Question special

Based on the meta-analysis it appears that early goal-directed therapy is at worst only more costly than usual care, but not harmful. In your conclusions, you suggest that the treatment interactions showing harm towards those with severe liver failure were probably spurious. Are there other studies showing EGDT is harmful? There was an article in JAMA last October that showed definite harm with an early resuscitation protocol in hospitalized patients in Zambia. While the study suggests we may not be as good at the physical exam as we think we are, it also hypothesizes that those with severe illness and malnutrition may be a more vulnerable population. Is there anything we can apply from this study to patients we see in the academic setting? Do you approach these patient’s differently? If so, can you discuss how you would approach, or advise a resident to approach, a septic patient who with end-stage cirrhosis, HIV, etc?

Ref: Andrews B, Semler MW, Muchemwa L, et al. Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: a randomized clinical trial. JAMA. doi:10.1001/jama.2017.10913