FROM CEM SEPSIS TOOLKIT

PAPERS TO COVER

NGUYEN

EARLY LACTATE CLEARANCE IS ASSOCIATED WITH IMPROVED OUTCOME IN SEVERE SEPSIS AND SEPTIC SHOCK P

Single centre prospective observational study of patients with septic shock

I

All patients had a central line & art line, had fluids to achieve a CVP of 8-12mmHg and vasoactive agents to achieve a MAP of >65mmHg & a U/O > 0.5mL/kg/hr

C

In hospital mortality and the association with multiple laboratory values including lactate clearance

O

Survivors; lactate clearance 38.1

Non survivors; lactate clearance 12.0

Significant p-value of .005

JANSEN

THE PROGNOSTIC VALUE OF BLOOD LACTATE LEVELS RELATIVE TO THAT OF VITAL SIGNS IN THE PRE-HOSPITAL SETTING: A PILOT STUDYP

Prospective observational study of 124 patients with

Systolic BP < 100mmHg or

RR <10 or > 29 or

GCS < 14

Epileptic seizures excluded

I

venous/capillary lactates were taken as soon as possible

C

Looked to find a cut off of lactate that best predicited in patient mortality ROC curves,

O

A lactate of 3.5mmol/L had a PPV of 44% and a NPV 88% ,The AUC was poor at 0.69 (95% CI 0.58-0.8)

JONES 2010

LACTATE CLEARANCE VS CENTRAL VENOUS OXYGEN SATURATION AS GOALS OF EARLY SEPSIS THERAPY: A RANDOMIZED CLINICAL TRIAL P

RCT of patients with septic shock

I

Sepsis treatment with ScvO2 monitoring vs lactate clearance

see next 2 slides

JONES 2010SCVO2 GROUP

Crystalloid boluses to a CVP of 8-12 mmHg

Aim for a MAP of >65 mmHg if not achieved with crystalloid give vasopressors(dopamine/norepi)

ScvO2 goal of ≥ 70% after CVP and MAP met

If HCT< 30% PRBCs given

If still <70% dobutamine was given

JONES 2010LACTATE GROUP

Crystalloid boluses to a CVP of 8-12 mmHg

Aim for a MAP of >65 mmHg if not achieved with crystalloid give vasopressors(dopamine/norepi)

Lactate clearance goal of >10%

Clearance was check between initial lactate and ≥ 2 hrs later

If HCT< 30% PRBCs given

If still <70% dobutamine was given

If treatment was to be continued due to inadequate lactate clearance and hct > 30% then serial lactate samples were taken 1 hourly

JONES 2010

LACTATE CLEARANCE VS CENTRAL VENOUS OXYGEN SATURATION AS GOALS OF EARLY SEPSIS THERAPY: A RANDOMIZED CLINICAL TRIAL C

Inferiority comparison of In hospital mortality rate

O

The study concluded no inferiority in the lactate group

Lactate clearance in-hospital mortality rate 17% (95%CI 11-24%)

ScvO2 in-hospital mortality rate 23% (95% CI 17-30%)

REFERENCES

CEM Sepsis Toolkit

Nguyen, H. Bryant, et al. "Early lactate clearance is associated with improved outcome in severe sepsis and septic shock*." Critical care medicine 32.8 (2004): 1637-1642.

Jansen, Tim C., et al. "The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study." Crit Care 12.6 (2008): R160.

Jones, Alan E., et al. "Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial." Jama 303.8 (2010): 739-746.