Before I write this I should lay my cards on the table – I am a first year doctor who has a fairly good handle on how to read and critique a paper (medicine was my second degree after Biology) but I am by no-means an expert. This summary is not meant to be comprehensive, it merely aims to summarise some of the key points of the paper that we have chosen to discuss as our first Twitter Journal Club paper. I have also not explained some of the more technical terms in detail (mainly due to time-constraints) but good definitions are readily available online (and in likelihood would be far better than something I could write!). If anyone notices any glaring errors please let me know!
Rivers et al. was published in The New England Journal of Medicine 2001. This was a randomised, controlled and predominately blinded study that recruited 263 patients with severe sepsis or septic shock. Patients were recruited over a 3 year period in the emergency department and were randomised into an early goal-directed therapy group or a standard treatment group (as the control). Both groups received 6 hours of treatment under the early goal-directed therapy or standard therapy groups before admission to the intensive care unit. Once in the intensive care unit the clinicians treating the patient were blinded to the treatment assignment. The primary endpoint was in-hospital mortality and mortality was also measured at 28 days and 60 days. The trial used an intention-to-treat approach.
133 patients received standard treatment, had a central venous catheter inserted and were treated according to a protocol for haemodynamic support (outlined in detail in the paper). 130 patients were randomised into the early-goal directed therapy (EDGT) group. These patients also had a central venous catheter inserted, however in the EDGT group the devices were capable of monitoring ScVO2 – monitoring the central venous oxygen saturation of the blood with the aim of keeping it above 70%. Again the treatment the patients received is described in detail in the paper. In both groups outcome measures were measured in the same way.
The headline finding – the in-hospital mortality in the control group was 46.5% vs 30.5% in the EGDT group (p = 0.009). At 28 days and 60 days there was also a statistically significant difference in mortality (p=0.01 and p=0.03) respectively. The conclusion of the paper – that early goal-directed therapy provides significant benefits in outcome for patients with severe sepsis or septic shock.
Please do read the paper before our discussion starts at 8pm and see the post on how the evening’s events will work for details on how we are running this. Looking forward to an interesting critique of this paper…