Shock Syndromes I
organ hypoperfusion, is of utmost importance.
Initial resuscitation
Initial goals of therapy are to restore effective tissue perfusion (by administering intravenous
fluids and vasoactive medications) while treating the underlying cause of the syndrome (through
antimicrobial administration and infectious source control, as applicable).
Patients should first be administered a fluid challenge of 30 mL/kg of crystalloid solution as quickly
as possible.
Over the years, quantitative resuscitation has been evaluated in several clinical studies and is no
longer recommended for routine use in patients with sepsis or septic shock.
This strategy includes intensive monitoring (e.g., placement of a central venous [superior
vena cava] catheter or echocardiography), setting goals for hemodynamic support, and using
therapies to achieve those goals (e.g., use and optimization of fluids, vasopressors, and Do2
methods).
ii.
Instead, further resuscitation should be guided by reassessment of hemodynamic parameters.
iii.
Quantitative resuscitation strategies have been evaluated in several large studies.
| (a) | “Early goal-directed therapy” |
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| (1) | The landmark study of early goal-directed therapy evaluated 263 patients with sepsis |
and septic shock treated in the ED for the first 6 hours after presentation.
| (2) | Treatment of patients in the standard therapy group was at the clinician’s discretion, |
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whereas treatment of those in the intervention arm uniformly incorporated a protocol
to achieve the previously mentioned goals and incorporated Scvo2 as a treatment goal
(70% or greater).
| (3) | Early, aggressive, goal-directed resuscitation was associated with a 16% absolute risk |
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reduction in hospital mortality compared with standard therapy (30.5% vs. 46.5%,
p<0.009).
| (4) | Critiques of this study include a higher-than-expected mortality rate in the standard |
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therapy arm, the incorporation of CVP as a resuscitation goal, and the study’s single-
centered nature.
| (5) | Many centers faced logistical and financial barriers to implementing the early goal- |
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directed therapy protocol. As such, alternative approaches to quantitative resuscitation
were developed and studied.
| (b) | Protocolized Care for Early Septic Shock (ProCESS) study |
|---|---|
| (1) | Randomized 1341 ED patients with septic shock in U.S. academic medical centers to |
three treatment arms:
•
Early goal-directed therapy (with the same protocol as noted previously)
•
Protocol-based standard care that did not require use of a central venous catheter
but that used clinician judgment for fluid administration and hypoperfusion,
together with a shock index (heart rate/SBP) of less than 0.8 and an SBP greater
than 100 mm Hg as resuscitation targets
•
Usual care (treatment according to the bedside physician)
| (2) | 60-day mortality did not differ between the treatment arms (early goal-directed |
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therapy 21.0% vs. protocol-based standard care 18.2% vs. usual care 18.9%, p=0.55,
for the three-group comparison).
| (3) | Patients in the early goal-directed therapy arm were more often admitted to the ICU |
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(91.3% vs. protocol-based standard care 85.4% vs. usual care 86.2%, p=0.01).
| (4) | This study has several critiques, primarily a likely shift of usual care toward therapy |
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that resembles quantitative resuscitation (both of which may have contributed to a type
II error).