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

Abstract

ACADEMIC EMERGENCY MEDICINE 2012; 19:252–258 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Lactate clearance (LC) and central venous oxygen saturation (ScvO₂) have been proposed as goals of early sepsis resuscitation. The authors sought to determine the agreement and prognostic value of achieving ScvO₂ or LC goals in septic shock patients undergoing emergency department (ED)‐based early resuscitation. Methods: This was a preplanned analysis of a multicenter ED randomized controlled trial of early sepsis resuscitation targeting three variables: central venous pressure, mean arterial pressure, and either ScvO₂ or LC. Inclusion criteria included suspected infection, two or more systemic inflammation criteria, and either systolic blood pressure of 4 mmol/L. Both ScvO₂ and LC were measured simultaneously. The ScvO₂ goal was defined as ≥70%. Lactate was measured at enrollment and every 2 hours until the goal was reached or up to 6 hours. LC goal was defined as a decrease of ≥10% from initial measurement. The primary outcome was in‐hospital mortality. Results: A total of 203 subjects were included, with an overall mortality of 19.7%. Achievement of the ScvO₂ goal only was associated with a mortality rate of 41% (9/22), while achievement of the LC goal only was associated with a mortality rate of 8% (2/25; proportion difference = 33%; 95% confidence interval [CI] = 9% to 55%). No agreement was found between goal achievement (κ = –0.02), and exact test for matched pairs demonstrated no significant difference between discordant pairs (p = 0.78). Conclusions: No agreement was found between LC and ScvO₂ goal achievement in early sepsis resuscitation. Achievement of a ScvO₂≥ 70% without LC ≥ 10% was more strongly associated with mortality than achievement of LC ≥ 10% with failure to achieve ScvO₂≥ 70%.