[Improvement effect of early goal-directed therapy on the prognosis in patients with septic shock].Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2015 Nov; 27(11):899-905.ZW
To evaluate the effect of the early goal-directed therapy (EGDT) on mortality in patients with septic shock, and to analyze the risk factors of mortality.
A retrospective controlled study was conducted. Complete clinical data of patients with septic shock admitted to emergency intensive care unit (EICU) of Sichuan Provincial People's Hospital from May 1994 to December 2014 were recorded and analyzed. According to the International Guidelines for Management of Severe Sepsis and Septic Shock (SSC) with the time of promulgation as dividing point, the patients were divided into two groups as before and after the publication of the guideline, i.e. early group (from May 1994 to April 2004) and late group (from May 2004 to December 2014). The patients of the late group were subdivided into 6-hour and 24-hour reaching standard groups and non-reaching standard group according to the time of reaching standard of EGDT. All patients were divided into death group and survival group according to the 28-day survival. The patients in early group were not treated according to EGDT guidance, so only age, the case history of chronic disease, the main site of infection, organ dysfunction, vital signs, urine output, the amount of fluid for resuscitation, blood routine, blood gas analysis, time for starting antibiotics treatment, the use of vasoactive drugs and hormone, etc. were recorded. The central venous pressure (CVP), central venous oxygen saturation (ScvO₂), blood lactate (Lac), and the monitor of other parameters of patients in late group were consummated late. The relationship of EGDT compliance standard time and tissue perfusion index recovery time between the two groups of patients was observed. The risk factor for mortality was analyzed by multiple factors logistic regression.
(1) 134 patients were included, and the overall 28-day mortality was 49.25%. (2) The 6-hour EGDT compliance rate of early group was 0 (0/58), and it was 28.95% (22/76) in late group (χ² = 20.087, P = 0.000). Compared with the early group, the 6-hour urine volume in the late group was significantly increased (mL · h⁻¹ · kg⁻¹: 1.72 ± 1.04 vs. 0.89 ± 0.24, t = 11.950, P = 0.001), 6-hour mean arterial pressure (MAP, mmHg, 1 mmHg = 0.133 kPa) was elevated (64.24 ± 3.90 vs. 56.21 ± 5.95, t = 6.444, P = 0.012), the use of antibiotics within 1 hour was increased (76.32% vs. 48.28%, χ² = 11.250, P = 0.001), the use of vasocative drugs (21.05% vs. 89.66%, χ² = 61.942, P = 0.000) and hormone (8.57% vs. 34.48%, χ² = 14.871, P = 0.000) were lowered, and the 28-day mortality rate was lowered significantly [34.21% (26/76) vs. 68.96% (40/58), χ² = 15.897, P = 0.000]. The difference was not statistically significant in the total recovery of liquid volume between late group and early group (mL: 1,856.31 ± 805.81 vs. 1,903.1 ± 897.11, t = 0.101, P = 0.752). (3) In all patients, it was shown by single factor analysis that the age, infection sites , altered mental status at admission, white blood cell (WBC) before treatment, 6-hour urine output after treatment, the number of organ with failure, the use of antibiotics within 1 hour, and incidence of acute renal injury (AKI) or acute lung injury/acute respiratory distress syndrome (ALI/ARDS) within 24 hours were risk factors of 28-day death (P < 0.05 or P < 0.01). In the late group, it was shown by single factor analysis that the age, the case history of chronic disease, infection sites, WBC, pH value, Lac, and ScvO₂ before treatment, 6-hour urine output after treatment, the number of organ with failure, the use of antibiotics within 1 hour, and incidence of AKI or ALI/ARDS within 24 hours were risk factors of 28-day death (P < 0.05 or P < 0.01). It was shown by the logistic regression analysis that aging [odds ratio (OR) = 4.81, P = 0.02], failure of 2 organs (OR = 28.63, P = 0.00) or ≥ 3 organs (OR = 62.69, P = 0.00) were the independent risk factors for mortality in patients with septic shock. (4) The 76 patients of late group were subdivided into three groups, namely 6-hour reaching standard of EGDT group (n = 22), 24-hour reaching standard of EGDT group (n = 28), and non-reaching standard of EGDT group (n = 28). Compared with those before treatment, the Lac after therapy was decreased obviously both in 6-hour EGDT group and 24-hour EGDT group, and the CVP, MAP, and ScvO2 were increased significantly. The Lac in 6-hour EGDT group was lowered more significantly as compared with that in 24-hour EGDT group (mmol/L: 1.64 ± 0.40 vs. 3.01 ± 1.13, P < 0.01), while MAP and ScvO2 were increased significantly [MAP (mmHg): 81.82 ± 18.01 vs. 69.01 ± 9.63; ScvO₂: 0.718 ± 0.034 vs. 0.658 ± 0.036, P < 0.05 and P < 0.01]. The urine output in both reaching standard of EGDT groups was more than 0.5 mL · h⁻¹ · kg⁻¹ without statistically different significance. The 28-day mortality rate of 24-hour EGDT group was 14.29%, and it was 0 in 6-hour EGDT group.
Mortality was as high as 68.96% during 10 years when the period before the use of 2004 SSC, and the mortality rate was lowered to 34.21% during 10 years during which the early fluid resuscitation treatment was based on EGDT. Aging and failure of more than 2 organs were independent risk factors for mortality in patients with septic shock. Compared with reaching the standard of EGDT within 24 hours, reaching the standard of EGDT within 6 hours can rapidly reverse hypoxic-ischemic tissue, thereby improving the prognosis of the patient with lowering of mortality rate.