Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE.
Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE.
复制标题
DOI：
10.1186/s13054-016-1288-3
复制
发表时间：
2016-07-01
期刊：
影响因子：
--
通讯作者：
Rivers EP
中科院分区：
文献类型：
--
作者：
Nguyen HB;Jaehne AK;Jayaprakash N;Semler MW;Hegab S;Yataco AC;Tatem G;Salem D;Moore S;Boka K;Gill JK;Gardner-Gray J;Pflaum J;Domecq JP;Hurst G;Belsky JB;Fowkes R;Elkin RB;Simpson SQ;Falk JL;Singer DJ;Rivers EP
在2001年之前，急诊科对严重败血症和感染性休克的早期处理没有标准。在有标准或常规护理的情况下，普遍死亡率超过40- 50%。作为回应，一种基于系统的方法，类似于急性心肌梗死，中风和创伤，称为早期目标导向治疗，与标准治疗进行了比较，该临床试验显著降低了死亡率。自该试验发表以来，在70多项观察性和随机对照研究中，包括7万多名患者，报告了类似的结果益处。因此，早期目标导向治疗在很大程度上被纳入败血症管理的前6小时（复苏包），并作为早期败血症管理的护理标准在国际上传播。最近的三项试验（ProCESS、ARISE和ProMISe）虽然报告了空前低的脓毒症死亡率，但质疑是否继续需要早期目标导向治疗的所有要素，或者是否需要对严重脓毒症休克患者进行协议化护理。回顾早期血流动力学发病机制、历史发展和早期目标导向治疗的定义，比较试验传导方法和脓毒症死亡率的变化情况，对于适当解释这些试验及其结论至关重要。本文的在线版本（doi:10.1186/s13054-016-1288-3）包含补充材料，可供授权用户使用。
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions. The online version of this article (doi:10.1186/s13054-016-1288-3) contains supplementary material, which is available to authorized users.