EBQ:Lactate clearance vs central venous oxygen saturation: Difference between revisions
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PMID 20179283
{{JC info
| title= Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
| abbreviation= Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
| expansion= Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
| published= 2010
| author= Jones AE.
| journal= JAMA
| year= 2010
| volume= 303
| issue= 8
| pages= 739-746
| pmid= 20179283
| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=185405
| pdfurl= http://jama.jamanetwork.com/data/Journals/JAMA/4501/jce05001_739_746.pdf
}}
 
==Clinical Question==
Is lactate clearance as good as SVO2 as a measure of oxygen delivery to tissues in patients presenting with severe sepsis and septic shock?
 
==Conclusion==
For patients with septic shock who were treated by normalizing CVP and MAP; attempt to normalize lactate clearance as opposed to normalize SVO2 showed no significant difference in in-hospital mortality.
 
==Major Points==
 
==Inclusion Criteria==
*>17 years old AND
*confirmed or presumed infection meeting criteria for severe sepsis or septic shock:
**2 or more SIRS criteria AND
**SBP <90 after 20 mL/kg bolus or blood lactate at least 36 mg/dL
 
==Exclusion Criteria==
*Pregnancy
*Primary diagnosis other than sepsis
*Likely surgery required within 6 hours of diagnosis
*Contraindication to chest or neck CVC
*Cardiopulmonary resuscitation
*Transfer from an institution with sepsis protocol already underway
*Advance directive restricting study protocol
 
==Interventions==
*Randomized into 1 of 2 resuscitation groups
*CVP was managed first in both groups to achieve a CVP of at least 8
**Isotonic boluses given
*SBP was managed second to maintain a MAP of at least 65
**Fluid resuscitation followed by vasopressors (dopamine and norepi)
*The groups differed in the third physiologic parameter that was targeted: SVO2 vs. lactate clearance
**SVO2 of 70%
**lactate clearance of 10%
**If hematocrit <30 and either target not achieved, PRBC transfusion to achieve hematocrit of at least 30
**If hematocrit was at least 30 and either target not achieved, then dopamine titrated to achieve effect
 
==Outcome==
*Intention to treat analysis
 
===Primary Outcomes===
*Absolute in-hospital mortality rate
**SVO2: 23%
**Lactate: 17%
**Did not reach -10% threshold
 
===Secondary Outcomes===
*ICU length of stay
**SVO2: 8.46%
**Lactate: 7.39%
**p-value = 0.75
*Hospital length of stay
**SVO2: 10.89%
**Lactate: 11.68%
**p-value = 0.60
*Ventilator-free days
**SVO2: 10.39%
**Lactate: 11.09%
**p-value = 0.67
*New onset of multiple organ failure
**SVO2: 25%
**Lactate: 22%
**p-value = 0.68
 
===Subgroup analysis===
 
==Criticisms==
 
 
==Funding==
 
==Sources==
 
 
<references/>
 
[[Category:EBQ]]

Latest revision as of 07:34, 4 November 2014

incomplete Journal Club Article
Jones AE.. "Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial". JAMA. 2010. 303(8):739-746.
PubMed Full text PDF

Clinical Question

Is lactate clearance as good as SVO2 as a measure of oxygen delivery to tissues in patients presenting with severe sepsis and septic shock?

Conclusion

For patients with septic shock who were treated by normalizing CVP and MAP; attempt to normalize lactate clearance as opposed to normalize SVO2 showed no significant difference in in-hospital mortality.

Major Points

Inclusion Criteria

  • >17 years old AND
  • confirmed or presumed infection meeting criteria for severe sepsis or septic shock:
    • 2 or more SIRS criteria AND
    • SBP <90 after 20 mL/kg bolus or blood lactate at least 36 mg/dL

Exclusion Criteria

  • Pregnancy
  • Primary diagnosis other than sepsis
  • Likely surgery required within 6 hours of diagnosis
  • Contraindication to chest or neck CVC
  • Cardiopulmonary resuscitation
  • Transfer from an institution with sepsis protocol already underway
  • Advance directive restricting study protocol

Interventions

  • Randomized into 1 of 2 resuscitation groups
  • CVP was managed first in both groups to achieve a CVP of at least 8
    • Isotonic boluses given
  • SBP was managed second to maintain a MAP of at least 65
    • Fluid resuscitation followed by vasopressors (dopamine and norepi)
  • The groups differed in the third physiologic parameter that was targeted: SVO2 vs. lactate clearance
    • SVO2 of 70%
    • lactate clearance of 10%
    • If hematocrit <30 and either target not achieved, PRBC transfusion to achieve hematocrit of at least 30
    • If hematocrit was at least 30 and either target not achieved, then dopamine titrated to achieve effect

Outcome

*Intention to treat analysis

Primary Outcomes

  • Absolute in-hospital mortality rate
    • SVO2: 23%
    • Lactate: 17%
    • Did not reach -10% threshold

Secondary Outcomes

  • ICU length of stay
    • SVO2: 8.46%
    • Lactate: 7.39%
    • p-value = 0.75
  • Hospital length of stay
    • SVO2: 10.89%
    • Lactate: 11.68%
    • p-value = 0.60
  • Ventilator-free days
    • SVO2: 10.39%
    • Lactate: 11.09%
    • p-value = 0.67
  • New onset of multiple organ failure
    • SVO2: 25%
    • Lactate: 22%
    • p-value = 0.68


Subgroup analysis

Criticisms

Funding

Sources

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