proCESS trial for sepsis vs EGDT

[LoudBark]

The rage for treating sepsis has been the Early Goal Directed Therapy. It is promoted by the "Surviving Sepsis" campaign. There are these 3 hour and 6 hour bundles. A central venous catheter needs to be placed. Measure CVP, CVO2 sat, mixed venous O2 sat, repeat lactic acid every 6 hours, give blood and dobutamine based on these parameters. This was all based on a single medical center trial with 260 or so patients and showed EGDT had a mortality of 30% and no EGDT had a mortality of 45%. At the time, everyone ran with it thinking EGDT was where it is at.

Then the proCESS trial came out. This was a multi center trial with 1360 patients, each divided into three groups: EGDT, therapy based on MAP and urine output, and usual care. No difference in mortality, LOS, organ failure.

So why is it that so many are still embracing a small trial from 2001 as opposed to the proCESS trial? Hospitals still are keeping close tabs on core measures with sepsis based on this 2001 trial with EGDT when a recent, large, multi center trial has shown that EGDT shows no mortality benefit over no EGDT.

Essentially what saves people's lives is giving lots of fluids early, if it doesn't work then pressors, and give broad spectrum antibiotics early. All the other fluff like lactic acid, CV O2 sat, mixed venous O2 sat, CVP all looks cute and fancy, but it is not saving lives.

Hospitals and physicians are now getting dinged if they don't meet these core sepsis measures, despite a major trial debunking their value.

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[sluggs]

I am not sure how to take this post:
1. Is there really a question here?
2. Is the OP just letting the board know that he read PROCESS?
3. Is the OP just advertising that he is an evidence-absolutist?

Lactic acid guides resuscitation. a good surrogate for the severity of the cardiogenic component of septic shock guide resuscitation (bedside echo, lactate clearance, ScVO2 all have pros and cons, but ignoring the heart is bad), and dynamic indices of fluid responsiveness are important.

 

[ORL10]

Im not sure what the OP is saying either, but I am not certain he actually read the study. The study did not directly look at monitoring vs, not monitoring of lactates. It looked at bundled care using EGDT (which had many aspects of care involved in it) vs. 2 different strategies of resus PSC arm and control arm. In the "control" arm people still checked lactates, still gave vasopressors and admitted sick patients to the ICU and people still got CVC when in the ICU. Also the amount of fluid, type of fluid and when to start vasopressors is still very subjective. Paul Marik advocates for a more fluid restrictive strategy (http://www.ncbi.nlm.nih.gov/pubmed/25110606),as for type of fluid some people use LR others NS others plasmalyte/normosol and in Europe more use albumin and some are hanging onto starches.

In the end you have to have some sort of "goal-directed" therapy to asses fluid responsiveness (echo, Passive Leg Raise with SVI or VTI, PPV, IVC u/s, lactate clearance, svo2 changes etc...)

Also most of he hospitals that participated in the study are not your run of the mill community shops.

 

[Hernandez]

Well....why change when the devil you know is as good as the new tangled approach.

 

[Hernandez]

Sepsis bundles are....dead.....I for one welcome our new pre-rivers overloads.

http://www.nejm.org/doi/full/10.1056/NEJMoa1404380#t=article