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Before I write this I should lay my cards on the table – I am a first year doctor who has a fairly good handle on how to read and critique a paper (medicine was my second degree after Biology) but I am by no-means an expert. This summary is not meant to be comprehensive, it merely aims to summarise some of the key points of the paper that we have chosen to discuss as our first Twitter Journal Club paper. I have also not explained some of the more technical terms in detail (mainly due to time-constraints) but good definitions are readily available online (and in likelihood would be far better than something I could write!). If anyone notices any glaring errors please let me know!

Rivers et al. was published in The New England Journal of Medicine 2001. This was a randomised, controlled and predominately blinded study that recruited 263 patients with severe sepsis or septic shock. Patients were recruited over a 3 year period in the emergency department and were randomised into an early goal-directed therapy group or a standard treatment group (as the control). Both groups received 6 hours of treatment under the early goal-directed therapy or standard therapy groups before admission to the intensive care unit. Once in the intensive care unit the clinicians treating the patient were blinded to the treatment assignment. The primary endpoint was in-hospital mortality and mortality was also measured at 28 days and 60 days. The trial used an intention-to-treat approach.

133 patients received standard treatment, had a central venous catheter inserted and were treated according to a protocol for haemodynamic support (outlined in detail in the paper). 130 patients were randomised into the early-goal directed therapy (EDGT) group. These patients also had a central venous catheter inserted, however in the EDGT group the devices were capable of monitoring ScVO2 – monitoring the central venous oxygen saturation of the blood with the aim of keeping it above 70%. Again the treatment the patients received is described in detail in the paper. In both groups outcome measures were measured in the same way.

The headline finding – the in-hospital mortality in the control group was 46.5% vs 30.5% in the EGDT group (p = 0.009). At 28 days and 60 days there was also a statistically significant difference in mortality (p=0.01 and p=0.03) respectively. The conclusion of the paper – that early goal-directed therapy provides significant benefits in outcome for patients with severe sepsis or septic shock.

Please do read the paper before our discussion starts at 8pm and see the post on how the evening’s events will work for details on how we are running this. Looking forward to an interesting critique of this paper…

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For the first Twitter Journal Club paper we have chosen Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock by Rivers et al (to access paper see http://bit.ly/jsxap2). This post aims to give some background to this paper and why so many on Twitter felt it was a good paper to start journal club with.

Sepsis is a medical emergency as any doctor who has been called to see a patient with suspected sepsis knows all too well. In my hospital every F1 starting their rotation is given a card asking in bold “Do you speak sepsis?” and giving details of the Sepsis Six – the six steps that you should be completing within the first hour of seeing such a patient. We are reminded over and over again that this is an emergency where time is of the essence. The OECD Report in 2001 (see http://ssc.sccm.org/background/worldsoldestkiller) found that severe severe sepsis accounts for as many deaths per year as lung, breast and colon cancer combined – a staggering figure.

Sepsis is caused by the body’s reaction to infection and is part of a continuum from a body wide inflammatory response to severe sepsis and septic shock (a terrifying thing for any doctor to manage). Time is of the absolute essence – these patients need treatment implementing within the first hour of them presenting (the sooner the better). Rivers et al published in 2001 examined the effects of early-goal directed therapy in patients with severe sepsis or septic shock before they were admitted to the intensive care unit. I won’t go into details on this paper – that is for tomorrow – but the impact of this paper can be clearly seen – it forms an important part of the Surviving Sepsis Campaign management guidelines. The website for this campaign is a fantastic resource and well worth a look http://www.survivingsepsis.org

Tomorrow (Sunday 5th June) at 8pm UK time (7pm GMT) we will be critiquing this paper in the first, of many I hope, Twitter Journal Club discussions. It would be fantastic to get as many people as possible involved in this discussion using the hashtag #twitjc.

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