早期目标导向和乳酸导向治疗成人严重脓毒症和脓毒性休克：随机对照试验的荟萃分析。

Early goal-directed and lactate-guided therapy in adult patients with severe sepsis and septic shock: a meta-analysis of randomized controlled trials.

机构信息

General ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.

Henan Key Laboratory of Critical Care Medicine, Zhengzhou, 450052, China.

出版信息

J Transl Med. 2018 Nov 29;16(1):331. doi: 10.1186/s12967-018-1700-7.

DOI:10.1186/s12967-018-1700-7

PMID:30486885

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6264603/

Abstract

BACKGROUND

The ProCESS, ARISE, and ProMISe trials have failed to show that early goal-directed therapy (EGDT) reduces mortality in patients with severe sepsis and septic shock. Although lactate-guided therapy (LGT) has been shown to result in significantly lower mortality, its use remains controversial. Therefore, we performed a meta-analysis to evaluate EGDT vs. LGT or usual care (UC) in adult patients with severe sepsis and septic shock.

METHODS

Relevant randomized controlled trials published from January 1, 2001 to March 30, 2017 were identified in PubMed, EMBASE, Web of Science, and the Cochrane Library. The primary outcome was mortality; secondary outcomes included red cell transfusions, dobutamine use, vasopressor infusion, and mechanical ventilation support within the first 6 h and Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

RESULTS

Sixteen studies enrolling 5968 patients with 2956 in EGDT, 2547 in UC, and 465 in LGT were included in this meta-analysis. Compared with UC, EGDT was associated with a lower mortality (10 trials; RR 0.85, 95% CI 0.74-0.97, P = 0.01), and this difference was more pronounced in the subgroup of UC patients with mortality > 30%. In addition, EGDT patients received more red cell transfusions, dobutamine, and vasopressor infusions within the first 6 h. Compared with LGT, EGDT was associated with higher mortality (6 trials; RR 1.42, 95% CI 1.19-1.70, P = 0.0001) with no heterogeneity (P = 0.727, I = 0%).

CONCLUSION

EGDT seems to reduce mortality in adult patients with severe sepsis and septic shock, and the benefit may primarily be attributed to red cell transfusions, dobutamine administration, and vasopressor infusions within the first 6 h. However, LGT may result in a greater mortality benefit than EGDT.

摘要

背景

ProCESS、ARISE 和 ProMISe 试验均未能表明早期目标导向治疗（EGDT）可降低严重脓毒症和感染性休克患者的死亡率。虽然乳酸导向治疗（LGT）已被证明可显著降低死亡率，但它的应用仍存在争议。因此，我们进行了一项荟萃分析，以评估 EGDT 与 LGT 或常规治疗（UC）在严重脓毒症和感染性休克的成年患者中的疗效。

方法

我们在 PubMed、EMBASE、Web of Science 和 Cochrane 图书馆中检索了 2001 年 1 月 1 日至 2017 年 3 月 30 日发表的相关随机对照试验。主要结局为死亡率；次要结局包括前 6 小时内红细胞输注、多巴酚丁胺使用、血管加压素输注和机械通气支持以及急性生理学和慢性健康评估 II 评分（APACHE II 评分）。

结果

纳入的 16 项研究共纳入 5968 例患者，其中 EGDT 组 2956 例，UC 组 2547 例，LGT 组 465 例。与 UC 相比，EGDT 组死亡率较低（10 项研究；RR 0.85，95%CI 0.74-0.97，P=0.01），UC 组死亡率>30%的患者亚组中差异更为显著。此外，EGDT 组患者在前 6 小时内接受了更多的红细胞输注、多巴酚丁胺和血管加压素输注。与 LGT 相比，EGDT 组死亡率较高（6 项研究；RR 1.42，95%CI 1.19-1.70，P=0.0001），异质性较低（P=0.727，I=0%）。