2. FROM CEM SEPSIS TOOLKIT

3. PAPERS TO COVER

4. NGUYEN EARLY LACTATE CLEARANCE IS ASSOCIATED WITH IMPROVED OUTCOME IN SEVERE SEPSIS AND SEPTIC SHOCK P Single centre prospective observational study of patients with septic shock I All patients had a central line & art line, had fluids to achieve a CVP of 8-12mmHg and vasoactive agents to achieve a MAP of >65mmHg & a U/O > 0.5mL/kg/hr C In hospital mortality and the association with multiple laboratory values including lactate clearance O Survivors; lactate clearance 38.1 Non survivors; lactate clearance 12.0 Significant p-value of.005

5. JANSEN THE PROGNOSTIC VALUE OF BLOOD LACTATE LEVELS RELATIVE TO THAT OF VITAL SIGNS IN THE PRE-HOSPITAL SETTING: A PILOT STUDY P Prospective observational study of 124 patients with Systolic BP < 100mmHg or RR 29 or GCS < 14 Epileptic seizures excluded I venous/capillary lactates were taken as soon as possible C Looked to find a cut off of lactate that best predicited in patient mortality ROC curves, O A lactate of 3.5mmol/L had a PPV of 44% and a NPV 88%,The AUC was poor at 0.69 (95% CI 0.58-0.8)

6. JONES 2010 LACTATE CLEARANCE VS CENTRAL VENOUS OXYGEN SATURATION AS GOALS OF EARLY SEPSIS THERAPY: A RANDOMIZED CLINICAL TRIAL P RCT of patients with septic shock I Sepsis treatment with ScvO2 monitoring vs lactate clearance see next 2 slides

7. JONES 2010 SCVO2 GROUP Crystalloid boluses to a CVP of 8-12 mmHg Aim for a MAP of >65 mmHg if not achieved with crystalloid give vasopressors(dopamine/norepi) ScvO2 goal of ≥ 70% after CVP and MAP met If HCT< 30% PRBCs given If still <70% dobutamine was given

8. JONES 2010 LACTATE GROUP Crystalloid boluses to a CVP of 8-12 mmHg Aim for a MAP of >65 mmHg if not achieved with crystalloid give vasopressors(dopamine/norepi) Lactate clearance goal of >10% Clearance was check between initial lactate and ≥ 2 hrs later If HCT< 30% PRBCs given If still <70% dobutamine was given If treatment was to be continued due to inadequate lactate clearance and hct > 30% then serial lactate samples were taken 1 hourly

9. JONES 2010 LACTATE CLEARANCE VS CENTRAL VENOUS OXYGEN SATURATION AS GOALS OF EARLY SEPSIS THERAPY: A RANDOMIZED CLINICAL TRIAL C Inferiority comparison of In hospital mortality rate O The study concluded no inferiority in the lactate group Lactate clearance in-hospital mortality rate 17% (95%CI 11-24%) ScvO2 in-hospital mortality rate 23% (95% CI 17-30%)

10. REFERENCES CEM Sepsis Toolkit Nguyen, H. Bryant, et al. "Early lactate clearance is associated with improved outcome in severe sepsis and septic shock*." Critical care medicine 32.8 (2004): 1637-1642. Jansen, Tim C., et al. "The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study." Crit Care 12.6 (2008): R160. Jones, Alan E., et al. "Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial." Jama 303.8 (2010): 739-746.