Download Lactate Clearance vs ScVO2 Monitoring in Severe

Lactate Clearance vs ScVO2 Monitoring in Severe Sepsis
17/2/11
Jones, A. et al (2010) “Lactate Clearance vs Central Venous Oxygen Saturation as Goals of
Early Sepsis Therapy: A Randomized Clinical Trial” JAMA, 303(8): 739-746
Early goal directed therapy (EGDT) to decrease mortality and morbidity in the River’s trial
(2001) – although trial heavily criticised.
Resuscitation targets:
- preload = CVP
- afterload = MAP
- tissue oxygen delivery end point controversial (ScvO2 vs lactate clearance)
- continuous spectrophotometric ScVO2 monitoring used in the Rivers trial but may not be
needed if lactate clearance can be shown to be non-inferior.
Goal = to compare lactate clearance as non-inferior to ScVO2 as a resuscitation target in
severe sepsis.
-
MRCT
prospective, randomized, parallel group, non-blinded
January 2007 – 2009
3 US urban hospitals
Inclusion criteria:
- severe sepsis or septic shock admitted to ED
- > 17 years
- confirmed or presumed infection
- 2 or more SIRS criteria
- hypoperfusion (SBP < 90mmHg post 20mL/kg volume or a blood lactate of at least
4.0mmol/L
Exclusion criteria:
-
pregnancy
primary diagnosis other than sepsis
suspected requirement for immediate surgery within 6 hours of diagnosis
an absolute contraindication to chest or neck CVL
CPR
transfer from another institution with a sepsis-specific resuscitative therapy underway
advanced directive orders that would restrict the study procedure
-> ScvO2 group mortality rate = 23%
-> lactate clearance group mortality rate = 17%
-> patients with septic shock and resuscitated to a normal CVP and MAP when randomised to
target SvO2 vs lactate clearance of 10% -> there was no difference in mortality.
-> lactate measurements in peripheral venous blood is as safe and efficacious as a
computerised spectrophotometric catheter in sepsis resuscitation.
Jeremy Fernando (2011)