严重脓毒症和脓毒性休克患者的早期目标导向性复苏：一项荟萃分析和试验序贯分析

Early goal-directed resuscitation for patients with severe sepsis and septic shock: a meta-analysis and trial sequential analysis.

作者信息

Jiang Li-bing, Zhang Mao, Jiang Shou-yin, Ma Yue-feng

机构信息

Emergency Medicine Research Institute of Zhejiang University; Emergency Medicine Center, Second Hospital Affiliated to Medical College, Zhejiang University, 88# Jie Fang road, Shang Cheng district, 310009, Hangzhou, China.

出版信息

Scand J Trauma Resusc Emerg Med. 2016 Mar 5;24:23. doi: 10.1186/s13049-016-0214-7.

DOI:10.1186/s13049-016-0214-7

PMID:26946514

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC4779580/

Abstract

BACKGROUND

The aim of this study was to explore whether early goal-directed therapy (EGDT) was associated with a lower mortality rate in comparison to usual care in patients with severe sepsis and septic shock.

METHODS

PubMed, EMBASE, Cochrane library and a Chinese database (SinoMed) were searched systematically to identify randomized controlled trials (RCTs) comparing standard EGDT with usual care in resuscitation of patients with severe sepsis and septic shock and the search time could date back to the publication of the study by Rivers in 2001. The study selection, data extraction and methodological evaluation were performed by two investigators independently. The primary outcome was all-cause mortality. The present meta-analysis had been registered in PROSPERO (CRD42015017667).

RESULTS

Our meta-analysis identified 6 studies and enrolling 4336 patients. There was no significant difference in mortality between the two groups, and the pooled odds ratio (OR) was 0.83 (95 % confident interval, CI, 0.64-1.08) with significant heterogeneity (p = 0.02, I(2) = 64%). However, the pooled OR of 3 multicenter RCTs was 1.03 (95% CI, 0.89-1.21) with no heterogeneity (p = 0.78, I(2) = 0%). The effects of EGDT on length of stay in the emergency department and intensive care unit were uncertain, and there was no effect of EGDT on hospital length of stay. There were no differences of mechanical ventilation rate and renal replacement therapy rate between the two groups, and patients in the EGDT group were more admitted in ICU than patients in the control group. During the early 6-h intervention period, patients in the EGDT group received more intravenous fluids, had a higher vasopressor usage rate, higher dobutamine usage rate and higher blood transfusion rate, than patients in the control group. Finally, there was no difference in the incidence of adverse events between the two groups, and the pooled OR was 1.06 (95%CI 0.80-1.39) with moderate heterogeneity (I(2) = 62%, p = 0.07).

DISCUSSION

Our meta-analysis showed that the application of EGDT was not associated with lower mortality rate currently. However it does not mean that it is useless of EGDT in patients with sever sepsis and septic shock. On the contrary, there was no difference in mortality rate between the two groups may be due to the improvement of therapeutic strategies in these patients. And the results may be related to the different compliance rate of EGDT resuscitation bundle.

CONCLUSIONS

The current evidence does not support the significant advantage of Early goal-directed therapy (EGDT) in the resuscitation of patients with severe sepsis and septic shock.

摘要

背景

本研究旨在探讨与常规治疗相比，早期目标导向治疗（EGDT）是否能降低严重脓毒症和脓毒性休克患者的死亡率。

方法

系统检索PubMed、EMBASE、Cochrane图书馆和一个中文数据库（中国生物医学文献数据库），以识别比较标准EGDT与常规治疗用于严重脓毒症和脓毒性休克患者复苏的随机对照试验（RCT），检索时间可追溯至2001年Rivers发表的研究。由两名研究者独立进行研究选择、数据提取和方法学评估。主要结局为全因死亡率。本荟萃分析已在国际前瞻性系统评价注册库（PROSPERO，注册号：CRD42015017667）登记。

结果

我们的荟萃分析纳入了6项研究，共4336例患者。两组死亡率无显著差异，合并比值比（OR）为0.8（95%可信区间，CI，0.64 - 1.08），存在显著异质性（p = 0.02，I² = 64%）。然而，3项多中心RCT的合并OR为1.03（95%CI，0.89 - 1.21），无异质性（p = 0.78，I² = 0%）。EGDT对急诊科和重症监护病房住院时间的影响不确定，且对住院总时长无影响。两组机械通气率和肾脏替代治疗率无差异，EGDT组入住ICU的患者多于对照组。在早期6小时干预期间，EGDT组患者比对照组接受了更多静脉输液，血管升压药使用率、多巴酚丁胺使用率和输血率更高。最后，两组不良事件发生率无差异，合并OR为1.06（95%CI 0.80 - 1.39），存在中度异质性（I² = 62%，p = 0.07）。