A total of 10, patients in 56 ICUs were screened, among whom patients belonging to predefined diagnostic categories with acute physiology scores of 11 or higher were randomly assigned to the three groups. The hemodynamic targets were reached by Mortality was If so, a grave responsibility rests upon ED systems to create and provide evidence-based management strategies targeting severe sepsis and septic shock. Previous studies have examined the effect of therapeutic interventions on outcome in septic shock, such as immuno-therapeutic agents, hemodynamic optimization, or pulmonary artery catheterization but have enrolled patients up to 72 hours after ICU admission.
Rivers et al examined whether early goal-directed therapy EGDT in the ED before ICU admission effectively reduces multi-organ dysfunction and mortality rates in patients with septic shock by using specific criteria for early identification, establishing goals of resuscitation, and implementing a treatment protocol.
This systematic review provides an analysis of studies instituting protocolized hemodynamic optimization for patients with severe sepsis and septic shock in the ED to determine if there is a significant reduction in mortality. Medical subject headings MeSH used were as follows: early goal-directed therapy, goal-directed therapy, goal-oriented therapy, hemodynamic optimization, sepsis bundles, supranormal oxygen delivery, sepsis oxygen delivery, resuscitation endpoints, cardiac optimization, supranormal resuscitation, mixed venous saturation, mixed central venous oxygen saturation, sepsis quality improvement, and sepsis protocol.
We screened references in reviews and relevant trials to identify further pertinent articles. We performed an Internet search with the Google search-engine to identify unpublished abstracts at national and international emergency medicine and critical care conferences.
And we contacted a clinical expert in the field for further assistance JS. Exclusion criteria were studies published prior to , non-English articles, studies not reporting the outcome of short-term mortality, studies not enrolling any patients from the ED, studies excluding septic patients, preliminary studies with later manuscripts reporting the same data, and series with fewer than 10 patients.
Of note, we included studies if a portion of patients were enrolled from the ED, with the remainder being enrolled from hospital floors or intensive care units.
Studies were also included if the treatment protocol administered the following additional treatment interventions: activated protein C, tight glycemic control, low tidal volume ventilation, or corticosteroid administration. To reduce publication bias, we also performed a systematic search for published abstracts that had not been published in manuscript format, even though critical appraisal of such publications is limited.
We also included published abstracts identified as references in relevant review papers. Abstracts explicitly stating that the location of the protocolized hemodynamic optimization intervention was performed only in the ICU and not in the ED were excluded, while all others were included for analysis.
On the data collection form each recorded the primary outcome measure of short-term mortality, secondary outcome measures, and applied a level of evidence score to each study. Secondary outcome measures included: research protocol, administration of other treatments, severity of illness scores, serum lactate levels, Scv02, and hospital length of stay.
Disagreements were solved by discussion. We scored articles with a methodologic quality assessment derived from prior literature. Level 4 studies were not fully prospective, including but not limited to use of a historical or retrospective control group. Level 5 studies were published abstracts or short reports. We used Fisher's exact test and a two tailed p-value to determine statistical significance for the primary endpoint of short-term mortality.
We performed meta-analysis using Comprehensive Meta-Analysis version 2. Pooled estimates are presented within publication type and across all studies. The random effect model assumes that the true effect size can vary from study to study and the pooled effect size is the average.
Database searches identified 1, articles Figure 1. Six hundred forty-four articles met exclusion criteria on electronic review yielding 65 articles that were manually evaluated for clinical relevance. There was The sample size for all studies ranged from 38 to One study was excluded 44 because it had data reported in a later study that was included for analysis.
Overall mortality for protocolized versus non-protocolized hemodynamic optimization for both published studies and published abstracts. Methodologic scores of identified trials that analyzed adult controlled trials implementing protocolized hemodynamic optimization in the emergency department for patients with severe sepsis and septic shock.
All studies used hemodynamic optimization pathways Table 2 with a mean arterial pressure MAP threshold for vasopressors. All studies but one 20 reported mixed central venous Scv02 or mixed venous Sv02 oxygen saturation monitoring. All but two 32 , 33 had transfusion thresholds for red blood cells.
In several studies, selected patients in the protocolized hemodynamic optimization group and control group were permitted to receive Activated Protein C, low tidal volume ventilation ventilation, tight glycemic control, and corticosteroids Table 2. In each identified study there was a lower mortality rate in the protocolized hemodynamic optimization group compared to control groups Table 1.
The cumulative odds ratio for all studies was 0. Relative risk of individual trials. The pooled risk estimates are shown as diamonds. This meta-analysis evaluates the impact of protocolized goal-directed hemodynamic optimization on short-term mortality in patients with severe sepsis and septic shock when initiated in the ED. Pooled data from the 25 included studies contain 9, subjects and demonstrate a Results: The hemodynamic targets were reached by Mortality was Morbidity was less frequent at the time of hospital discharge in the protocol group 1.
Increasing oxygen delivery to achieve normal SvO 2 values and lactate concentration during the immediate postoperative period after cardiac surgery can shorten the length of hospital stay.
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