Minerva anestesiologica
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Three randomized clinical trials have recently provided data on the lack of effectiveness of "early-goal directed therapy" (EGDT) (i.e. optimization of tissue oxygenation in the first 6 hours since sepsis diagnosis using different therapeutic interventions based on the assessment of the central venous oxygen saturation to titrate such interventions) in the initial management of patients with septic shock. In a first trial including 31 US hospitals (the ProCESS study, N.=1341), three different therapeutic strategies (EGDT vs. protocol-based therapy vs. usual care) were compared and no difference in the primary endpoint (60-day mortality) was found (EGDT 21%, protocol-based therapy 18% and usual care 19%). No significant difference in death by 90 days or in other secondary outcomes, including serious adverse events, was found, as well. ⋯ By 90 days, mortality was similar between groups (29% vs. 29%, respectively; P=0.90). Moreover, EGDT significantly increased costs and was associated with a longer hospital length of stay. We discussed some issues related to the differences between these studies and the pivotal paper from Rivers et al. and how EGDT should be still considered in the treatment of sepsis.
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Minerva anestesiologica · Oct 2015
Observational StudySwiss physicians' perspectives on advance directives in elective cardiovascular surgery.
When patients are incompetent, advance directives (AD) can help physicians take crucial medical decisions. However, prevalence remains low. The objective was to investigate physicians' perspectives and attitudes towards AD in order to determine potential targets for improvement. ⋯ Not all physicians knew the concept of AD. The majority thought that AD were useful and would help patients write them, in order to respect their autonomy. Personal-related factors such as feelings of inducing fear or harm patients were more important than logistic factors in impeding the promotion of AD. Emphasizing AD during medical school might present a potential target to increase AD prevalence, particularly in the preoperative setting.