Early goal-directed therapy in the treatment of severe sepsis and septic shock.
Early goal-directed therapy in the treatment of severe sepsis and septic shock.
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DOI：
10.1056/nejmoa010307
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发表时间：
2001-11-08
影响因子：
158.5
通讯作者：
Tomlanovich, M
中科院分区：
文献类型：
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作者：
Rivers, E;Nguyen, B;Tomlanovich, M
背景：目标导向治疗已被用于重症监护病房的严重脓毒症和脓毒性休克。这种方法涉及调整心脏前负荷、后负荷和收缩力，以平衡氧气输送与氧气需求。本研究的目的是评估早期目标导向治疗入院前的重症监护室的有效性。方法：我们随机分配的患者到达城市急诊科严重脓毒症或感染性休克，接受6小时的早期目标导向治疗或标准治疗（作为对照）入院前的重症监护室。随后承担患者护理的临床医生对治疗分配不知情。住院死亡率（主要疗效结局）、复苏终点以及急性生理学和慢性健康评估结果：在263例入选患者中，130例被随机分配到早期目标导向治疗组，133例被随机分配到标准治疗组;在基线特征方面，两组之间没有显著差异。早期目标导向治疗组的住院死亡率为30.5%，而标准治疗组为46.5%（P=0.009）。在7至72小时的时间间隔内，分配到早期目标导向治疗的患者的平均（+/-SD）中心静脉血氧饱和度显著较高（70.4+/-10.7% vs. 65.3+/-11.4%），乳酸浓度较低（3.0+/-4.4 mmol/L vs. 3.9+/-4.4 mmol/L），较低的碱缺乏（2.0+/-6.6vs. 5. 1 +/-6.7 mmol/L），pH值（7.40+/-0.12 vs. 7.36+/-0.12）高于标准治疗组（所有比较P均小于/等于0.02）。在同一时期，接受早期目标导向治疗的患者的平均APACHE II评分显著低于接受标准治疗的患者，表明器官功能障碍较轻（13.0 ± 6.3 vs. 15.9 ± 6.4，P
Background: Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit.Methods: We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups.Results: Of the 263 enrolled patients, 130 were randomly assigned to early goal-directed therapy and 133 to standard therapy; there were no significant differences between the groups with respect to base-line characteristics. In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P=0.009). During the interval from 7 to 72 hours, the patients assigned to early goal-directed therapy had a significantly higher mean (+/-SD) central venous oxygen saturation (70.4+/-10.7 percent vs. 65.3+/-11.4 percent), a lower lactate concentration (3.0+/-4.4 vs. 3.9+/-4.4 mmol per liter), a lower base deficit (2.0+/-6.6 vs. 5.1+/-6.7 mmol per liter), and a higher pH (7.40+/-0.12 vs. 7.36+/-0.12) than the patients assigned to standard therapy (P lessthan/equal 0.02 for all comparisons). During the same period, mean APACHE II scores were significantly lower, indicating less severe organ dysfunction, in the patients assigned to early goal-directed therapy than in those assigned to standard therapy (13.0+/-6.3 vs. 15.9+/-6.4, P