Earlier this week a major study on the detection and treatment of sepsis was published in the New England Journal of Medicine. The following expert commentary has been produced to contextualise the relevance of these findings.
Sepsis is an important cause of morbidity and mortality. In Scotland there is a national drive (the Scottish Patient Safety Programme) to reduce sepsis-related death by promoting core quality improvement interventions. Therefore, new evidence to inform our current practice is of significance.
In 2001 Rivers E et al. published a landmark study in the New England Journal of Medicine showing that in a single centre involving patients presenting to an emergency department with severe sepsis and septic shock, that early goal-directed therapy (EGDT) using a protocol significantly reduced mortality compared to those receiving usual care.1 This important study underpinned the long-standing tenet of medical practice that early detection and treatment of sepsis will reduce mortality.
The ProCESS US randomised multi-centre study was published in the New England Journal of Medicine on 18 March 2014, with the aim of determining whether the Rivers et al. findings were generalisable and whether all aspects of the protocol in relation to EGDT were necessary.2 The study identified some key findings: there was no difference in mortality (in hospital mortality to 60 days, 90 mortality or one year mortality) between the three arms. This may suggest a negative trial. However, overall mortality was significantly lower than reported in the Rivers study in 2001 despite the fact that this study also included very sick patients. The levels of adherence in the study in relation to early recognition and early antibiotic treatment were high and on par with what one would realistically expect to achieve in real world practice. Therefore, it is a refining trial showing that early recognition and resuscitation are key beneficial interventions. I would suggest that it is the prompts and improved process of care provided by the protocols that improved early recognition, timely treatment and monitoring which drove the lower mortality observed. It is clear that since 2001, the paradigm shift advocated by the study of Rivers et al. has shifted our basic management to improve care. The lack of difference in the three arms suggests that no one resuscitative path is bad or better thereby allowing sites the flexibility of crafting best local approach to care within these. Furthermore, the requirement for intense invasive haemodynamic monitoring, which can be potentially harmful, is probably unnecessary and more focus on less costly, lower risk alternatives such as lactate measurements are equally effective.
In summary, more technical care is not always better but simple interventions applied consistently and timeously are equally effective. We continue to streamline the effective interventions for improved sepsis management.
Professor Dilip Nathwani
Consultant in Infectious Diseases, NHS Tayside
References
1. 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.
http://dx.doi.org/10.1056/NEJMoa010307
2. The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014. Epub 2014 March 18.
