Early goal-directed therapy reduces mortality in adult patients with severe sepsis and septic shock: Systematic review and meta-analysis

Clinical and Economic Evaluation of the Blood Purification with Selective Sorption Techniques in ICU Patients

The objective was to analyze the clinical and economic feasibility of using selective methods  of lipopolysaccharide (LPS) sorption  for sepsis treatment.

Materials and methods.  A clinical and economic model was used to assess the feasibility of using some technologies of selective lipopolysaccharide sorption. The model was developed in accordance with the current industry standard «Clinical and Economic Research» used in Russia. The target  population was patients of 18 years old and older with sepsis. The methodology involved the evaluation of available randomized clinical trials, as well as studies involving data from network meta-analyses and systematic  reviews of the use of the studied  technologies. The calculation of direct  medical and indirect non-medical  costs was made with an analysis of the impact on the budget  during  the first year and on the time horizon for five years.

Results. The value of direct  and indirect costs was determined when using sorption  devices based on Efferon LPS, Toraymyxin,  Alteco LPS Adsorber,  Toxipak  columns. It was shown that  among the therapeutic alternatives, the use of the Efferon LPS column had the least burden on the budget.

Conclusion. The  use of selective  lipopolysaccharide sorption  technologies in the  intensive  care program  for sepsis patients, although accompanied  by an increase  in direct  and indirect financial costs, leads to budget  savings in the medium  term. Improving  the mechanism  for compensating the costs of using this technology is a promising way to improve the outcomes of sepsis treatment.

Comparison of Intermittent versus Continuous Superior Venal Caval Oxygen Saturation Monitoring in Early Goal Directed Therapy in Septic Shock: A Systematic Review

Early goal directed therapy (EGDT) is a bundle of care (monitoring ScvO2 and lactate along with clinical parameters and instituting therapy) that has shown to improve outcomes in patients with septic shock. We conducted a systematic review of clinical trials and observational studies to compare intermittent versus continuous monitoring of ScvO2. We did major database searches till August 2020. Hospitalized children (>2 months age) and adults with septic shock were included. The intervention was “intermittent ScvO2 monitoring,” and the comparator was “continuous ScvO2 monitoring.” The primary outcome is “all-cause mortality.” Of 564 citations, 3 studies (n = 541) including both children and adults were included in the analysis. There was no significant difference in the “overall/all-cause mortality” (two randomized controlled trials; 258 participants) between the “intermittent” and “continuous” ScvO2 monitoring groups (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.8–1.24). However, a single observational study (283 participants) showed a significant increase in mortality in the intermittent group (RR: 1.46; 95% CI: 1.03–2.05). The GRADE evidence generated for “overall/all-cause mortality” was of “moderate certainty.” To conclude, the present meta-analysis did not find any significant difference between “intermittent” and “continuous” ScvO2 monitoring in patients with septic shock.

Quality assessment of meta-analyses evaluating randomized clinical trials to improve the prognosis of septic shock: an overview of systematic reviews

Objective: Clinical guidelines for the treatment of septic shock are based on the studies with the best scientific evidence, which are meta-analyses of clinical trials. However, these meta-analyses may have methodological limitations that prevent their conclusions from being extrapolated to routine clinical practice. Therefore, the objective of this study is to determine the quality of these meta-analyses through a systematic review.Methods: In this systematic review, we searched MEDLINE, Scopus and EMBASE from inception to May 2019. We selected meta-analyses from clinical trials that determined the effectiveness of an intervention in reducing the incidence of mortality in patients with septic shock. All items were extracted from the Overview Quality Assessment Questionnaire (OQAQ), which collects information from both systematic reviews and meta-analyses.Results: A total of 34 studies were included. Most elements of the OQAQ were conducted satisfactorily, although 35.3% of meta-analyses did not use a quality assessment of the studies included in other analyses. In 52.9% of meta-analyses, the quality of the studies was high or very high.Conclusions: The methods used to obtain the results should be taken into account when recommending an intervention to treat septic shock if the evidence comes from a meta-analysis of the analyzed characteristics.

'Intermittent' versus 'continuous' ScvO2 monitoring in children with septic shock: a randomised, non-inferiority trial

PURPOSE

To compare the effect of 'intermittent' central venous oxygen saturation (ScvO₂) monitoring with 'continuous' ScvO₂ monitoring on shock resolution and mortality in children with septic shock.

METHODS

Primary outcome was the achievement of therapeutic goals or shock resolution in the first 6 h. We randomly assigned children < 17 years' age with septic shock to 'intermittent ScvO₂' or 'continuous ScvO₂' groups. All children were subjected to subclavian/internal jugular line insertion and managed as per Surviving Sepsis Campaign Guidelines. To guide resuscitation, we used ScvO₂ estimated at other clinical and laboratory parameters were monitored similarly in both groups.

RESULTS

We enrolled 75 and 77 children [median (IQR) age: 6 (1.5-10) years] in the 'intermittent' and 'continuous' groups, respectively. Baseline characteristics were comparable between the groups. When compared to the 'continuous' group, fewer children in the 'intermittent' group achieved shock resolution within first 6 h [19% vs. 36%; relative risk (RR) 0.51; 95% CI 0.29-0.89; risk difference - 18.0%; 95% CI - 32.0 to - 4.0]. The lower bound of confidence interval, however, crossed the pre-specified non-inferiority margin. There was no difference in the proportion of children attaining shock resolution within 24 h (63% vs. 69%; RR 0.86; 95% CI 0.68-1.08) or risk of mortality between the groups (47% vs. 43%; RR 1.06; 95% CI 0.74-1.51).

CONCLUSIONS

Given that a greater proportion of children attained therapeutic end points in the first 6 h, continuous monitoring of ScvO₂ should preferably be used to titrate therapy in the first few hours in children with septic shock. In the absence of such facility, intermittent monitoring of ScvO₂ can be used to titrate therapy in these children, given the lack of difference in the proportion of patients achieving shock resolution at 24 h or in risk of mortality between the intermittent and continuous groups.

The effect of early goal-directed therapy for treatment of severe sepsis or septic shock: A systemic review and meta-analysis

PURPOSE

To assess the effects of early goal-directed therapy (EGDT) on reducing mortality compared with conventional management of severe sepsis or septic shock.

MATERIALS AND METHODS

We included a systemic review, using the Medline and EMBASE. Seventeen randomized trials with 5765 patients comparing EGDT with usual care were included.

RESULTS

There were no significant differences in mortality between EGDT and control groups (relative risk [RR], 0.89; 95% confidence interval [CI], 0.79-1.00), with moderate heterogeneity (I2=56%). The EGDT was associated with lower mortality rates when the mortality rate of the usual care group was greater than 30% (12 trials; RR, 0.83; 95% CI, 0.72-0.96), but not when the mortality rate in the usual care group was less than 30% (5 trials; RR, 1.03; 95% CI, 0.92-1.16). The mortality benefit was seen only in subgroup of population analyzed between publication of the 2004 and 2012 Surviving Sepsis Campaign guidelines, but not before and after these publications.

CONCLUSION

This meta-analysis was heavily influenced by the recent addition of the trio of trials published after 2014. The results of the recent trio of trials may be biased due to methodological issues. This includes lack of blinding by incorporating similar diagnostic and therapeutic interventions as the original EGDT trial.

Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

Severe sepsis and septic shock are major causes of morbidity and mortality in patients entering the emergency department (ED) or intensive care unit (ICU). Despite substantial efforts to improve patient outcome, treatment of sepsis remains challenging to clinicians. In this context, early goal directed therapy (EGDT) represents an important concept emphasizing both early recognition of sepsis and prompt initiation of a structured treatment algorithm. As part of the AME evidence series on sepsis, we conducted a systematic review of all randomized controlled EGDT trials. Focus was laid on the setting (emergency department versus ICU) where EGDT was carried out. Early recognition of sepsis, through clinical or automated systems for early alert, together with well-timed initiation of the recommended therapy bundles may improve patients' outcome. However, the original "EGDT" protocol by Rivers and coworkers has been largely modified in subsequent trials. Currently, many investigators opt for an "expanded" EGDT (as suggested by the Surviving Sepsis Campaign). Evidence is also presented on the effectiveness of automated systems for early sepsis alert. Early recognition of sepsis and well-timed initiation of the SSC bundle may improve patient outcome.

Effect of early goal directed therapy in the treatment of severe sepsis and/or septic shock

BACKGROUND

Many investigators have reproduced the mortality reduction shown in the original trial of early goal directed therapy (EGDT) in patients with severe sepsis and/or septic shock. Three large randomized controlled trials (RCTs) found neutral results when compared to usual care and a modified form of EGDT. Some have interpreted these studies as a reason to question the efficacy of EGDT.

OBJECTIVES

The purpose of this study was to comprehensively examine the effect of EGDT in the treatment of severe sepsis and/or septic shock in the literature.

METHODS

A systematic review and meta-analysis of RCTs and prospective studies were performed, which extracted studies from PubMed, Elsevier ScienceDirect, Cochrane, Clinicaltrials.gov, Google Scholar, China Knowledge Resource Integrated Database, and Wanfang Database. The mortality trend in the control group from included studies was analyzed.

RESULTS

Seven RCTs and twelve prospective studies enrolling 3502 EGDT and 3791 usual care participants were included in the analysis. EGDT was found to reduce overall mortality compared to usual care groups. This reduction in mortality was apparent in prospective and randomized control trials conducted before 2010. Over this time period there was a reduction in mortality in patients receiving usual care.

LIMITATIONS

This conclusion was limited by the small size of some selected studies and complicated by the long range of time during the conduction of these studies. These studies were further biased because of the lack of blinding and the crossover of care between the EGDT and usual care groups.

CONCLUSIONS

EGDT significantly reduced mortality in patients with severe sepsis and/or septic shock over 15 years since its publication. Recent studies examining usual care with EGDT have similar mortality benefit because of the diminished treatment effect. This treatment effect is diminished for multiple reasons. With progress in the management of this disease the benefit of EGDT on overall mortality has become comparable with the usual care for sepsis patients. This is because many of the components of EGDT have been incorporated into usual care protocols. As a result, the conclusion that EGDT is ineffective cannot be made. A more rigorous RCT which adjusts for the factors that narrows the treatment effect between groups is required. Given the current state of sepsis care and equipoise that exist, this would be difficult.

The effect of parenteral selenium on outcomes of mechanically ventilated patients following sepsis: a prospective randomized clinical trial

Background

Sepsis and septic shock is characterized by oxidative stress that mainly promotes systemic inflammation and organ failure due to excessive free radical production and depletion of antioxidant defenses. Therefore, we investigated the effect of selenium administration on antioxidant status, levels of cytokines and clinical outcomes.

Methodology

This study was a prospective randomized control trial (RCT) whereby patients received selenium as sodium selenite (2 mg IV bolus followed by 1.5 mg continuous infusion for 14 days) plus standard therapy. The control group received standard therapy without selenium. The primary endpoint was 28-day mortality. The changes in the mean levels of glutathione peroxidase (GPX) activity, IL-6, IL-8 and IL-10, the incidence of ventilator-associated pneumonia (VAP) and other secondary endpoints were also recorded. VAP was broken down into early VAP and late VAP to see the clinical significance of each. We also recorded any adverse outcomes from selenium infusion.

Results

Over 24-month period, 54 patients were recruited and randomized and an intention to treat (ITT) principle was applied (selenium, n = 29; control, n = 25) in the final analysis. There was no statistically significant difference between the two groups in 28-day mortality although it was lower in the selenium group compared with the control group: 9 (31 %) in the selenium versus 10 (40 %) in the control groups (p = 0.49). At day 0, GPX activity was 0.185 ± 0.3 versus 0.19 ± 0.3 U/mL (p = 0.9), day 3, GPX activity was 0.52 ± 0.5 versus 0.17 ± 0.2 U/mL (p = 0.02), at day 7 it was 0.55 ± 0.5 versus 0.24 ± 0.3 U/mL (p = 0.032), at day 10 it was 0.62 ± 0.7 versus 0.33 ± 0.4 U/mL (p = 0.048) and at day 14 it was 1.1 ± 1 versus 0.89 ± 1 U/mL (p = 0.70) for the selenium versus control groups, respectively. However, there were no significant differences between the mean plasma levels of all the three inflammatory cytokines at any point in time between the two groups. There was a significant reduction in occurrence of VAP in the selenium group compared with the control group (55.2 versus 84 %, p = 0.023), respectively.

Conclusion

High-dose selenium administration within the time frame of early goal-directed therapy was not resulted in reduction of 28-day mortality, but increased the activity of glutathione peroxidase with no effect on the levels of inflammatory cytokines at any point in time in mechanically ventilated septic patients. However, selenium supplementation in mechanically ventilated patients following sepsis was associated with reduced occurrence of VAP.

Trial registration: IRCT201212082887N4 at WHO Clinical Trial Registry, August 29, 2014