ARISE! Everyone got EGDT!

After release of the ProCESS results many bloggers, particularly in the field of emergency medicine, began crowing that early goal directed therapy (EGDT) for septic shock was dead. Many of them openly admitted to having had a death wish on EGDT for some time. My take on ProCESS was a bit different:

What does this all mean?

“Usual care” for sepsis has, over the past decade, incorporated evidence based process improvements, including the principles of EGDT. This is attributable in large part to the Surviving SepsisCampaign, which was once criticized as a marketing campaign disguised as evidencebased medicine.

“Usual care” has now improved to the point where system improvements in the form of bundles may no longer be important...

The real questions addressed by this study concerned which specific components of the resuscitation bundle (EGDT) need to be preserved and which can be dispensed with. It appears now that dobutamine and aggressive transfusion will take a back seat.

That leaves us with the question of the central line. From the ProCESS trial we can conclude that clinical volume assessment is an acceptable alternative to CVP monitoring in many patients. Central venous oxygen saturation is not essential (lactate measurements and clinical parameters are reasonable surrogates).

Now ARISE has been released and the EGDT death wishers have erupted again. I won't go into the details of the paper here. The full text and an appendix detailing what the patients received are available at the link. Suffice it to say: although fewer patients among the controls got a central line (most did though) or received vasoactive drugs (most did in both groups) treatment in the two groups was largely the same.

What was actually being compared in this study? To me it was strictly protocolized EGDT versus EGDT minus the SVO2 monitor with more room for clinical judgment.

In perspective

What do the Rivers study, ProCESS and ARISE tell us? Here's my take:

Volume assessment remains important but the best way to do so is unknown. Do it via CVP, physical exam or other means, however you will.

Assessment of tissue perfusion is important but the best method is unknown, whether via SVO2, lactate monitoring or bedside clinical examination.

Lower transfusion targets can be applied to septic shock just as in other conditions.

Since publication of the Rivers study “usual care” has risen to the standard of EGDT due to uptake of the Surviving Sepsis guidelines.

Guidelines and pathways must leave room for clinical judgment if evidence is to be applied for all it's worth.

EGDT is not dead. The notion is sound. How best to set resuscitation goals and monitor their achievement is not as simple as some have thought.