Lactate Clearance Measures Efficacy of Goal-Directed Therapy in Sepsis
Mortality did not differ significantly when lactate clearance or central venous oxygen saturation was used to measure tissue oxygen delivery.
Goal-directed resuscitation for severe sepsis focuses on three targets: (1) fluid resuscitation to a central venous pressure of 8–12 mm Hg, (2) pressure support to a mean arterial pressure of at least 65 mm Hg, and (3) adequate oxygen delivery (via blood transfusion, dobutamine infusion, or both) to central venous oxygen saturation (ScvO2) of at least 70%. Measurement of ScvO2, however, requires a special catheter. These authors tested the hypothesis that use of lactate clearance >10% is not inferior to use of ScvO2 70% for assessing the adequacy of oxygen delivery.
In a prospective study conducted at the emergency departments of three U.S. medical centers, 300 patients with severe sepsis and septic shock were randomized to resuscitation to a target central venous pressure of 8–12 mm Hg, mean arterial pressure of >65 mm Hg, and either ScvO2 70% or lactate clearance >10% at 2 hours after initiation of resuscitation. The primary outcome was absolute in-hospital mortality. Overall, 23% of patients in the ScvO2 group died, compared with 17% in the lactate clearance group; the 6% difference between groups did not reach the predetermined statistical threshold of a 10% difference. Rates of adverse events were similar between groups.
Early goal-directed therapy in patients with sepsis reportedly decreases mortality by as much as 46%, but the need for a special catheter to measure ScvO2 can be an obstacle to its implementation. This study's findings suggest that a serum lactate decrease of 10% within 2 hours after initiation of sepsis resuscitation is not inferior to an ScvO2 of 70% for measuring adequate oxygen delivery and that lactate measurement might substitute for ScvO2 measurement.
Diane M. Birnbaumer, MD, FACEP
Dr. Birnbaumer works in the same department as Dr. Lewis, the editorialist. However, Dr. Lewis did not participate in Dr. Birnbaumer's coverage of this article.
Published in Journal Watch Emergency Medicine February 26, 2010
Jones AE et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: A randomized clinical trial. JAMA 2010 Feb 24; 303:739.
Lewis RJ. Disassembling goal-directed therapy for sepsis: A first step. JAMA 2010 Feb 24; 303:777.