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 ScvO2 data were not available for the usual-care groups), showed no evidence of benefit.
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 data4,5 indicating no evidence of harm caused by transfusions.
”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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发表于 2015-10-13 19:35:43
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