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

Publication ,  Journal Article
PRISM Investigators, ; Rowan, KM; Angus, DC; Bailey, M; Barnato, AE; Bellomo, R; Canter, RR; Coats, TJ; Delaney, A; Gimbel, E; Grieve, RD ...
Published in: N Engl J Med
June 8, 2017

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 .).

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Published In

N Engl J Med

DOI

EISSN

1533-4406

Publication Date

June 8, 2017

Volume

376

Issue

23

Start / End Page

2223 / 2234

Location

United States

Related Subject Headings

  • Vasoconstrictor Agents
  • Treatment Outcome
  • Survival Analysis
  • Shock, Septic
  • Resuscitation
  • Randomized Controlled Trials as Topic
  • Quality-Adjusted Life Years
  • Practice Guidelines as Topic
  • Middle Aged
  • Male
 

Citation

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PRISM Investigators, ., Rowan, K. M., Angus, D. C., Bailey, M., Barnato, A. E., Bellomo, R., … Yealy, D. M. (2017). Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. N Engl J Med, 376(23), 2223–2234. https://doi.org/10.1056/NEJMoa1701380
PRISM Investigators, Donald M., Kathryn M. Rowan, Derek C. Angus, Michael Bailey, Amber E. Barnato, Rinaldo Bellomo, Ruth R. Canter, et al. “Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis.N Engl J Med 376, no. 23 (June 8, 2017): 2223–34. https://doi.org/10.1056/NEJMoa1701380.
PRISM Investigators, Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R, et al. Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. N Engl J Med. 2017 Jun 8;376(23):2223–34.
PRISM Investigators, Donald M., et al. “Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis.N Engl J Med, vol. 376, no. 23, June 2017, pp. 2223–34. Pubmed, doi:10.1056/NEJMoa1701380.
PRISM Investigators, Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R, Canter RR, Coats TJ, Delaney A, Gimbel E, Grieve RD, Harrison DA, Higgins AM, Howe B, Huang DT, Kellum JA, Mouncey PR, Music E, Peake SL, Pike F, Reade MC, Sadique MZ, Singer M, Yealy DM. Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. N Engl J Med. 2017 Jun 8;376(23):2223–2234.

Published In

N Engl J Med

DOI

EISSN

1533-4406

Publication Date

June 8, 2017

Volume

376

Issue

23

Start / End Page

2223 / 2234

Location

United States

Related Subject Headings

  • Vasoconstrictor Agents
  • Treatment Outcome
  • Survival Analysis
  • Shock, Septic
  • Resuscitation
  • Randomized Controlled Trials as Topic
  • Quality-Adjusted Life Years
  • Practice Guidelines as Topic
  • Middle Aged
  • Male