EBQ:Lactate clearance vs central venous oxygen saturation

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.
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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.

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

Sources

Authors

Colin Hoff, Daniel Ostermayer, Ross Donaldson