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Summary of the Rivers 2001 Trial
Protocolized early goal-directed therapy initiated in the ED in severe sepsis and septic shock patients improved resuscitation parameters and reduced mortality.
Key Points from Rivers 2001
- Included 263 patients presenting to the ED with severe sepsis or septic shock (SIRS + infection + hypoperfusion). Hypoperfusion defined as SBP < 90 mmHg despite 30 mL/kg fluid bolus or lactate > 4 mmol/L
- Randomized patients to standard of care vs. protocolized early goal-directed therapy (EGDT) prior to ICU admission. ED team was not blinded, but accepting ICU team was blinded to treatment assignment
- All EGDT patients received central line capable of continuous ScvO2 and received protocolized care to maximize CVP (goal 8-12 mmHg), MAP (>65 mmHg), ScvO2 (>70%), and Hct (>30%)
- Significant baseline criteria included: lactate 7 mmol/L, anion gap 21 mmol/L, ScvO2 50%, and 95% receiving appropriate antibiotics
- Primary endpoint (hospital mortality) was lower with EGDT (30.5% vs. 46.5%, p=0.009, NNT 6). 28-day and 60-day mortality rates were also lower.
- During the 6-hour resuscitation period, EGDT patients received 5 L of crystalloid, two-thirds received RBC transfusion, more required dobutamine (13.7% vs. 0.8%). Resuscitation metrics (ScvO2, lactate clearance, and MAP) were all improved with EGDT
Citation
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. PMID 11794169
