EBQ:Lactate clearance vs central venous oxygen saturation: Difference between revisions

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

Authors:

@@ Line 31: / Line 31: @@
 ==Exclusion Criteria==
+*Pregnancy
+*Primary diagnosis other than sepsis
-==Interventions==
+*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==