Point: should lactate clearance be substituted for central venous oxygen saturation as goals of early severe sepsis and septic shock therapy? Yes.

摘要

Quantitative resuscitation in critically ill patients consists of structured cardiovascular interventions, such as intravascular volume expansion and vasoactive agent support, to achieve explicit predefined physiologic parameters or goals. The concept of quantitative resuscitation (also referred to as hemodynamic optimization or goal-directed therapy) as a treatment strategy to improve clinical outcome was first reported in high-risk surgery patients. A recent meta-analysis of randomized clinical trials that compared quantitative resuscitation with standard resuscitation in septic shock found that when therapy was initiated within 24 h of the onset of sepsis (six trials, 740 patients), resuscitation targeting specific physiologic end points improved mortality compared with standard resuscitation (39% vs 57%: OR, 0.50; 95% CI, 0.37-0.69). In contrast, when therapy was initiated > 24 h after the onset of sepsis (three trials, 261 patients), resuscitation targeting specific physiologic end points did not improve mortality (64% vs 58% for standard resuscitation; OR, 1.16; 95% CI, 0.60-2.22). Although the data supporting the use of early quantitative resuscitation are robust, the optimal end points or goals of such therapy are controversial.