One of the fundamental problems of using lactate clearance as a sole resuscitation target is that a normal lactate (< 2mM/L) can be present in 25-50% of septic shock patients. The mortality of these patients is 20-50% even with aggressive therapy. These observations indicate that using lactate and ScvO2 are complimentary endpoints and not mutually exclusive.1-8
1. Levraut J, Ciebiera JP, Chave S, et al. Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction. Am J Respir Crit Care Med. Apr 1998;157(4 Pt 1):1021-1026. 2. Wacharasint P, Nakada TA, Boyd JH, Russell JA, Walley KR. Normal-Range Blood Lactate Concentration in Septic Shock is Prognostic and Predictive. Shock. May 1 2012. 3. Dugas AF, Mackenhauer J, Salciccioli JD, Cocchi MN, Gautam S, Donnino MW. Prevalence and characteristics of nonlactate and lactate expressors in septic shock. J Crit Care. Aug 2012;27(4):344-350. 4. Cannon CM, Holthaus CV, Zubrow MT, et al. The GENESIS Project (GENeralized Early Sepsis Intervention Strategies): A Multicenter Quality Improvement Collaborative. J Intensive Care Med. Aug 17 2012. 5. Hernandez G, Castro R, Romero C, et al. Persistent sepsis-induced hypotension without hyperlactatemia: Is it really septic shock? J Crit Care. Dec 1 2010. 6. Vallet B, Chopin C, Curtis SE, et al. Prognostic value of the dobutamine test in patients with sepsis syndrome and normal lactate values: a prospective, multicenter study. Crit Care Med. Dec 1993;21(12):1868-1875. 7. Rhodes A, Lamb FJ, Malagon I, Newman PJ, Grounds RM, Bennett ED. A prospective study of the use of a dobutamine stress test to identify outcome in patients with sepsis, severe sepsis, or septic shock. Crit Care Med. Nov 1999;27(11):2361-2366. 8. De Backer D, Creteur J, Silva E, Vincent JL. The hepatosplanchnic area is not a common source of lactate in patients with severe sepsis. Crit Care Med. Feb 2001;29(2):256-261. Lactate ≠ScvO2 Kathrina From: [email protected] [mailto:[email protected]] On Behalf Of Erik Benjamin Kulstad Sent: Friday, May 03, 2013 12:59 AM To: Townsend, Sean, M.D. Cc: [email protected] Subject: Re: [Sepsis Groups] Noninvasive EGDT I suspect new insights to this question will be answered by the ProCESS study, which is about to enroll the last patient... https://crisma.upmc.com/processtrial/info2.asp On Wed, May 1, 2013 at 1:47 PM, Townsend, Sean, M.D. <[email protected]<mailto:[email protected]>> wrote: Did you happen to know that all patients in that trial received a central line and that CVP was optimized using it? I think therefore we can’t call that trial “non-invasive.” Also, although that trial enrolled 300 patients, the intervention did not differ until the level of optimizing ScvO2, i.e. all patients that benefited from CVP, a fluid bolus, antibiotics etc. and met targets progressively dropped out of the running to actually compare lactate clearance to ScvO2. Thus, in the end, 29 patients got a head to head comparison of lactate clearance to ScvO2 optimization. This would suggest that enrollment in the trial should have been 3000 patients in order to test the actual difference in intervention at the power requirement of 300. One can make the argument reasonably that the assertion of non-inferiority is underpowered by a factor of 10. One must also wonder about extraordinarily high lactates. None were enrolled in the trial. So, if I have a lactate of 9 and clear it by 10% to 8.1 should I be comfortable that I have hit my resuscitation targets? Doesn’t make me so comfortable. Sean R. Townsend, M.D. Vice President of Quality & Safety California Pacific Medical Center 2330 Clay Street, #301 San Francisco, CA 94115 email [email protected]<mailto:[email protected]> office (415) 600-5770<tel:%28415%29%20600-5770> fax (415) 600-1541<tel:%28415%29%20600-1541> From: [email protected]<mailto:[email protected]> [mailto:[email protected]<mailto:[email protected]>] On Behalf Of Ram Parekh Sent: Tuesday, April 30, 2013 1:50 PM To: Vipul Kella Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Noninvasive EGDT We have at our hospital and at most of the GNYHA hospitals in the New York area. This protocol is based on the non-inferiority study of lactate clearance by Jones/Shapiro and was implemented with our current Stop Sepsis collaborative which has given ED providers the option of utilizing the 'invasive' or 'non-invasive protocol' as EGDT options. Thus, the protocol was simultaneously implemented in over 50 hospitals at the same time. On Mon, Apr 29, 2013 at 9:57 AM, Vipul Kella <[email protected]<mailto:[email protected]>> wrote: Has anyone implemented the noninvasive EGDT protocol at their hospital? What was your experience? -- Vipul Kella, MD FACEP Medical Emergency Professionals (MEP) _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org -- Erik Kulstad, M.D., M.S. 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