So we awaited the results of the proMISe Trial with baited breath and we have seen the results of ARISE / proCESS.
The news from this was expected to perhaps be different, would the wheel be re-invented….or not?! The answer was unsurprising in the end. EGDT does not appear to alter overall 90 day mortality. What did the previous 2 big trials tell us?
- Mortality – no real difference at 90 days 18.6% Vs. 18.8%
- Median length of stay slightly longer in EGDT group
- Hospital & ICU LOS: no difference
- Vasopressor requirement slightly greater in the EGDT group (p<0.001)
- median duration of vasopressor infusion – no difference
- no difference in number receiving mechanical ventilation or RRT
- 28d all cause mortality No sig. diff
- mortality at ICU discharge no sig. diff
- Volume of fluid administered during the first 6 hours in the EGDT group, slightly greater (p<0.001)
- Mortality – no differences at 60 days 18.2% Vs. 18.9%
- No difference in 90 day or 1 year mortality either.
The headline result of this latest large trial was that there was no difference in 90 day mortality (29%).
SOFA scores were higher in the protocolised group than in the usual care group. Those randomised into the EGDRT protocol had more lines inserted early on, more expeditious admission to ITU and received twice as much blood.
The EGDT group received more dobutamine, which was the area that interested me the most. We all discuss guiding our resuscitation with reference to mixed venous oxygen saturation, but do we actually pay much attention to it in reality? This is a bit similar to the good old calculation of ARDS Vs ALI using the PaO2/FiO2 ratio….how many of us can safely say we all do that on ward rounds?? (Massive apologies if you do as a regular part of your practice). Use of indodilators and vasopressors will be discussed later on here.
There were similar provisions of vasopressors, no difference in advanced support free days and length of stay. It was postulated that the EGDT group would have a cost implication, but there were similar costs of care at 90 days (£12,414 ($17,647) vs £11,424 ($16,239) (p 0.25); therefore yet another insignificant finding.
The problem with all of these studies is that ‘all’ patients these days are going to receive some form of ‘goal-directed’, as it would be completely unethical to bias them out! The original Rivers study we all refer to was groundbreaking at the time, so these cannot re-invent the wheel.
Nowadays, we are all so well drilled in the treatment of septic patients, particularly with the surviving sepsis campaign and the fact we can all reel of the sepsis 6 in our sleep! Everyone wants to replicate the Rivers study, but unless we discover a magic bullet (like we assumed APC was), this is unlikely to happen.
They keys are still:
- Rapid assessment and don’t sit on these patients
- Early IV antibiotics
- Enough IV resuscitation (4 litres in 8 hours average – 500ml/hr), which I firmly believe should be guided by Echo assessment (basic LV assessment with IVC collapsibility index and responsiveness. Don’t forget passive leg raising! Take care with Non invasive cardiac output random number generators.
- consideration of tissue perfusion optimisation, and there’s where our good friend dobutamine should be considered.
USE YOUR BRAIN – have we learnt anything new…..not a lot!
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