ARISE and sepsis

 

Essentially, for those who don't know, ARISE is attempting to enrol 1600 patients to look at whether a bundle of care called Early Goal Directed Therapy  is better than standard care in sepsis.

EGDT is an algorithmic approach to sepsis managment where we ensure the following:

SpO2>93% (acheived with oxygen +/- ventilatory support)

CVP>8 (or 12 if ventilated) (achieved with fluid loading)

MAP 65-90 (achieved with noradrenaline)

Antibiotics given early (appropriate ABs, after cultures taken)

Then we add some bells and whistles. Note though that up to this point there is really not much there that is not happening in standard care (except perhaps that we are getting onto things more aggressively because the patient is part of a study) so effectively randomisation kicks in at this point. Standard care patients will have a normal central line and just be managed as usual. EGDT patients will have a special CVC that allows continuous monitoring of ScvO2 (central venous oxygen saturation). If this is < 70% dobutamine is started to increase oxygen delivery and if that doesn't work the patient is transfused up to Hb>100g/L and if that doesn't work the patient is paralysed and cooled to decrease oxygen consumption.

I suspect that we will find that there is no difference and what we will really take away from the study is that we need to do those basic things well. Recognise the septic patient and get in early with fluids, vasopressors, oxygen and antibiotics.

Which brings me to which patients to include. If your patient has a suspected infection and has any physiological derangement they are a potential ARISE subject. Strictly speaking they need suspected infection and two SIRS criteria:

  1. Core temperature < 36.0°C or > 38.0°C
  2. Heart rate > 90 beats/minute
  3. Respiratory rate > 20 breaths/minute or PaCO2 < 32 mmHg or the requirement for mechanical ventilation for an acute process
  4. White blood cell count > 12.0 or < 4.0 x109/L or > 10% immature band forms

Then they need to have some evidence of shock defined as sBP<90 despite 1L fluid bolus OR lactate >4.

There are various exclusion criteria but if your patient is worth giving IV antibiotics to, consider whether they meet any of the SIRS criteria and call ICU and let them sort it out.