Goal-Directed Resuscitation for Septic Shock

Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial

Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA
JAMA. 2010;303:739-746

Study Summary

Early goal-directed fluid resuscitation is the cornerstone of therapy for septic shock, but the optimal target for goal-directed resuscitation has not been well studied. The investigators sought to determine whether lactate clearance and central venous oxygen saturation (ScvO₂) are equally effective as guides for early sepsis resuscitation. A cohort of 300 patients presenting to the emergency department with septic shock were randomly assigned to resuscitation guided either by normalization of ScvO₂ (> 70%) or lactate clearance (at least 10% from baseline or remaining below 2 mmol/L), in addition to standard goals for mean arterial and central venous pressure. The 2 groups did not differ in the treatments that were administered during the 6 hours of goal-directed resuscitation or during the first 72 hours of hospitalization. Death occurred in 23% of patients managed with the ScvO₂ protocol and in 17% of patients managed with the lactate clearance protocol, with no difference in adverse events between the 2 groups. The investigators concluded that early goal-directed fluid resuscitation of patients with septic shock can be safely guided by either ScvO₂ or lactate clearance.

Viewpoint

Although early goal-directed fluid resuscitation has become the de facto standard for management of patients with septic shock, at least according to international guidelines, healthy skepticism persists with respect to the efficacy of such an approach. Skepticism is partly related to the available evidence, which comes from a single-center clinical trial and was graded as 1C in the most recent Surviving Sepsis Campaign guidelines, and to the fact that an algorithmic approach to complex patient management may not be effective. For example, although a low ScvO₂ is abnormal, it does not indicate the underlying pathophysiology that led to the derangement (eg, sepsis, cardiogenic shock, fever). Of greater significance, a high ScvO₂ cannot always be considered normal because dysfunctional tissue oxygen extraction (as in sepsis) may lead to increased ScvO₂ and thus falsely reassure the clinician about the health of the patient. The current study helps to address these concerns by investigating lactate clearance, a marker that has been shown to be associated with better outcomes from fluid resuscitation for septic shock. Although this study was not designed to determine whether one clinical measure was superior to the other, knowing the value of lactate clearance and its apparent equivalence to venous oxygen saturation provides another measure to consider when assessing the complete picture of a critically ill patient with septic shock. These new data are even more important in emergency departments and hospitals without access to rapid or real-time measures of ScvO₂.

Abstract