Evidence for Non-Invasive Protocol
The paper that allowed us to start non-invasive protocols=gamechanger. [1. Jones AE, Shapiro NI, et al.; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010 Feb;303(8):739?46.]
Is septic shock without lactate elevation as sick as those with? This retrospective study would say they are not. Maybe the alactemic septic patient can just be fluid resuscitated and get their pressors without having to worry about going further. [2. J Crit Care 2011;26:435] [3. Crit Care Res Pract. 2012;2012:536852]
Additional evidence [2. Crit Care 2008;12:R33],[2. Crit Care 2006;10:R80]
Napoli AM, Seigel TA. The role of lactate clearance in the resuscitation bundle. Crit Care. 2011;15(5):199. Epub 2011 Oct 24. PubMed PMID: 22078132;
PubMed Central PMCID: PMC3334784.
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010 Feb 24;303(8):739-46. PubMed PMID: 20179283; PubMed Central PMCID: PMC2918907.
Nguyen HB, Kuan WS, Batech M, Shrikhande P, Mahadevan M, Li CH, Ray S, Dengel A; ATLAS (Asia Network to Regulate Sepsis care) Investigators. Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation. Crit Care. 2011;15(5):R229. Epub 2011 Sep 27. PubMed PMID: 21951322; PubMed Central PMCID:PMC3334775.
Rivers EP, Elkin R, Cannon CM. Counterpoint: should lactate clearance be substituted for central venous oxygen saturation as goals of early severe sepsis
and septic shock therapy? No. Chest. 2011 Dec;140(6):1408-13; discussion 1413-9. PubMed PMID: 22147818; PubMed Central PMCID: PMC3244279.
Jones AE. Point: should lactate clearance be substituted for central venous oxygen saturation as goals of early severe sepsis and septic shock therapy? Yes.
Chest. 2011 Dec;140(6):1406-8. PubMed PMID: 22147817; PubMed Central PMCID: PMC3244278.
Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, Willemsen SP, Bakker J; LACTATE study group. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010 Sep 15;182(6):752-61. Epub 2010 May 12. PubMed PMID: 20463176.
Nguyen's Asian quality improvement trial added lactate clearance to standard EGDT. These patients were hemodynamically stable with normal ScvO2 and good fluid loading before trial entrance. After multi-variate analysis, patients who cleared lactate had lower risk of death than those who did not. [2. Nguyen HB et al. Outcome Effectiveness of the severe sepsis resuscitation bundle with the addition of lactate clearance as a bundle item: a multi-national evaluation. Crit Care 2011;15:R229]
This flawed study question lactate non-expressors with septic shock. Unfortunately they looked at lactate level after initial resus [1. Dugas. J Crit Care 2012;27:344]
Lactate Non-Expressors are a distinct and less ill population [1. doi:10.1155/2012/536852]
Lactate predicts mortality all the way up to 20 mmol/L [1. Academic Emerg Med 2012;19:983]
Lactate normalization within 6 hours is the best predictor of survival [1. CHEST. 2012 doi:10.1378/chest.12-0878]
Even in the ICU lactate clearance was the best predictor of death [1. Annals of Intensive Care 2013, 3:3 ]
Evidence for the Invasive Protocol (ScvO2 & Lactate Guided Resuscitation)
Meta-Analysis. [1. Jones AE, Brown MD, et al.; Emergency Medicine Shock Research Network investigators. The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis. Crit Care Med. 2008 Oct;36(10):2734-9.]
The original, the seminal ED sepsis work. [1. Rivers, E, Nguyen, B, et al. (for the Early Goal?Directed Therapy Collaborative Group). Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med. 2001 Nov; 345(19):1368-77.]
2nd RCT: A prospective, randomized controlled trial was performed involving 273 patients in the early stage of shock at risk of potential MODS development.
The incidence of MODS in the EGDT group was significantly lower than that in control group (P=0.002). The Lactate(2), Lactate(4), SOFA(T), SOFA(S), and the number of dysfunctional organs in EGDT group were also significantly lower (P=0.045, 0.016, 0.009, 0.010, 0.002). EGDT was associated with a significantly lower total mortality rate of MODS than the conventional therapy (P=0.007), and also with a significantly lower mortality rate of MODS after controlling for severe sepsis (P=0.047 and 0.044)[1. Chen ZQ, Jin YH, Chen H, Fu WJ, Yang H, Wang RT. Early goal-directed therapy lowers the incidence, severity and mortality of multiple organ dysfunction syndrome. Nan Fang Yi Ke Da Xue Xue Bao. 2007 Dec;27(12):1892-5.]
A point counterpoint debate with Rivers from Chest. [1. Rivers EP. Point: adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest. 2010 Sep;138(3):476?80;discussion 484-5.]
Best Review Article on ScvO2 [3. Am J Resp Crit Care Med 2011;184:514]
One argument to continue to use invasive strategy is that lactate may not detect low, but persistent levels of oxygen debt. [22. Crit Care Med 2004;32:1825]
Reanalysis of the Jones trial shows ScvO2 clearance did not have as good a mortality benefit as lactate clearance, but remember; very view patients needed anything more that fluids/pressors in this trial [11. Puskarich et al. Prognostic Value and Agreement of Achieving Lactate Clearance or Central Venous Oxygen Saturation Goals During Early Sepsis Resuscitation. Acad Emerg Med 2012;19:252]
GENESIS Project [1. J Intensive Care Med. 2012 Aug 17. The GENESIS Project (GENeralized Early Sepsis Intervention Strategies): A Multicenter Quality Improvement Collaborative.]
Intermittent ScvO2 is just as good as Continuous in this prospective cohort trial [cite source='doi']10.1136/emermed-2012-201356[/cite] (Emerg Med J. 2013;30(11):906-909.)
Sonography of the IVC for Prediction of Fluid Responsiveness
[1. Brennan JM, Blair JE, et al. A comparison by medicine residents of physical examination versus hand?carried ultrasound for estimation of right atrial pressure. Am J Cardiol. 2007 Jun;99(11):1614-6.],[2. Brennan JM, Ronan A, et al. Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin J Am Soc Nephrol. 2006 Jul;1(4):749?53. Epub 2006 May 24.],[3. Carr, Brendan G., Dean, Anthony J., et al.; Intensivist Bedside Ultrasound (INBU) for Volume Assessment in the Intensive Care Unit: A Pilot Study. Journal of Trauma?Injury Infection & Critical Care. 2007 Sept: 63(3): 495?502.],[4. Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990 Aug;66(4):493?6.],[1. Moretti R, Pizzi B. Inferior vena cava distensibility as a predictor of fluid responsiveness in patients with subarachnoid hemorrhage. Neurocrit Care. 2010 Aug;13(1):3?9.],[2. Nagdev AD, Merchant RC, et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med. 2010 Mar;55(3):290?5. Epub 2009 Jun 25.],[1. Weekes A., Tassone H., Tayal V.S. et al. 233: The Sonodynamic Study: Comparison of Qualitative Versus Quantitative Assessment and Inter-Rater Reliability In Serial Ultrasonography Evaluations of Inferior Vena Cava Dynamics and Left Ventricular Systolic Function In Fluid Resuscitation of Emergency Department Patients With Symptomatic Hypotension. Annals of Emergency Medicine. 2010 Sept: 56(3), Supplement , Page S77.],[1. Yanagawa, Youichi; Sakamoto, Toshihisa; Okada, Yoshiaki. Hypovolemic Shock Evaluated by Sonographic Measurement of the Inferior Vena Cava During Resuscitation in Trauma Patients. Journal of Trauma?Injury Infection & Critical Care. 2007 Dec. 63(6):1245?1248.][1. Intensive Care Med. 2004 Sep;30(9):1740-6. Barbier C. et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients]
Dialysis study shows IVCCI of >30% predicts hypotension and when it is safe to continue fluid removal [1. Intensive Care Med 2010;36:692]
New study showed ok spec for CVP < 8 and shock index [2. Journal of Critical Care Volume 27, Issue 6, December 2012 Pages 609–615]
Lactate as a Marker for Adequate Resuscitation
Elevated lactate is a marker of severe sepsis
[1. Jansen TC, van Bommel J, et al for the LACTATE study group. Early lactate-guided therapy in Intensive Care Unit patients: A multicenter, open?label, randomized controlled trial. Am J Respir Crit Care Med. 2010 Sept;182(6): 752-761]|[1. Levy MM, Dellinger RP, et al.; Surviving Sepsis Campaign. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010 Feb;38(2):367?74.]|[9. Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, Bellamy SL, Christie JD: Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 2009, 37:1670-1677.]|[10. Okorie ON, Dellinger P: Lactate: biomarker and potential therapeutic target. Crit Care Clin 2011, 27:299-326.][1. Nichol AD, Egi M, Pettila V, et al. Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study. Crit Care 2010;14:R25.]|[3. Mizock BA, Falk JL. Lactic acidosis in critical illness. Crit Care Med 1992;20:80-93.]
|[4. Howell MD, Donnino M, Clardy P, Talmor D, Shapiro NI. Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 2007;33:1892-9.]|[5. Shapiro NI, Howell MD, Talmor D, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med 2005;45:524-8.]|[6. Cady LD, Jr., Weil MH, Afifi AA, Michaels SF, Liu VY, Shubin H. Quantitation of severity of critical illness with special reference to blood lactate. Crit Care Med 1973;1:75-80.]
|[7. Aduen J, Bernstein WK, Khastgir T, et al. The use and clinical importance of a substrate-specific electrode for rapid determination of blood lactate concentrations. JAMA 1994;272:1678-85.]
Persistent elevation of lactate is associated with dismal outcome. Lactate clearance is associated with better outcome.
[11. Bakker J, Gris P, Coffernils M, Kahn RJ, Vincent JL: Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg 1996, 171:221-226]'[12. Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA, Tomlanovich MC: Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 2004, 32:1637-1642]'[13. Arnold RC, Shapiro NI, Jones AE, Schorr C, Pope J, Casner E, Parrillo JE, Dellinger RP, Trzeciak S: Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock 2009, 32:35-39]'[16. Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, Edwards J, Cho T, Wittlake WA: Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 2007, 35:1105-1112.]'[10. Nguyen HB, Loomba M, Yang JJ, et al. Early lactate clearance is associated with biomarkers of inflammation, coagulation, apoptosis, organ dysfunction and mortality in severe sepsis and septic shock. J Inflamm (Lond) 2010;7:6.]'[11. Broder G, Weil MH. Excess Lactate: An Index of Reversibility of Shock in Human Patients. Science 1964;143:1457-9.]'[12. De Backer D. Lactic acidosis. Minerva Anestesiol 2003;69:281-4.]
For more on Lactate, see the FAQ.
In this study, 9.1% of the hypotensive patients had a lactate < 2 and 24.2% had a lactate < 4. [1. Na S. Implementation of a 6-hour severe sepsis bundle in multiple asian countries is associated with decreased mortality. Chest. 2009;136: 20S.]
In this second study, 11.6% of the patients had the lactate <2 and 25% had lactates <4 [2. Cannon CM. The GENESIS Project (GENeralization of Early Sepsis InterventionS): A Multicenter Quality Improvement Collaborative.]
Patients without lactate elevations don't seem to be particularly sick [1. Crit Care Res Pract. 2012;2012:536852.]
Cryptic (Occult) Sepsis
In abstract form, this demonstrated that the cryptic shock patients probably got the lion's share of mortality benefit as opposed to the patients that were already on the downslope. [1. Donnino MW. Cryptic Septic Shock: A Sub-analysis of Early, Goal-Directed Therapy http://meeting.chestpubs.org/cgi/content/abstract/124/4/90S-b]
In a newly published study, they compared cryptic and overt shock patients; the mortality between the two groups was the same. This was a reanalysis of the Jones paper. Of interest, many of the patients in the Occult Shock group had lactates < 4; are these patients less sick? [1. Resuscitation 2011;82:1289]
Kumar proved antibiotic timing is incredibly important in septic shock. [1. Kumar A, Roberts D, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96.]
And it needs to be the correct antibiotic. [1. Kumar A, Ellis P, et al.; Cooperative Antimicrobial Therapy of Septic Shock Database Research Group. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest. 2009 Nov;136(5):1237?48.]
If antibiotics were delayed until after shock recognition, severe sepsis patients did markedly worse. Delay for patients not in shock did not seem to have an effect on mortality [4. Puskarich et al. Crit Care Med 2011;39:2066]
Time from EGDT Criteria to ABX assoc with mortality [1. Crit Care Med 2010; 38:1045–1053]
de Groot showed early antibiotics didn't matter unless the pt was in shock [1. Crit Care 2015;19:194]
Get the operation within 6 hours in perforated viscous [1. Critical Care 2014, 18:R87}
De Backer's Meta-Analysis of dopamine vs. norepi, may be the final piece in making norepi the 1st choice pressor for sepsis [1. CCM 2012;40:725]
Small study only capable of suggesting hypotheses: In patients with Hb 6-8, transfusion improved micro-dialysis assessed lactate/pyruvate ratio. But some patients improved and some got worse. Patients with bad L/P pretransfusion were most likely to improve with transfusion. (Intensive Care Med 2012;38:1843)
Propensity analysis showed decreased mortality in patients who received PRBC transfusion [1. CCM 2012;40:3140]
Barriers to Implementation
Carlbom DJ, Rubenfeld GD. Barriers to implementing protocol?based sepsis resuscitation in the emergency department??results of a national survey. Crit Care Med. 2007 Nov; 35(11):2525?32.
Mikkelsen ME, Gaieski DF, et al. Factors associated with nonadherence to early goaldirected therapy in the ED. Chest. 2010 Sep;138(3):551?8. Epub 2010 Feb 19. Surviving Sepsis Campaign Guidelines
Dellinger RP, Levy MM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008 Jan; 36(1):296?327. Erratum in: Crit Care Med. 2008 Apr;36(4):1394?6. Normal Vital Signs do not predict adequate resuscitation
Rady MY, Rivers EP, Nowak RM. Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med. 1996 Mar; 14(2):218?25. Intubation will improve organ perfusion
Hernandez G, Peña H, et al. Impact of emergency intubation on central venous oxygen saturation in critically ill patients: a multicenter observational study. [1. Crit Care. 2009; 13(3):R63. Epub 2009 May 4.]
In an ED study, placing A-line, CVP, or getting ScvO2 was v. hard [2. Journal of Emergency Medicine Volume 42, Issue 5, May 2012, Pages 503–510]
Still patient benefit even if we miss the 6-hour time window for bundle completion [1. Shock 2011;36(6):542]
When we look at the microcirculation, some patients will actually benefit from MAPs of >65. They used NE and pushed MAP to 85 mm Hg and then checked micro-circ effects with NIRS and SDF [1. Crit Care 2011;15:R222]
Meta-analysis shows norepi is better than dopamine for severe sepsis [1. Crit Care Med 2011;Oct 27-De Backer]
Dopamine causes a-fib–If you wind up with new a-fib in severe sepsis, you have a higher risk of stroke and of death [1. JAMA. 2011;306(20):2248-2254]
Vasopressin even at the 0.4 u/hr dose may impair gastric perfusion [1. Anesthesiology. 2011; 114(6):1396-402]
Classification of what sepsis, severe sepsis, and septic shock varies amongst different studies and affects predicted mortality [2. Intensive Care Med (2012) 38:811–819]
PRBCs in one article do not improve ScvO2 or Organ Function, but not clear that these pts should have received transfusion by EGDT criteria [1. JEM;2012:43(4):593]
The CV and MicroCirc effects of dobutamine. Use if echo evidence of systolic dysfunction [1. Journal of Critical Care, Volume 27, Issue 6, December 2012, Pages 630–638]
EGDT safe and effective in ESRD patients and they got intubated less [1. Critical Care 2004, 8(Suppl 1):P163 (DOI 10.1186/cc2630)]
CRP seems just as good as Procalcitonin for when to stop ABX [cite]23921272 [/cite]
Marik's take on what to do with severe sepsis [1. Annals of Intensive Care 2011;1:17]
Point/Counterpoint on Resuscitation Goals from Rivers and Jones
Proof of my contention of Denominator Shift Bias
[1. JAMA. 2012 Apr 4;307(13):1405-13.]
Many septic patients do not meet criteria within 3 hours [cite source='pubmed']24680548[/cite]
Predictors of Floor Decompensation
Crit Care Med. 2015 May;43(5):983-8. doi: 10.1097/CCM.0000000000000861. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Capp R1, Horton CL, Takhar SS, Ginde AA, Peak DA, Zane R, Marill KA. Author information Abstract OBJECTIVES: Approximately one in every four patients who present to the emergency department with sepsis progresses to septic shock within 72 hours of arrival. In this study, we describe key patient characteristics present within 4 hours of emergency department arrival that are associated with developing septic shock between 4 and 48 hours of emergency department arrival. DESIGN AND SETTING: This study was a retrospective chart review study of all patients hospitalized from the emergency department with two or more systemic inflammatory response syndrome criteria present within 4 hours of emergency department arrival from September 2010 to February 2011 at two large academic institutions. Patients were excluded if they presented with a ST-elevation myocardial infarction, acute stroke, or trauma; had a cardiac arrest prior to arrival; were pregnant; or admitted from the emergency department psychiatric unit or transferred from an outside hospital. We identified patients with within 4 hours of emergency department arrival and identified those with septic shock at 48 hours after emergency department arrival, using a standard set of guidelines. The primary objective was identifying the number of patients who present with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. As to the second objective, we used multivariate logistic regression analysis to identify patient factors associated with the progression of sepsis to septic shock for the aforementioned population. MEASUREMENTS AND MAIN RESULTS: A total of 18,100 patients were admitted from the emergency department, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within 4 hours of emergency department arrival. Although 50 patients presented to the emergency department with septic shock within 4 hours of arrival, 111 patients with sepsis (8.4%) progressed to septic shock between 4 and 48 hours of emergency department arrival. Characteristics associated with the progression of septic shock between 4 and 48 hours of emergency department arrival included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44). CONCLUSION: Approximately 12% of septic emergency department patients develop shock within 48 hours of presentation, and more than half of these patients develop shock after the first 4 hours of emergency department arrival. Over a third of patients who have sepsis within 4 hours of emergency department arrival and develop septic shock between 4 and 48 hours of emergency department arrival are not admitted to an ICU.