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What is the evidence behind using early, targeted therapy for my patients presenting with septic shock?
Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock (Rivers Trial)
Rivers E et al. NEJM (November 2001)
Bottom line: This randomized clinical trial compared early goal-directed therapy to standard therapy in 263 patients with severe sepsis or septic shock. Patients randomized to early goal directed therapy received six hours of treatment prior to admission to the intensive care unit, while patients who received standard therapy were the control group. Clinicians were blinded to the treatment assignment. In-hospital mortality, resuscitation endpoints, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups. Early goal-directed therapy was associated with a significantly lower in-hospital mortality rate (30.5%) compared to standard therapy (46.5%), as well as improved resuscitation endpoints and APACHE II scores. These results suggest that early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.
Why should I use a validated tool like the CIWA to guide treatment of alcohol withdrawal?
Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal
Daeppen J B et al. JAMA Intern Med. (May 2002)
Bottom Line: This randomized, double-blind, controlled trial included 117 patients with alcohol dependence and compared a symptom-triggered group with a fixed-schedule group for alcohol withdrawal treatment. 56 patients in the symptom-triggered group were treated with oxazepam when they experienced symptoms of alcohol withdrawal, while 61 were treated with oxazepam every 6 hours in addition to as-needed doses. The primary outcome measures were the amount and duration of oxazepam treatment, incidence of complications, and patient comfort level. Results showed that the symptom-triggered group was associated with a decrease in the quantity of medication (37.5 mg vs. 231.4 mg, P<.001) and duration of treatment (20 hours vs. 62.7 hours, P<.001). Withdrawal complications were limited to a single episode of seizures in the symptom-triggered group. This suggests that symptom-triggered benzodiazepine treatment for alcohol withdrawal is safe, comfortable, and associated with a decrease in the quantity of medication and duration of treatment.
Why is dexamethasone included in empiric therapy for acute bacterial meningitis?
Dexamethasone in Adults with Bacterial Meningitis
de Gans J et al. NEJM (November 2002)
Bottom Line: This prospective, randomized, double-blind, multicenter trial included a total of 301 patients and compared the effects of dexamethasone (10 mg) with placebo in adults with acute bacterial meningitis. The primary outcome measure was the score on the Glasgow Outcome Scale at eight weeks. Treatment with dexamethasone 15 to 20 minutes before or with the first dose of antibiotic and every 6 hours thereafter for four days was associated with a reduction in the risk of an unfavourable outcome (relative risk, 0.59; 95 percent confidence interval, 0.37 to 0.94; P=0.03) and a reduction in mortality (relative risk of death, 0.48; 95 percent confidence interval, 0.24 to 0.96; P=0.04). Among the patients with pneumococcal meningitis, there were unfavourable outcomes in 26 percent of the dexamethasone group, as compared with 52 percent of the placebo group (relative risk, 0.50; 95 percent confidence interval, 0.30 to 0.83; P=0.006). Gastrointestinal bleeding occurred in two patients in the dexamethasone group and in five patients in the placebo group. Thus, early treatment with dexamethasone improves the outcome in adults with acute bacterial meningitis and does not increase the risk of gastrointestinal bleeding.
Trial Files Issue #2023-14
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