4th December 2014: Goal-Directed Resuscitation for Patients with Early Septic Shock

Presented by Dr Angus Butchart

The design and implementation of systems to manage sepsis are a frequent topic in this journal club topic, and on ICUs throughout the world. We discussed ProCESS a while ago and ProMISe, a UK ICNARC designed study, will report in the New Year. This week we look at ARISE, the petulant middle child in a harmonised triad of studies which were designed to work out whether the Rivers model of early goal directed therapy (EGDT) improved outcome in patients presenting to emergency departments with sepsis.

The development of #FOAMcc over the last few years has given us a great many useful, intelligent, critiques of ARISE (below) and these are all valuable background reading and viewing for our journal club. The blog post for the previous journal club on ProCESS also suggests some of the questions we should try to answer this week.

This is stuff we have to get right and get better at. We can debate the merits of each of the individual protocols or even whether there is really a need for protocols when we are so good at managing sepsis that it couldn’t be improved (one interpretation of the ARISE and ProCESS). We cannot argue, however, with the mortality and morbidity arising from sepsis and we can’t, with good conscience, say that we get the treatments we know work to the patients in good time.

This is the challenge for the next few years, accurate early diagnosis, the provision of robust systems to initiate beneficial treatment, and avoiding iatrogenic harm are going to be the three corner stones of sepsis management for the foreseeable future – microbe genomic studies won’t add much for a while.

There is a lot of comment that this is the end of the line for EGDT, but is that really the case. Of course, some of the components of these bundles are probably not useful and perhaps harmful – CVP, liberal transfusion policy, dobutamine, supra-normal oxygen delivery – but does that mean that the other components of these bundles don’t deserve further dissection. What about fluids vs vasopressors – when should we start noradrenaline in septic patients. Scott Weingart suggests after 3-4L – seems a lot – perhaps we should be starting vasopressors to restore “physciological” vascular tone and then adding fluid to maintain a normal intravascular volume – if we can work out what it is – we will talk about this on Thursday.

ARISE presentation at ESICM – essential watching.

Interview with Sandra Peake.

Meta-analysis in Critical Care published after PROMISE.

The Bottom Line review – essential reading.

EMCrit blog on the trial with accompanying podcast.

Intensive Care Network resource with interview with Anthony Delaney (@TheARISEstudy) who ran the trial – supra-essential listening.

Editorial from Nature Reviews Nephrology on this and <a href="http://www simvastatin price.trialsjournal.com/content/14/1/150″ target=”_blank”>TRISS, which we will discuss in a few weeks.

Guidance from the ESICM and Surviving Sepsis Campaign in the aftermath of PROCESS.