Lactate clearance vs. Scv02 for Early Goal-Directed Therapy
- Included 300 patients presenting to the ED with severe sepsis or septic shock
- Randomized patients to either central venous oxygen saturation (Scv02 > 70%) or lactate clearance (>10% clearance).
- This was the third goal of therapy following maximization of central venous pressure (CVP > 8 mmHg) and mean arterial pressure (MAP > 65 mmHg)
- Lactate clearance = 100 x (lactate initial – lactate delayed) / lactate initial
- Lactate clearance was initially measured 2 hours after initial lactate, and then every hour thereafter.
- Lactate levels less than 2 mmol/L were considered to be at goal
- As with Scv02, if lactate clearance was < 10%, pRBCs and dobutamine were given (based on Rivers 2001 criteria)
- Primary endpoint (hospital mortality rate) was non-inferior between Scv02 and lactate clearance (23% vs. 17%, Cl difference of -3% to +15%)
- The median lactate clearance at 2 hours was 40%
- Baseline lactate levels were much lower than those seen in the original Rivers 2001 early-goal directed therapy trial (7 mmol/L vs. 4 mmol/L)
- Only 10% of patients required pRBC transfusion or dobutamine; thus, the difference in protocol only applied to a minority of study patients
In ED patients with severe sepsis or septic shock, early goal-directed therapy with lactate clearance is non-inferior to central venous oxygen saturation for hospital mortality.