Sepsis: ProCESS shows Progress

The treatment of severe sepsis, colloquially known as blood poisoning, has underwent a real revolution in the last 10+ years largely on the basis of a seminal paper by Emanuel Rivers.

The Rivers study, conducted at one center, demonstrated impressive morality reductions when septic patients were treated to reach specific physiologic goals (that were essentially set to reflect normal physiology). The study protocol required the insertion of a central venous catheter.

Since that paper, early goal-directed therapy (EGDT) has become the paradigm and is the cornerstone to the sepsis management bundle. 

However, some debate has occurred over which goals are most important to achieve and whether the bundle can be de-bundled.

A major study on this topic, known as ProCESS and led by Pitt, was recently published in The New England Journal of Medicine.

The aim of this study was to determine whether EGDT with or without a central venous catheter for sepsis in emergency departments was superior to routine care. The results of the study, somewhat surprisingly, did not demonstrate any difference in mortality amongst the groups. 

The implication, to me, of this study is that early recognition and prompt treatment of severe sepsis is the key step that must be performed. I think part of this result is explained by the widespread diffusion of the general principles exemplified in the Rivers trial. Whether or not a formal protocol or central venous catheter is in place does not matter if one is treating severe sepsis appropriately. However, not everyone can function without a protocol so smaller hospitals may still fare better under a protocol-driven approach--as the accompanying editorial notes.