Our use of serum lactates as targets for resuscitation in sepsis is more than a little flawed. Once upon a time, we resuscitated using central venous oxygenation as part of the Rivers’ trial. Whether those targets were actually a valid part of the multi-pronged bundle remains an excellent and open question. Of course, CVO2 requires invasive monitoring – and serum lactate became our less-invasive surrogate. And, yes, patients with high lactates do poorly – but that doesn’t specifically address the assumption lactate-guided resuscitation is tied to outcomes, or the optimal resuscitation strategy.
This multi-center trial out of Latin America looks at another marker of perfusion status, capillary refill time, that is likewise observationally associated with mortality in sepsis. In a randomized, open-label trial, the first eight hours of resuscitation was guided either by lactate levels or capillary refill time. Resuscitation in both arms used a specific protocol of fluids, fluid-responsiveness assessments, vasopressors, and inodilators.
Without unpacking these specifics in too great of detail, as will be done by many other critical care physicians, the results are quite interesting: of 424 patients randomized, they observed 34.9% mortality in the CRT-guided cohort compared with 43.4% in the lactate-guided cohort. Other secondary outcomes, including lactates at 48 and 72 hours, SOFA scores at 72 hours, generally favored the CRT cohort.
Is this the end of lacate? Certainly, in a resource austere setting, it would generally indicate there’s no rush to adopt lactate use in the context of a just-as-good, zero-cost means of assessment. The accompanying editorial wonders aloud: why not use both? While this seems like a reasonable idea, it probably doesn’t go far enough – why not use all the data for an individual patient to determine their optimal treatment, rather than our current one-size-fits-all nuclear option? Reliance on any single approach to resuscitation – perhaps mandated by “quality” measures – is almost certain to be short-sighted. While I do not advocate a return to the wild west of late recognition and neglect, these data should add further fuel to a reassessment of our golden idols and targets in the treatment of sepsis.
“Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial”
This is reassuring from a pre-hospital position, where lactate monitoring is seldom available.
There’s been question marks about lactate clearance as a target, or marker of success, for treatment in sepsis for some time now. However, it is still used as a way to identify the severity of disease. Do you think that it would have any use in a pre-hospital setting, given this new information?
I think it’s a little hard to discount the prognostic value of lactate, independent of other physiologic variables or assessments. This study was more interested in using lactate improvement as a clinical target, rather than invalidating it as a measure of illness/organ dysfunction. In the prehospital setting, if the goal is simply aiding early recognition of sepsis for the purposes of alerting a receiving facility, I wouldn’t assume disutility. It is possible there are narrow applications of prehospital interventions that may not be harmful, and may be beneficial.
Hunter CL, Silvestri S, Dean M, Falk JL, Papa L. End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis. American Journal of Emergency Medicine. 2013 Jan; 31(1):64-71.
https://www.ncbi.nlm.nih.gov/pubmed/22867820
A nice non-invasive method for some potentially informative prognostic information pre-hospital.
No one disputes sick people are sick (lactate, ETCO2, SCVO2, etc.), rather we’re still fumbling around trying to determine the target markers to measure adequacy of resuscitation, let alone the best way to actually balance fluids, pressors, and other therapies ….