October - 2014
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 Goal-Directed Resuscitation for Patients with Early Septic ShockThe ARISE Investigators and the ANZICS Clinical Trials Group NEJM, 2014, Online first October 1 2014 This page is only available to Crit-IQ subscribers. To view the rest of this review and gain access to our vast array of critical care teaching tools including podcasts, vodcasts, modules, exam preparation tools, teaching aids and much more, login here, or Become a Member to register |
October |
Previous Comments
| As with PROCESS, I have concerns about the language of this trial and the population it is purported to help. For the language, Early Goal Directed Therapy is what we do in medicine. We give therapy to meet a patient's need and prolong life and we titrate to effect. Saying EGDT does not reduce mortality is wrong because the control group in this trial received some other clinician's version of EGDT. It says we don't have to use dobutamine or blood. We don't have to titrate to CVP but it doesn't say EGDT doesn't matter. Looking at the drastic reduction of fluid with the EGDT protocol and the control group c/w, there is significant contamination of 'world wide' changes in sepsis managment since the River's study. I don't think this study is comparable to that one as 'sepsis' management has been a hot topic in the field for 10 years. Additionally, the River's study was conducted in a totally different context and the patients were sicker. With my public health doctor hat on, this study was a victory. In reality, the vast majority of sepsis deaths do not occur in high resourced settings and in high resourced settings, they occur in individuals with multiple comorbidities. In the introduction, the ARISE authors emphasize the role of context and Rivers may not be applicable to the Australian context. But why did we repeat it in a context of healthier population with improved access to resources? We already knew that because world-wide sepsis mortality follows a socio-economic line - and I'd bet there are pockets in Australia too! One needs only look at the recent massive contextual differences in Ebola mortality to be reminded that resources matter in battling infection. There is an ethical obligation we have in research in the first world: most of us work outside 'ivory towers'. Who will take up this research that says that Early Goal Directed Therapy doesn't work? Will it spread to areas where sepsis mortality is high and resources are low? Is that ethical? Is the language right - do we really mean: 'early goal directed therapy' doesn't work because clinicians where research isn't affordable might think that it is does? | |
| Cynthia-16 Oct, 2014 12:11:28 PM | |
| I agree with the above statement. I would be interested to see how "usual therapy" has changed since Rivers EGDT study was reported. I suspect usual therapy is now a subconscious form of EGDT, as anyone who has been treating septic patients in the last ten years, must have come across the concept of EGDT and i would find it astonishing to believe that the way we approach and treat septic patients has not beeen influenced by his work. A fantastic study, but it certainly doesn't prove that EGDT doesnt work or isn't needed. In my mind it points towards the success of EGDT which as a concept has now become a part of most acute physicians/intensivists approach to managing these patients. | |
| Davidrmoir-17 Oct, 2014 02:11:14 AM | |
Comment
This is a must read 1600 patient trial testing EGDT vs standard care in 51 Australia/New Zealand ICUs. It follows the initial Rivers trial, the PRoCESS trial...