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									KNOWLEDGE TO PRACTICE • DES CONNAISSANCES À LA PRATIQUE

CJEM Journal Club

Quantitative resuscitation in sepsis
Reviewed by: Catherine Patocka, MDCM;* Joel Turner, MDCM;† Eddy Lang, MDCM†


   Clinical question                                                    because it is heavily weighted on one single-centre trial.6–8
   Does a quantitative resuscitation strategy improve mor-                Quantitative resuscitation, as seen in the study by
   tality from severe sepsis?                                           Rivers and coauthors,4 involves structured cardiovascular
   Article chosen                                                       intervention with intravascular volume expansion and
   Jones AE, Brown MD, Trzeciak S, et al. The effect of a
   quantitative resuscitation strategy on mortality in
                                                                        vasoactive agent support to achieve explicit predefined
   patients with sepsis: a meta-analysis. Crit Care Med                 physiologic end points using measurements and samples
   2008;36:2932–3.                                                      from invasive central venous and arterial monitors. A
   Study objective                                                      significant barrier to the widespread implementation of
   The authors sought to determine whether quantitative                 EGDT has been the use of such invasive monitoring.9,10
   resuscitation (structured cardiovascular intervention
                                                                          Also known as “goal-oriented resuscitation,” quanti-
   with intravascular volume expansion and vasoactive
   agent support to achieve explicit predefined physio-                 tative resuscitation is not new, as clinical trials using
   logic end points) improves mortality in severe sepsis                some form of it have been performed for 20 years.11
   and whether the timing of this resuscitation impacts                 Jones and colleagues sought to determine whether the
   mortality.                                                           mortality benefit seen in these trials was derived from
                                                                        quantitative resuscitation in general, rather than the
                                                                        choice of specific end points.
BACKGROUND
                                                                        STUDY DESIGN AND POPULATION STUDIED
Severe sepsis and septic shock are significant sources of
morbidity and mortality in the emergency department                     The study was a systematic review and meta-analysis. The
(ED), with in-hospital mortality rates from sepsis                      investigators looked at all randomized controlled trials of
remaining virtually unchanged between 1970 and                          adult patients with a presumed or confirmed diagnosis of
2000.1–3 In 2001, Rivers and colleagues4 demonstrated a                 sepsis receiving a structured cardiovascular intervention
16% absolute reduction in mortality in patients with                    aimed at achieving predefined hemodynamic end points
severe sepsis treated with a protocol-driven resuscita-                 (Box 1).
tion strategy aimed at hemodynamic optimization in the
ED. Their strategy, termed “early goal-directed ther-                       Box 1. Inclusion criteria of the subject study
apy” (EGDT), used an algorithmic approach to achieve
                                                                            •   Randomized controlled trials
specific resuscitation end points.                                          •   Patients aged > 17 yr
   In 2008, the Surviving Sepsis Campaign, a conglomer-                     •   Presumptive or confirmed diagnosis of sepsis
ation of physicians from multiple specialties endorsed by                   •   Experimental study using
11 societies, updated their guidelines to recommend that                        - intervention consisting of a structured cardiovascular
such a quantitative resuscitation strategy be implemented                          resuscitation protocol administered to achieve
                                                                                   predefined hemodynamic end points
at the time of recognition of severe sepsis.5 This particu-
                                                                                - a control group that received standard of care therapy
lar recommendation has met with significant
								
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