Septic shock

Question 1

Early Goal-Directed Therapy

Answer 1

• Early Goal-Directed Therapy (EGDT) - Rivers et al. (2001): EGDT in the first 6 hours of septic shock improved survival rates.
• ProCESS Trial (2014): In patients with septic shock, early goal-directed therapy was not superior to standard care for reducing all-cause mortality at 60 days.
• ARISE Trial (2014): Early goal-directed therapy did not reduce all-cause mortality at 90 days compared to standard care.
• ProMISe Trial (2015): Early goal-directed therapy did not show a reduction in mortality compared to standard care in septic shock.

Question 2

Crystalloid vs. Colloid Fluids

Answer 2

• SAFE Trial (2004): Found no significant difference in 30-day mortality between patients resuscitated with albumin or saline.
• VISEP Trial (2008): In patients with severe sepsis and septic shock, use of lower fluid volume with hyperoncotic hydroxyethyl starch (HES) is associated with increased risk of kidney injury.
• CHEST Trial (2012): Hydroxyethyl starch compared with saline for resuscitation did not decrease mortality but did increase the use of renal-replacement therapy.
• ALBIOS Trial (2014): Albumin replacement in patients with severe sepsis or septic shock did not improve mortality compared with crystalloid fluid.

Menmonic

Question 3

Choice of Crystalloid Fluids

Answer 3

• SPLIT Trial (2015): Found no difference in acute kidney injury when comparing saline to a balanced crystalloid solution (Plasma-Lyte) for fluid resuscitation in the ICU.
• SMART Trial (2018): Use of balanced crystalloids resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline.
• SALT-ED Trial (2018): Similar to the SMART trial, found that balanced crystalloids resulted in fewer adverse kidney events than saline in noncritically ill adults.

Question 4

Steroids in Septic Shock

Answer 4

• CORTICUS (2008): Hydrocortisone did not improve survival or shock reversal in septic shock patients, but hastened reversal of shock in patients who responded to the ACTH test.
• ADRENAL Trial (2018): Hydrocortisone therapy in septic shock patients does not improve 90-day mortality but does hasten resolution of shock and may decrease the duration of the initial episode of mechanical ventilation.

Question 5

Vasopressors in Septic Shock

Answer 5

• VANISH Trial (2016): There was no significant difference in the rate of kidney failure-free days between norepinephrine and vasopressin in septic shock.

Question 6

Antibiotic Timing and Choice

Answer 6

• Kumar et al. (2006): Every hour of delay in administering appropriate antibiotics after the onset of hypotension was associated with an increase in mortality.