title: Protocol-Based Resuscitation for Septic Shock: A Meta-Analysis of Randomized Trials and Observational Studies.
abstract: OBJECTIVE
  Owing to the recommendations of the Surviving Sepsis Campaign guidelines, protocol-based resuscitation or goal-directed therapy (GDT) is broadly advocated for the treatment of septic shock. However, the most recently published trials showed no survival benefit from protocol-based resuscitation in septic shock patients. Hence, we aimed to assess the effect of GDT on clinical outcomes in such patients.
  
  
  METHODS
  We performed a systematic review that included a meta-analysis. We used electronic search engines including PubMed, Embase, and the Cochrane database to find studies comparing protocol-based GDT to common or standard care in patients with septic shock and severe sepsis.
  
  
  RESULTS
  A total of 13269 septic shock patients in 24 studies were included [12 randomized controlled trials (RCTs) and 12 observational studies]. The overall mortality odds ratio (OR) [95% confidence interval (CI)] for GDT versus conventional care was 0.746 (0.631-0.883). In RCTs only, the mortality OR (95% CI) for GDT versus conventional care in the meta-analysis was 0.93 (0.75-1.16). The beneficial effect of GDT decreased as more recent studies were added in an alternative, cumulative meta-analysis. No significant publication bias was found.
  
  
  CONCLUSIONS
  The result of this meta-analysis suggests that GDT reduces mortality in patients with severe sepsis or septic shock. However, our cumulative meta-analysis revealed that the reduction of mortality risk was diminished as more recent studies were added.
authors.affiliation: Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Woo Kyung
authors.initials: WK
authors.lastname: Lee
authors.affiliation: Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Ha Yeon
authors.initials: HY
authors.lastname: Kim
authors.affiliation: Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Jinae
authors.initials: J
authors.lastname: Lee
authors.affiliation: Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul, Korea.
authors.forename: Shin Ok
authors.initials: SO
authors.lastname: Koh
authors.affiliation: Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.|Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Jeong Min
authors.initials: JM
authors.lastname: Kim
authors.affiliation: Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.|Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea. nswksj@yuhs.ac.
authors.forename: Sungwon
authors.initials: S
authors.lastname: Na
mesh_terms: D006801:Humans; D064887:Observational Studies as Topic; D016032:Randomized Controlled Trials as Topic; D012151:Resuscitation / Q000379:methods*; D012772:Shock, Septic / Q000401:mortality / Q000628:therapy*
keywords: Sepsis; meta-analysis; septic shock; shock