Friday, April 27, 2012

Lactate Clearance and ScvO2 Goals in Sepsis


Early goal-directed sepsis care is successful - but no one can say precisely what makes it successful.  Hawthorne effect?  Early antibiotics appear to have uncertain association with better outcomes.  Is it the blood?  Is it meeting the central venous oxygenation goal of >70%?

Other studies have shown equivalency in outcomes while performing serial lactic acid measurements, and this is another study in the same vein.  203 patients form the analysis cohort, in which 93 received management decisions based on lactate clearance and 110 which received management decisions based on the ScvO2.  All included patients had both values measured simultaneously, but were blinded to the opposition.

And, this is another study where the two measures are different but similar - which is probably why the analysis is so convoluted.  Of the 203 enrolled, 175 either fortuitously or by design met the ScvO2 goal, while 178 met the lactate clearance goal.  Meeting the ScvO2 goal led to a death rate of 21% and meeting the lactate clearance goal led to a death rate of 17%.  There was no difference in therapeutic interventions between the ScvO2 goal group and the lactate clearance group.

However, if you met the lactate clearance without meeting the ScvO2 goal, you had an 8% (2/25) mortality, while the ScvO2 group that didn't clear lactate had a 41% mortality (9/22).  Unfortunately, there were a number of baseline differences between the groups, and it's hard to draw any conclusions or hypotheses from this finding.  It's also clear they didn't identify any specific interventions that improved survival in their cohort - and, more appropriately, simply observed that poor lactate clearance simply portends a worse outcome, without any specific recommendation on how to address it.

"Prognostic Value and Agreement of Achieving Lactate Clearance or Central Venous Oxygen Saturation Goals During Early Sepsis Resuscitation"

2 comments:

  1. interesting article- what I think this shows is less about which goal may be better but that with maximal resuscitation, some patients may still not meet their goals. in this case, ScvO2 and lactate may be prognostic, with this study suggesting not clearing lactate is a worse indicator

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  2. Agreed - it seems more about prognosis than anything. I'm more of a lactate clearance guy, in general, but I do like how EGD has specific guidance regarding treatment based on SCVO2; failing to clear lactate doesn't have a specific prescribed intervention. Fine for creative academicians, not as helpful for busy community docs.

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