Septic shock: is it really necessary to place an arterial catheter in all intensive care patients? A major French study calls this routine practice into question

Each year, around 50 million people, including 20 million children, are affected by sepsis, the body's excessive immune response to a serious infection, which remains a major cause of mortality and morbidity in intensive care. Despite advances in management, treatments remain poorly personalized and their results heterogeneous across patients. In most intensive care units, placement of an arterial catheter - a thin probe inserted into an artery to monitor blood pressure continuously - has become an almost automatic procedure for patients in septic shock. But this practice, often considered indispensable, is not as essential as many people think. This is demonstrated by the EVERDAC (Early Versus Deferred Arterial Catheterization)* study, conducted in nine intensive care units in France, thanks to the support of the réseau CRICS-TRIGGERSEP (Clinical Research in Intensive Care & Sepsis Trial Group for Global Evaluation and Research in Sepsis), labeled by F-CRIN.

Coordinated by Drs Grégoire Muller and Thierry Boulain, members of CRICS-TRIGGERSEP and hospital practitioners in the intensive care and resuscitation department at the Centre Hospitalier Universitaire (CHU) d'Orléans, this study, supported by the Ministère de la Santé, sought to find out whether it is really necessary to introduce an arterial catheter in the first few hours of septic shock, or whether it was possible to monitor blood pressure by cuff and delay safe catheter placement.

A widespread practice... but not necessarily justified

In intensive care, the arterial catheter is used to measure blood pressure in real time and facilitate blood sampling. Yet no study had so far proved that this invasive monitoring improved survival. "We realized that some catheters might be placed out of habit, not necessarily necessity, explains Dr. Muller. And this gesture is not trivial: it exposes risks of complications (infections, haematomas, pain, blood loss) and requires care time.

The EVERDAC study: testing a more reasoned approach

EVERDAC compared two strategies in over 1,000 adult patients admitted to the ICU for septic shock:

• Usual strategy: immediate placement of an arterial catheter.
• Deferred non-invasive strategy: cuff monitoring, with catheter placement only if the patient's condition requires it.

The researchers assessed 28-day survival, hospital stay and complications to determine whether a less invasive approach could be as effective.

Towards gentler resuscitation

The results, published in The New England Journal of Medicine, confirm thatthe delayed strategy is as safe as immediate placement: in patients in shock,monitoring blood pressure by cuff and delaying catheter placement results in no more deaths at 28 days. Furthermore, complications related to the arterial catheter (hematoma or local bleeding)were less frequent with the non-invasive strategy: 1% versus 8%. The only minor setback: the automatic cuff caused a little more discomfort in some patients (13% vs. 9%), without severity.

This study could change practices in critical care, in France and abroad:

• Less invasive procedures and pain for patients,
• Less infectious risks,
• Less waste of equipment and blood,
• And time saved for nursing teams.

"Our aim is not to call everything into question, but to adapt our practices to each patient, in a more reasoned and humane way. The study demonstrates that we can start without an arterial catheter and only place it when necessary, without any loss of chance on survival, while reducing local complications." emphasizes Dr. Muller.

*https://clinicaltrials.gov/study/NCT03680963

**https://www.nejm.org/doi/full/10.1056/NEJMoa2502136