Young patient, lactate of 5.2, pneumonia… You know what you're supposed to do–put in the central line and start early goal directed therapy. Problem is, most people can't see sticking a central line in a patient that does not need pressors and otherwise looks well. Yet these patient have an annoying habit of going on to decompensate and perish. Well now there may be another way. Thanks to an article just published in JAMA, we may have a path to non-invasive treatment of severe sepsis. In this EMCrit Podcast, I interview Dr. Alan E. Jones, author of the article, Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Then I discuss how this article changes the game when it comes to caring for severe sepsis patients.
First, here is the article:
[PubMed]
Dr. Alan Jones was the lead author. He and his co-authors from the EMShockNet, designed a 300-patient randomized, controlled trial in 3 academic emergency departments. Patients were adults with essentially the same entry criteria as the original EGDT study. Both groups received the EGDT protocol except one group got continuous ScvO2 monitoring while the other group got serial lactates. Either serial normal lactates (<2 mmol/L) or a decrease in lactate of greater than or equal to 10% was considered equivalent to an ScvO2 > 70. Lactates that were rising or had cleared < 10% were considered equivalent to ScvO2 < 70. Mortality trended towards a higher rate in the ScvO2 group, but by the predetermined trial parameters, both arms were considered equivalent.
I got a chance to interview Dr. Jones and we talked about the following points:
- Though the trial did not specifically test this strategy, the purpose of the study was to find a path to non-invasive care of severe sepsis.
- Only 10% of the patients in either arm required blood transfusions or inotropes
- In young patients, in certain clinical scenarios, we might move to inotropes before blood, in the Hb 7-10 range.
In addition, Dr. Jones mentioned that in an upcoming preplanned sub-analysis we'll actually get to see if the lactate clearance values and ScvO2 correlated.
I then go on to discuss how this article allows a non-invasive path to managing the young pt with severe sepsis. Let's say we have that young pneumonia patient with a lactate of 5.2
- First, give 2L of the crystalloid of your choice
- Make sure that the SaO2 is > 90%
- Then check the IVC non-invasively with ultrasound.
- IVC < 1.5 cm and has a > 50% collapse with deep inhalation, give more fluid.
- IVC > 1.5 cm and very little collapse, move on
- Confirm that the MAP is still >65, if not then place a central line and do standard EGDT
- Check a repeat lactate. If it cleared ? 10%, then you're done
- If it hasn't transfuse if Hb < 7.
- Give inotropes if Hb > 10 or signs of poor heart function on echo
- Hb 7-10, use your judgment
- Keep trending the lactate
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Here’s another approach to the non-invasive assessment of the need for, and response to, fluid challenges in sepsis and shock:
http://www.ncbi.nlm.nih.gov/pubmed/18652712?dopt=Abstract
Dr. Mallon told me about this method. USCOM has developed an ultrasound device that uses a supra-sternal transducer approach to measure changes in Cardiac Output, Stroke Volume and Systemic Vascular Resistance in response to reversible leg-raising induced internal fluid shifts to the central circulation, and he thought it worked pretty well. After reading a few of the published papers, I bought some stock in the company.
Dr. Riner,
I have seen the lit on this device and it is indeed very interesting. Passive leg raising with this device is a great method to assess fluid responsiveness as you mention. We are going to be trialing this device shortly, I believe.
scott
G’day Scott, Like your choice of topic! However, prob doesn’t change the game much in my part of the world… 😉 I’ll be interested to see the paper correlating lactate and ScvO2… For interests sake (probably like many people) I’ll sometimes check a venous gas off the central line and see if I can predict what it will be based on the lactate level and trend. Seems a pretty good match to me – the exceptions will presumably be causes of hyperlactemia other than impaired oxygen delivery/ utilization (the key issues in sepsis). The comment on the rarity of transfusion… Read more »
One comment about peripheral dobutamine; while I cannot find good evidence to support its use peripherally as a continuous infusion, cardiologists routinely give boluses of dobutamine during stress tests to simulate exercise without any concern. Perhaps this would provide a smidge of evidence that there are no deleterios effects should it extravasate.
I’ll keep looking and let you know.
Great podcast.
H-
Haney- that’s a great point!
One more thing….I mis-wrote earlier….the dobutamine is not given in boluses during the stress test, it’s actually given as a continuous infusion during the study; 5 ug/kg/min/kg up to 40ug/kg/min.
…more evidence of peripheral dobutamine safety?
H-
Hey, great review!- keep it up- Just a thought, another noninvasive way to gauge fluid responsiveness is w/an art line and seeing the systemic variation in pulse pressure (although these pt’s are usually intubated to optimize this method)
Hi Scott,
I was wondering how your New York City Severe Sepsis Project was going? Especially your non invasive protocol. I work at a Kaiser in California and working on establishing a protocol similar to yours for our group and wanted to see how your outcomes have been.
Thanks so much!!!
Hi Scott, we do follow lactate clearance. I have a problem with the definition of lactate clearance as it relates to the time gap between the initial and later draw. It would seem logical that if you can decrease lactate by 10% in 2 hours, you are resuscitating the patient better than a decrease 10% decrease in 4 hours. While we follow both, getting a central line placed in the ED and monitoring to start still seems to be a major hurdle to the sepsis bundle in most institutions. I am not sure SVO2 and lactate clearance really relate to… Read more »
Many different skeins in this comment. Lactate > 4, UNTREATED, has a bad mortality. Treated, these folks do v. well. No need for ICU based solely on the initial lactate. Base it on your post-resus lactate. Getting lactate down by 10% was equivalent to standard EGDT in a population that was no that sick. Doesn’t mean that should be your ultimate goal. Ultimate goal should be lactate normalization.
interesting.. especially listening 7 years post-pod