Saturday, 18 October 2014

Aggressive early resuscitation in sepsis - ARISE

So, ARISE is now out, and what do we have to show for it?

The ARISE trial, released in the NEJM this past fortnight, has led many to believe that Early Goal Directed Therapy is dead.

But what is that exactly?  Can you define what EGDT actually is?

I'm not sure I do.

ARISE, along with the similar trial PROCESS, have found no difference in outcome when you aggressively manage critically ill septic patients for the first 6 hours using an arbitrary protocolised management plan, using arbitrary endpoints (that have never been specifically correlated with outcome) guided by a monitoring device (ScvO2) that has unproven value, when compared with "standard care".

And this is where it gets sticky.

The potential problem with this is that the centres that signed up for the trials are by definition interested in the outcome of the study.  They are likely to be very keen to implement the best treatment they can.  Virtually every hospital in the study had closed model intensive care units staffed with qualified intensivists.  The studies were not randomised by institution, so it is highly likely that the management of the "standard" care patients was far more aggressive than the standard arm of the original River's trial.

Evidence to support this is that the control arm of the ARISE study had one of the lowest mortality rates published in chorts of this type of patient.

My point is this.  By dismissing the concept of EGDT, we may inadvertently introduce complacency into less motivated and knowledgeable sites, who are content to under-resuscitate because "it really doesn't matter what you do in the first 6 hours."

Lets be careful not to throw the baby out with the bathwater.