Thursday, April 6, 2017

EGDT for sepsis is unhelpful (PRISM)

PulmCCM - April 5, 2017 
"Three large, well-conducted randomized trials around the world (ProCESSARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous "sepsis bundles," protocols based on the single-center 2001 Rivers trial of EGDT for sepsis.
Evidence this convincing is rare in critical care, but experts at some centers noted the relatively low mortality (~25%) in the Big Three trials and continued advocating EGDT, believing it might help the sickest patients with sepsis. Each of the three trials individually could have been underpowered to find this benefit, went the argument.
As it turns out, the clever designers of ProCESS, ARISE, and ProMISe thought of this ahead of time. They synchronized entry criteria, treatment protocols, outcomes, and data collection -- so they could pool their data into a meta-analysis, gaining increased power for their conclusions.
That meta-analysis, called PRISM and published in the New England Journal of Medicine, concludes that EGDT did not improve survival from sepsis, even in the sickest patients, but did increase use of intensive care, vasoactive infusions, and overall costs."