Background Serum lactate and central venous oxygen saturation (ScvO 2 ) are commonly used and commonly recommended as markers of tissue oxygenation in shock states. Medical literature has both explicitly stated and implied that the two biomarkers are interchangeable in the management of patients with shock. However, there have been relatively few direct comparisons of these tests in clinical circumstances, and the relationship between them is uncertain. The objective of our study was to evaluate whether simultaneous or near-simultaneous measurements of lactate and ScvO 2 reveal a consistent relationship between these two biomarkers. Methods A retrospective cohort study was conducted in an urban, academic US hospital. All adults in ICUs between March 2007 and March 2017 who had a lactate measurement and ScvO 2 or mixed venous oxygen saturation (SvO 2 ) measurement made +/− 1 h from the lactate were included. Linear and non-linear correlations of ScvO 2 and lactate were assessed in a variety of shock states. Results Two thousand sixty-two patients were included. Lactate and ScvO 2 correlated poorly ( r 2 = 0.0041, p = 0.0019). This was true for patients with ScvO 2 ≤ 65% ( r 2 = 0.0431, p < 0.001), patients with normal kidney and liver function ( r 2 = 0.0517, p < 0.001), and septic shock patients ( r 2 = 0.0037, p = 0.17). For patients with an O 2 extraction ratio ≥ 50%, lactate and ScvO 2 were strongly correlated ( r 2 = 0.93, p = 0.0019), but these patients represented only 2.8% of patients in whom the ratio could be calculated. Conclusions Lactate can predict ScvO 2 when patients are at or below the critical oxygen delivery threshold, but relatively few shock patients meet this criterion. In the overall population of critically ill patients, serum lactate predicts ScvO 2 poorly, even after controlling for factors that may affect lactate production. Lactate and ScvO 2 should not be assumed to be interchangeable markers of tissue oxygenation/perfusion. Electronic supplementary material The online version of this article (10.1186/s40560-019-0401-5) contains supplementary material, which is available to authorized users.
Certain medical societies have publicly questioned the use of early antibiotics in patients with sepsis without septic shock. However, we recently demonstrated that among emergency department patients with suspected infection, antibiotic delay was associated with development of shock, and that for those patients who developed shock in spite of early antibiotics, mortality was unexpectedly low. The purpose of our study was to determine if early antimicrobial administration in patients with suspected infection but not septic shock affects risk of mortality if septic shock does develop. METHODS:This was a single center retrospective cohort study from March 2007 to March 2020. All adults presenting to the emergency department with suspected infection and first antimicrobial administered < 24 hours from triage were included. Septic shock at presentation was defined by receiving vasopressors within 3 hours of triage. We performed univariate and multivariate logistic regressions predicting progression to septic shock and mortality. We also compared mortality in patients who presented with shock compared with patients who developed shock after treatment was initiated.RESULTS: 74,655 patients were included in the study. Of these, 541 (0.7%) patients were characterized as having septic shock on presentation. 5,510 (7.4%) patients did not have septic shock on presentation but progressed to septic shock after treatment initiation. For patients in the latter group, in-hospital mortality was 10.7%. For patients with septic shock on presentation, inhospital mortality was 23% (p<0.001). Median time to antibiotics for the septic shock on presentation group was 0.35 hours, and 97% of these patients received their antimicrobials within 5 hours of triage. In a multivariate logistic regression model including only patients without septic shock on presentation, time to first antimicrobial had OR of 1.03 [95% CI: 1.02-1.04; p<0.001] for progression to septic shock and 1.02 [95% CI: 0.98-1.04; p = 0.090] for in-hospital mortality. In a multivariate logistic model including only patients with septic shock on presentation, time to first antimicrobial had an OR of 1.25 [95% CI: 1.05-1.48; p = 0.010] for in-hospital mortality.CONCLUSIONS: Delays in first antimicrobial administration in patients with suspected infection or septic shock are associated with increased likelihood of disease progression and in-hospital mortality. However, early administration of antibiotics in nonshock patients with suspected infection is associated with decreased mortality rate by half, even if shock does subsequently develop.CLINICAL IMPLICATIONS: Antibiotics administered before the onset of shock may mitigate the mortality associated with septic shock.
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