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  2. Vol 50, No 4 (2018)
  3. Sinto

Comparison of Survival Prediction with Single versus Combination Use of Microcirculation End Point Resuscitation in Sepsis and Septic Shock

Robert Sinto, Suhendro Suwarto, Djoko Widodo

Abstract


Background: lactate clearance and central venous oxygen saturation (ScvO2) are two methods for determining tissue oxygenation adequacy. There is a controversy regarding method better associates with and predicts sepsis and septic shock patients’ mortality. This study address the association of achieving one or two targets of microcirculatory resuscitation endpoints and early mortality in sepsis and septic shock. Methods: a cohort study was conducted in adult sepsis and septic shock patients in Intensive Care Unit, Cipto Mangunkusumo Hospital, Indonesia. Patients’ resuscitation endpoints data and outcome were observed during the first 120 hours of hospitalization. Cox’s proportional hazard regression analysis was used to analyse the early mortality risk in subject groups achieving lactate clearance target only, ScvO2 target only, both targets, and not achieving any target in 6 hours after onset of resuscitation adjusted for number of organ dysfunction. Results: subjects consisted of 268 patients. There were significant differences in the mortality risk between subjects who achieved both targets with subjects who achieved ScvO2 target only (adjusted hazard ratio [aHR] 13.47; 95% confidence interval [CI] 5.17-35.08) and subjects who not achieve any target (aHR 16.12; 95%CI 7.43-34.95). There were insignificant difference the early mortality risk between subjects who achieved both targets with subjects achieved lactate clearance target only (aHR 2.29; 95%CI 0.83-6.32). Conclusion: in patients with sepsis and septic shock, achievement of lactate clearance and ScvO2 targets associates with similar early mortality risk compared to achievement of lactate clearance target only. However, it associates with lower early mortality risk compared with ScvO2 target only.

Keywords


central venous oxygen saturation; early mortality; lactate clearance; sepsis; septic shock

References


Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801-10.

Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:762-74.

Rhodes A, Evans LE, Alhazzani W, Levy M, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45:486-552.

Hollenberg SM. General hemodynamic support. In: Vincent JL, Carlet J, Opal SM, editors. The sepsis text. Massachusetts: Kluwer Academic Publishers; 2002. h.375-87.

Jones AE, Puskarich MA, Sepsis-induced tissue hypoperfusion. Crit Care Clin. 2009;25:769-79.

Otero RM, Ngunyen HB, Huang DT, Gaiesk DF, Goyal M, Gunnerson KJ, et al. Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings. Chest. 2006;130;1579-95.

Trzeciak S, Cinel I, Dellinger RP, Shapiro NI, Arnold RC, Parrillo JE, et al. Resuscitating the microcirculation in sepsis: the central role of nitric oxide, emerging concepts for novel therapies, and challenges for clinical trials. Acad Emerg Med. 2008;15:399–413.

Arnold RC, Shapiro NI, Jones AE, Schorr C, Pope J, Casner E, et al. Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock. 2009;32:35-9.

Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739-46.

Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32:1637-42.

Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med. 2005;45:524-8.

Trzeciak S, Dellinger RP, Chansky ME, Arnold RC, Schorr C, Milcarek B, et al. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med. 2007;33:970-7.

Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, etal. Trial of early, gol-directedresuscitation for septicshock. N Engl J Med. 2015;372:1301-11.

ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683-93.

The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371:1496-1506.

Surviving Sepsis Campaign. Updated Bundles in Response to New Evidence. 2015.

Macias WL, Nelson DR. Severe protein C deficiency predicts early death in severe sepsis. Crit Care Med. 2004;32:S223-8.

Mikkelsen ME, Gaieski DF, Goyal M, Miltiades AN, Munson JC, Pines JM, et al. Factors associated with nonadherence to early goal-directed therapy in the ED. Chest 2010;138:551-8.

Phua J, Koh Y, Du B, Tang YQ, Divatia JV, Tan CC, et al. Management of severe sepsis in patients admitted to asian intensive care units: prospective cohort study. BMJ. 2011;342:d3245.

Sinto R, Suwarto S, Sedono R, Harimurti K, Sejati A. End point resuscitation-based prediction model for early mortality of severe sepsis and septic shock. Crit Care. 2014;18(Suppl 1):P62.

Moreno R, Vincent JL, Matos R, Mendonca A, Cantraine F, Thijs L, et al. The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care: results of a prospective, multicentre study. Intensive Care Med. 1999;25: 686–96.

Ssekitoleko R, Pinkerton R, Muhindo R, Bhagani S, Moore CC. Aggregate evaluable organ dysfunction predicts in-hospital mortality from sepsis in uganda. Am J Trop Med Hyg. 2011;85:697–702.

Blanco J, Muriel-Bombín A, Sagredo V, Taboada F, Gandía F, Tamayo L dkk. Incidence, organ dysfunction and mortality in severe sepsis: a spanish multicentre study. Crit Care. 2008;12:R158.

Esper AM, Martin GS. Extending international sepsis epidemiology: the impact of organ dysfunction. Crit Care. 2009;13:120.

Osuchowski MF, Welch K, Yang H, Siddiqui J, Remick DG. Chronic sepsis mortality characterized by an individualized inflammatory response. J Immunol 2007;179:623-30.

Xiao H, Siddiqui J, Remick DG. Mechanisms of mortality in early and late sepsis. Infect Immun. 2006;74:5227-35.

Rivers EP, Katranji M, Jaehne KA, Brown S, Dagher GA, Cannon C, et al. Early interventions in severe sepsis and septic shock: a review of the evidence one decade later. Minerva Anestesiol. 2012;78:712-24.

Rivers EP, McIntyre L, Morro DC, Rivers KK. Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity. CMAJ. 2005;173:1054-65.

Ali A, Gearay S, Bennett D, Terblanche M. Lactate and Scv02 combinations do not predict mortality in ICU patients. Crit Care. 2010;12(Suppl 1):P158.

Ngunyen HB, Kuan WS, Batech M, Shrikhande P, Mahadevan M, Li CH, et al. 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:R229.

Beest PA, Hofstra JJ, Schultz MJ, Boerma EC, Spronk PE, Kuiper MA. The incidence of low venous oxygen saturation on admission the the intensive care unit: a multi-center observational study in the netherlands. Crit Care. 2008;12:R33.

Ho KM, Harding R, Chamberlain J, Bulsara M. A comparison of central and mixed venous oxygen saturation in circulatory failure. J Cardiothorac Vasc Anesth. 2010;24:434–9.

Kopterides P, Bonovas S, Mavrou I, Kostadima E, Zakynthinos E, Armaganidis A. Venous oxygen saturation and lactate gradient from superior vena cava to pulmonary artery in patients with septic shock. Shock. 2009;31:561-7.

Nagdyman N, Fleck T, Barth S, Abdul-Khaliq H, Stiller B, Ewert P, et al. Relation of cerebral tissue oxygenation index to central venous oxygen saturation in children. Intensive Care Med. 2004;30:468-71.

Varpula M, Karlsson S, Ruokonen E, Pettila V. Mixed venous oxygen saturation cannot be estimated by central venous oxygen saturation in septic shock. Intensive Care Med. 2006;32:1336–43.

Jones AE, Jackson MS. Point: should lactate clearance be substituted for central venous oxygen saturation as goals of early severe sepsis and septic shock therapy? yes. Chest. 2011:1406-7.


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