A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators

作者：Angus, D. C.; Barnato, A. E.; Bell, D.; Bellomo, R.; Chong, C. -R.; Coats, T. J.; Davies, A.; Delaney, A.; Harrison, D. A.; Holdgate, A.; Howe, B.; Huang, D. T.; Iwashyna, T.; Kellum, J. A.; Peake, S. L.^*; Pike, F.; Reade, M. C.; Rowan, K. M.; Singer, M.; Webb, S. A. R.; Weissfeld, L. A.; Yealy, D. M.; Young, J. D.

来源：Intensive Care Medicine, 2015, 41(9): 1549-1560.

DOI：10.1007/s00134-015-3822-1

• Early goal-directed therapy or EGDT
• Resuscitation
• Septic shock
• Central venous oxygen saturation
• Meta-analysis
• Systematic review
• Randomised clinical trials

To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. @@@ Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. @@@ From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2 % [495/2134] versus control: 22.4 % [582/2601]; pooled OR 1.01 [95 % CI 0.88-1.16], P = 0.9, with heterogeneity [I (2) = 57 %; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95 % CI 0.86-1.15), P = 0.93] with no heterogeneity (I (2) = 0.0 %; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95 % CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95 % CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I (2) = 71 %; P < 0.001) but did not change overall results [pooled OR 0.94 (95 % CI 0.82 to 1.07); P = 0.33]. @@@ EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.

• 出版日期2015-9