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Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis.

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Date
2017-06
Authors
PRISM Investigators
Rowan, Kathryn M
Angus, Derek C
Bailey, Michael
Barnato, Amber E
Bellomo, Rinaldo
Canter, Ruth R
Coats, Timothy J
Delaney, Anthony
Gimbel, Elizabeth
Grieve, Richard D
Harrison, David A
Higgins, Alisa M
Howe, Belinda
Huang, David T
Kellum, John A
Mouncey, Paul R
Music, Edvin
Peake, Sandra L
Pike, Francis
Reade, Michael C
Sadique, M Zia
Singer, Mervyn
Yealy, Donald M
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Abstract
BACKGROUND:After a single-center trial and observational studies suggesting that early, goal-directed therapy (EGDT) reduced mortality from septic shock, three multicenter trials (ProCESS, ARISE, and ProMISe) showed no benefit. This meta-analysis of individual patient data from the three recent trials was designed prospectively to improve statistical power and explore heterogeneity of treatment effect of EGDT. METHODS:We harmonized entry criteria, intervention protocols, outcomes, resource-use measures, and data collection across the trials and specified all analyses before unblinding. After completion of the trials, we pooled data, excluding the protocol-based standard-therapy group from the ProCESS trial, and resolved residual differences. The primary outcome was 90-day mortality. Secondary outcomes included 1-year survival, organ support, and hospitalization costs. We tested for treatment-by-subgroup interactions for 16 patient characteristics and 6 care-delivery characteristics. RESULTS:We studied 3723 patients at 138 hospitals in seven countries. Mortality at 90 days was similar for EGDT (462 of 1852 patients [24.9%]) and usual care (475 of 1871 patients [25.4%]); the adjusted odds ratio was 0.97 (95% confidence interval, 0.82 to 1.14; P=0.68). EGDT was associated with greater mean (±SD) use of intensive care (5.3±7.1 vs. 4.9±7.0 days, P=0.04) and cardiovascular support (1.9±3.7 vs. 1.6±2.9 days, P=0.01) than was usual care; other outcomes did not differ significantly, although average costs were higher with EGDT. Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher serum lactate level, combined hypotension and hyperlactatemia, or higher predicted risk of death) or for hospitals with a lower propensity to use vasopressors or fluids during usual resuscitation. CONCLUSIONS:In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics. (Funded by the National Institute of General Medical Sciences and others; PRISM ClinicalTrials.gov number, NCT02030158 .).
Type
Journal article
Subject
PRISM Investigators
Humans
Shock, Septic
Cardiotonic Agents
Vasoconstrictor Agents
Treatment Outcome
Erythrocyte Transfusion
Combined Modality Therapy
Fluid Therapy
Resuscitation
Hospitalization
Infusions, Intravenous
Hospital Mortality
Survival Analysis
Quality-Adjusted Life Years
Aged
Middle Aged
Cost-Benefit Analysis
Female
Male
Randomized Controlled Trials as Topic
Practice Guidelines as Topic
Permalink
https://hdl.handle.net/10161/21358
Published Version (Please cite this version)
10.1056/nejmoa1701380
Publication Info
PRISM Investigators; Rowan, Kathryn M; Angus, Derek C; Bailey, Michael; Barnato, Amber E; Bellomo, Rinaldo; ... Yealy, Donald M (2017). Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. The New England journal of medicine, 376(23). pp. 2223-2234. 10.1056/nejmoa1701380. Retrieved from https://hdl.handle.net/10161/21358.
This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.
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