EGDT lactate. Prof. Jan Bakker MD, PhD Chair dept Intensive Care Adults. Tuesday, March 20, 12
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1 EGDT lactate Prof. Jan Bakker MD, PhD Chair dept Intensive Care Adults
2 100 n=156 Hospital mortality (%) r= >3 >4 >5 >6 >7 >8 >9 >10 Lactate mmol/l
3 Intensive Care Med (2007) 33: DOI /s ORIGINAL Michael D. Howell Michael Donnino Peter Clardy Daniel Talmor Nathan I. Shapiro Occult hypoperfusion and mortality in patients with suspected infection Emergency Room
4 J Crit Care 2011;26:435 Persistent sepsis-induced hypotension without hyperlactatemia may not constitute a real septic shock. Our results support the need to review the current definition of septic shock. Hyperlactatemia could represent an objective parameter worth to be explored as a potential diagnostic criterion for septic shock
5 MULTICENTER STUDY OF EARLY LACTATE CLEARANCE AS A DETERMINANT OF SURVIVAL IN PATIENTS WITH PRESUMED SEPSIS Ryan C. Arnold,* Nathan I. Shapiro, Alan E. Jones, Christa Schorr, Jennifer Pope, Elisabeth Casner, Joseph E. Parrillo, R. Phillip Dellinger, Stephen Trzeciak,* and on behalf of the Emergency Medicine Shock Research Network (EMShockNet) Investigators *Department of Emergency Medicine, UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper SHOCK, Vol. 32, No. 1, pp. 35Y39, 2009 TABLE 4. Survivors versus nonsurvivors (n = 166) ORdeath: 4.9 ( ) clearance <10% clearance >10% Survivors (n = 128) Nonsurvivors (n = 38) P Age, mean (SD), y 66 (15) 66 (16) 1.00 SBP G90 mmhg despite i.v. fluids, n (%) 42 (33) 21 (55) 0.02 Initial serum lactate, mean (SD) 4.3 (2.6) 4.7 (2.8) 0.41 Serial serum lactate, mean (SD) 2.2 (1.6) 3.6 (2.8) G0.001 Individual organ failure, n (%) Cardiovascular 42 (33) 21 (55) 0.02 Pulmonary 20 (16) 8 (21) 0.64 Renal 43 (34) 11 (29) 0.70 Hepatic 9 (7) 5 (13) 0.40 Coagulopathy 15 (12) 8 (21) 0.26 Total SOFA score, mean (SD) 3.6 (2.6) 3.7 (2.7) 0.84 Continuous ScvO 2 monitoring, n (%) 112 (87) 36 (95) 0.28 ScvO 2 Q70% achieved, n (%) 99 (88) 26 (72) 0.03 Lactate clearance Q10%, n (%) 122 (95) 29 (76) 0.001
6 Prognostic Value of Blood Lactate Levels: Does the Clinical Diagnosis at Admission Matter? Tim C. Jansen, MD, Jasper van Bommel, MD, PhD, Paul G. Mulder, PhD, Alexandre P. Lima, MD, Ben van der Hoven, MD, Johannes H. Rommes, MD, PhD, Ferdinand T. F. Snellen, MD, and Jan Bakker, MD, PhD JTrauma.2009;66: Fig. 4.
7 Review Article Blood lactate monitoring in critically ill patients: A systematic health technology assessment* Tim C. Jansen, MD; Jasper van Bommel, MD, PhD; Jan Bakker, MD, PhD Crit Care Med 2009 Vol. 37, No. 10 Conclusions: The use of blood lactate monitoring has a place in risk-stratification in critically ill patients, but it is unknown whether the routine use of lactate as a resuscitation endpoint improves outcome. This warrants randomized controlled studies on the efficacy of lactate-directed therapy.
8 Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy Alan Randomized E. Jones, MD Clinical Trial Nathan I. Shapiro, M Table 5. Hospital Mortality and Length of Stay Variable Lactate Clearance Group (n = 150) ScvO 2 Group (n = 150) Abbreviations: ICU, intensive care unit; ScvO,centralvenousoxygensaturation. JAMA. 2010;303(8): (doi: /jama ) Proportion Difference (95% Confidence Interval) In-hospital mortality, No. (%) a Intent to treat 25 (17) 34 (23) 6 ( 3to15) Per protocol 25 (17) 33 (22) 5 ( 3to14) P Value b Length of stay, mean (SD), d ICU 5.9 (8.46) 5.6 (7.39).75 Hospital 11.4 (10.89) 12.1 (11.68).60 Hospital complications Ventilator-free days, mean (SD) 9.3 (10.31) 9.9 (11.09).67 Multiple organ failure, No. (%) 37 (25) 33 (22).68 Care withdrawn, No. (%) 14 (9) 23 (15).15
9 ScvO2 and Lactate ScvO2 60% n=15 7! 6.5! T0 6! Lactate mmol/l! 5.5! 5! 4.5! p<0.01 4! T2 3.5! 3! 45! 50! 55! 60! 65! 70! ScvO2 %!
10 Early Lactate-Guided Therapy in Intensive Care Unit Patients A Multicenter, Open-Label, Randomized Controlled Trial Tim C. Jansen 1, Jasper van Bommel 1, F. Jeanette Schoonderbeek 3, Steven J. Sleeswijk Visser 4, Johan M. van der Klooster 5, Alex P. Lima 1, Sten P. Willemsen 2, and Jan Bakker 1, for the LACTATE study group* 1 Department of Intensive Care, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; 2 Department of Biostatistics, University Medical Centre Rotterdam, Rotterdam, The Netherlands; 3 Department of Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands; 4 Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands; and 5 Department of Intensive Care, St. Franciscus Gasthuis, Rotterdam, The Netherlands LACTATE study group D Gommers 1, B v.d Hoven 1, W Thijsse 1, C Groeninx Van Zoelen 1, J Weigel 1, P Gerritsen 1, B v.d Berg 1, J Lenoble 1, D Reis Miranda 1, J Rischen 1, B. Dellen 1, M Zijnen 1, C Ince 1, E Kompanje 1, C Birsak 1, H de Geus 1, J Epker 1, M Muller 1, W Mol 1, W in t Veld 1, C. Bruning 1, E forman 1, E Klijn 1, P Mulder 2, M Middelkoop 3, J Zandee 3, Wilma Smit 3, G Burggraaff 3, I Meynaar 4, L Dawson 4, M v Spreuwel 4, P Tangkau 4, E Salm 4 5, M. Ruijters 4, N Verburg 4, R. Kleijn 4, A Rietveld 5, P de Feiter 5 and A Brouwers 5 Ikazia hospital Rotterdam St. Fransiscus Gasthuis hospital Rotterdam Reinier de Graaf hospital Delft Erasmus MC Rotterdam ClinicalTrial.gov number NCT Am J Respir Crit Care Med Vol 182. pp , 2010 Originally Published in Press as DOI: /rccm.20091
11 No lactate levels standard therapy every 2h lactate level goal: 20% ScvO2 mandatory goal > 70%
12 MAP>60 mm Hg
13 Log rank test: p = 0.076
14 Subgroups non sepsis sepsis 1,0 1,0 0,8 0,8 Cum Survival 0,6 0,4 Cum Survival 0,6 0,4 0,2 0,2 0,0 0,0 0,00 20,00 40,00 60,00 80,00 100,00 120,00 0,00 20,00 40,00 60,00 80,00 100,00 120,00 opnameduur_zh opnameduur_zh
15 Cox s proportional hazards analysis ICU Mortality HR 0.66 ( ) p=0.037 Hospital mortality HR 0.61 ( ) p=0.006
16 Organ failure SOFA score Control (n=177) Protocol (n=171) Baseline 6.3 ( ) 6.4 ( ) End of protocol (T=8h) Observation time (T=9-72h) 7.2 ( ) 6.9 ( ) 7.0 ( ) 6.4 ( ) ** **
17 Resource use Weaning and ICUstay
18 Differences in treatment following randomization 1100! 1000! 900! Protocol! Control! 800! Fluids (ml)! 700! 600! 500! 400! 300! 200! 100! 0! 0-2h! 2-4h! 4-6h! 6-8h!
19 Survival in relation to baseline lactate level % Protocol Control R 2 =0.83 R 2 = >3 >4 >5 >6 >7 >8 >9 >10 >11 >12 >13 Lactate mmol/l
20 Conclusion Therapy aimed to optimize the balance between oxygen demand and oxygen supply (ScvO2) and decrease lactate levels by 20% /2h for 8h in patients with increased lactate levels reduced inhospital mortality (when corrected for predefined risk factors) and it decreased organ failure and use of health care resources.
Early lactate-guided therapy in ICU patients: a multicenter, open-label,
Page 1 of 58 AJRCCM Articles in Press. Published on May 12, 2010 as doi:10.1164/rccm.200912-1918oc Media embargo until 2 weeks after above posting date; see thoracic.org/go/embargo Early lactate-guided
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