and future directions.
abstract: Severe sepsis and septic shock are among the leading causes of mortality in the intensive care unit. Over a decade ago, early goal-directed therapy (EGDT) emerged as a novel approach for reducing sepsis mortality and was incorporated into guidelines published by the international Surviving Sepsis Campaign. In addition to requiring early detection of sepsis and prompt initiation of antibiotics, the EGDT protocol requires invasive patient monitoring to guide resuscitation with intravenous fluids, vasopressors, red cell transfusions, and inotropes. The effect of these measures on patient outcomes, however, remains controversial. Recently, three large randomized trials were undertaken to re-examine the effect of EGDT on morbidity and mortality: the ProCESS trial in the United States, the ARISE trial in Australia and New Zealand, and the ProMISe trial in England. These trials showed that EGDT did not significantly decrease mortality in patients with septic shock compared with usual care. In particular, whereas early administration of antibiotics appeared to increase survival, tailoring resuscitation to static measurements of central venous pressure and central venous oxygen saturation did not confer survival benefit to most patients. In the following review, we examine these findings as well as other evidence from recent randomized trials of goal-directed resuscitation. We also discuss future areas of research and emerging paradigms in sepsis trials.
authors: Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA. guptar4@vcu.edu.
authors: Ravi G
authors: RG
authors: Gupta
authors: Division of General Internal Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980070, Richmond, VA, 23298, USA.
authors: Sarah M
authors: SM
authors: Hartigan
authors: Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA.
authors: Markos G
authors: MG
authors: Kashiouris
authors: Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA.
authors: Curtis N
authors: CN
authors: Sessler
authors: Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980019, Richmond, VA, 23298, USA.
authors: Gonzalo M L
authors: GM
authors: Bearman
mesh_terms: D001794:Blood Pressure; D002985:Clinical Protocols; D019317:Evidence-Based Medicine; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D010100:Oxygen / Q000097:blood; D010347:Patient Care Planning; D012151:Resuscitation / Q000379:methods* / Q000592:standards; D012772:Shock, Septic / Q000503:physiopathology / Q000628:therapy*
chemical_list: D006454:Hemoglobins; D010100:Oxygen