And the debate goes on! How much fluid should we give our septic patients? The results from the ProCESS trial are out and I am still not sure that we have an answer. So I listened to one of my go to guys to help me understand…..Scott Weingart.
Patients enrolled were those that were recognised to be in septic shock. These (1341) were then divided into 3 groups:
(1) protocolised EGDT- mandatory placement of central line to monitor ScVO2 and CVP, administration of IV fluids, vasopressors, dobutamine and PRBC.
(2) protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions.
(3) ‘usual care’ which was not standardised.
Primary outcome was 60 day mortality.
No differences in 60 day mortality, 90 day mortality or 1 year mortality between the groups.
Patients in the usual care group received least amount of IVF during the first 6 hours compared to the other two groups. Patients in the EGDT received more dobutamine and PRBC in the first 6 hours compared to the other two groups.
Some Blog Conclusions.
Does not feel that there are great differences in the amount of fluid given to the two groups. Striking number of potentially unnecessary central lines- EGDT group 93% vs 56% and 57%.
Difference in administration of blood not as great as he would have expected.
“overall sepsis outcomes have improved over recent years, and early recognition and antibiotic administration may be the most important components of care. In the early emergency department phase of care, protocolised fluid and vasopressor therapy may not be as important as we thought. Good clinical assessment and regular review seem to be as effective and perhaps more important than any specific monitoring modality or oxygen delivery-targeted drug and blood therapy.”
“The different resuscitative approaches did not create one clear superior method, and while some resource use varied, the primary and secondary analyses largely agreed on this observation. Of our three, no one resuscitative path is bad or better; this allows sites the flexibility of crafting best local approach to care within these constructs.”
“Protocols don’t improve survival in severe sepsis and septic shock, but especially in the golden early hours, they might still have value as a handy checklist to keep everyone on top of their game. Early antibiotics, adequate fluid resuscitation and vasopressor support are the essential components of care for severe sepsis and septic shock.”
“they report a significant difference in fluid administration but I don’t think the difference is clinically significant. [EMCrit agrees even though the lead author sees a big difference in the three groups] We’re talking a litre difference between the most and the least with the other group half way between. If one group was 6l and one was 2l then that would seem to me a clinically significant difference. Note that the paper reports the numbers as 2.3, 3.3 and 2.8. These figures don’t include the mandatory fluid bolus that was part of the inclusion criteria. So in reality it was more like 4-5 l in each group”
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