[NEJM读者来信]：感染性休克的早期目标指导治疗（作者回答）
作者回答The authors reply:
Auinger 和 Maggiorini建议，ProCESS , ARISE 和 ProMISe 试验报告基线ScvO2平均值，因为这些指标显著高于Rivers研究中的EGDT组和常规治疗组。但是，他们所提到的三项试验中EGDT组的数值并非基线数值，而且随机分组后至少1小时的数值（置入ScvO2监测导管后）。Rivers研究中是随机分组前的数值 （所有患者在随机分组前均留置了ScvO2监测导管），因此，将两者进行比较是不正确的。对于三项研究中高危患者通过疾病严重程度和（或）血乳酸水平进行亚组分析（这两者均为基线ScvO2的替代指标，因常规治疗组没有ScvO2的数据）显示没有获益。
Auinger and Maggiorini suggest that the ProCESS,1 ARISE,2 and ProMISe trials reported mean ScvO2 values at baseline that are considerably higher than those in both the EGDT group and the usual-care group in the study by Rivers et al.3 The values to which they refer for the EGDT groups in the three trials, however, are not baseline values and are typically from at least 1 hour postrandomization (after insertion of the catheter with ScvO2 monitoring capability). The values in the study by Rivers et al. are prerandomization (all patients received catheters with ScvO2 monitoring capability before randomization in this study), and, therefore, the comparison is not valid. Subgroup analyses of high-risk patients in the three multi center trials, using illness-severity scores, serum lactate concentrations, or both as proxies for baseline ScvO2(because ScvO2data were not available for the usual-care groups), showed no evidence of benefit.
我们同意Priebe的意见，即输注静脉等张盐溶液可引起高氯血症和酸中毒。在ProMISe研究中，尽管我们没有记录晶体液的种类或血氯水平，但是，EGDT组和常规治疗组随机分组后72小时内输注的晶体液量相同，因而，很可能两组使用的液体是相似的。输血的证据相互矛盾，近期数据提示输血没有危害。
We agree with Priebe that administration of intravenous isotonic saline solutions can cause hyperchloremia and acidosis. In the ProMISe trial, although we did not record the type of crystalloid administered or the serum chloride level, the volume of crystalloid administered by 72 hours after randomization was similar in the EGDT and usual-care groups, and it is likely that, on average, the fluids used were the same in the two groups. With respect to red-cell transfusions, the evidence base is conflicting, with more recent data4,5indicating no evidence of harm caused by transfusions.
Manaktala 和 Claypool 担心对于ProCESS, ARISE 和 ProMISe 试验结果产生错误解读。有关结果的解读，我们在文章摘要的总结部分这样写到：“对于早期发现且接受静脉抗生素和充分液体复苏的感染性休克患者，根据严格的EGDT方案进行血流动力学治疗不能改善预后。
”Manaktala and Claypool are concerned about misinterpretation of the results of the ProCESS, ARISE, and ProMISe trials. With interpretation in mind, we stated in the Conclusions section of the abstract of our article that “in patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome.”
Paul R. Mouncey, M.Sc.G. Sarah Power, M.Sc.Intensive Care National Audit and Research CentreLondon, United KingdomTimothy J. Coats, M.D.University of LeicesterLeicester, United Kingdom1. The ProCESS Investigators. A randomized trial of protocol based care for early septic shock. N Engl J Med 2014;370:1683-93.2. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-506.3. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.4. Lacroix J, H®¶bert PC, Fergusson DA, et al. Age of transfused blood in critically ill adults. N Engl J Med 2015;372:1410-8.5. Murphy GJ, Pike K, Rogers CA, et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 2015;372:997-1008.
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