• Don’t overdo the fluids. "We want to give patients what they need but not more," Dr. Osborn explained. The 2012 guidelines will recommend that physicians use some sort of fluid challenge test while administering fluid boluses. The goal is to keep giving fluid only so long as hemodynamic improvement is seen in response. This can be achieved in a variety of ways, including monitoring change in pulse pressure, stroke volume variation, heart rate, or arterial pressure.
• Lactate clearance. Serum lactate is recognized as an indicator of global organ hypoperfusion and shock. But incorporating lactate clearance as one of the goals of early sepsis therapy has been "a very hot topic," Dr. Winters observed.
Improved clarity was provided by a prospective 556-patient quality improvement study by investigators in the Asian Network to Regulate Sepsis Care. Patients who got the primary severe sepsis management bundle of care as recommended in the 2008 Surviving Sepsis Campaign guidelines had an unadjusted mortality of 43.6%. This bundle includes early antibiotic administration, hemodynamic monitoring and support, and achievement of a central venous oxygen saturation level greater than 70% by 6 hours. However, patients who got the bundle plus lactate clearance had a 20.5% mortality rate (Crit. Care 2011;15:R229 [doi:10.1186/cc10469]).
The importance of lactate clearance was further underscored by the findings in the GENESIS Project (Generalized Early Sepsis Intervention Strategies). This quality improvement initiative, conducted at five 5 U.S. community hospitals and six tertiary centers, showed a 42.8% mortality in 1,554 historical controls treated for sepsis before implementation of the Surviving Sepsis Campaign resuscitation bundle. In another 4,801 patients who got the bundle, mortality was significantly lower at 28.8%. And, in those who received the bundle plus lactate clearance, mortality further fell to about 22% (J. Intensive Care Med. 2012 [doi:10.1177/0885066612453025]).
Thus, the coming Surviving Sepsis Campaign 2012 guidelines will suggest that in patients with elevated lactate levels as a marker of hypoperfusion, resuscitation should be targeted at normalizing lactate as rapidly as possible (grade 2C). Having said that, however, a normal lactate doesn’t indicate absence of shock. Other factors, such as the patient’s central venous oxygen saturation level, need to be considered as well, the physicians emphasized.
The Surviving Sepsis Campaign guidelines are sponsored by 27 medical organizations. Among them are the Society of Critical Care Medicine, ACEP, the Society of Hospital Medicine, the American College of Chest Physicians, the American Thoracic Society, the Infectious Diseases Society of America, the Surgical Infection Society, the Pediatric Acute Lung Injury and Sepsis Investigators, and a host of international groups.
Dr. Osborn and Dr. Winter reported having no financial conflicts.