1. CHOOSING YOUR TARGETS WHILE RESUSCITATING SEPSIS Antoine Vieillard-Baron, Boulogne, France

2. Crit Care 2008 IS IT REALLY SERIOUS TO BELIEVE THAT EVERYONE COULD BE RESUSCITATED USING THE SAME TARGETS? THIS IS THE MAIN ISSUE OF THE EVIDENCE-BASED MEDICINE

4. CVP 8-12 mmHg SVR MSPRAP From Guyton Physiol Rev 1955 In physiology, the principle is to maintain the CVP as low as possible to promote systemic venous return. And this is the role of the RV

5. CCM 2007

7. MAP > 65 mmHg

8. Laminary flow in a patient under VA ECMO

10. MAP is a determinant for organ perfusion Windkessel effect: Transformation of the pulsatile flow into a continuous one (Stephen Hales 1677-1761) MAP = CO x SVR + RAP Volume, inotropes Vasopressors Volume

11. No change in CO Baseline Vasodilation

12. 388 patients in each group (65-70 versus 80-85)

13. Sv(c)O 2 > 65% (70)

16. Crit Care Med 2012

17. Pattern  1 Pattern  2

18. LACTATE CLEARANCE

19. Jama 2010 Study of non-inferiority Goal: 10% lactate clearance

20. NO DIFFERENCE IN LACTATE CLEARANCE BETWEEN BOTH GROUPS??

21. AJRCCM 2010

23. IS THERE SOMETHING “NEW”?

24. Usual-care: 439 patients EGDT: 446 patients 90d-Mortality ~31-33% May 2014

25. Usual-care: 804 patients EGDT: 796 patients 90d-Mortality ~18% October 2014

26. H0-6Rivers (EGDT) Arise (usual care) ProCESS (usual care) Rivers (control) Fluids (mL)49811713 (+2591) 23003499 Vasopressors (%) 27584430 Red-cell transfusion (%) 6477.518.5 Dobutamine (%) 13.72.60.90.8 CVP (mmHg)13.811.9NA11.8 MAP (mmHg)95757681 60-d mortality (%) 4418.818.957 ProCESS: CVP not permitted in the usual care group Arise: CVP permitted according to physician’s decision (62% of patients)

27. 0.7%/site/3 months

29. CONCLUSION TOO MUCH MONEY TO DEMONSTRATE NOTHING, EXCEPT THAT YOU HAVE TO RESUSCITATE PATIENTS AND THAT TIME IS CRUCIAL LITTERATURE IS VERY CONFUSING AND THE MAIN GOAL SEEMS TO PUBLISH IN “BIG JOURNALS” IN AN IDEAL WORLD, RESUSCITATION HAS TO BE ADAPTED TO EACH PATIENT BASED ON A GOOD KNOWLEDGE OF PHYSIOLOGY