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Counterpoint: Should Lactate Clearance Be Substituted for Central Venous Oxygen Saturation as Goals of Early Severe Sepsis and Septic Shock Therapy? NoLactate Clearance Not a Goal for Septic Shock

Emanuel P. Rivers, MD, MPH, FCCP; Ronald Elkin, MD; Chad M. Cannon, MD
Author and Funding Information

From the Department of Emergency Medicine and Surgery (Dr Rivers), Henry Ford Hospital, Wayne State University; Department of Medicine (Dr Elkin), Pulmonary and Critical Care Medicine, California Pacific Medical Center; and Department of Emergency Medicine (Dr Cannon), University of Kansas Hospital.

Correspondence to: Emanuel P. Rivers, MD, MPH, FCCP, Department of Emergency Medicine, Wayne State University, 270 Clara Ford Pavilion, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202; e-mail: erivers1@hfhs.org

CVP = central venous pressure; Do2 = systemic oxygen delivery; r-APC = recombinant activated protein C; SBP = systolic BP; SvO2 = mixed venous oxygen saturation; V˙ o2 = oxygen consumption.

Data are presented as mean ± SD or %. EGDT = early goal-directed therapy; NS = not significant; SAPS = Simplified Acute Physiology Score; Scvo2 = central venous oxygen saturation. See Table 1 legend for expansion of other abbreviations.

a

No statistical significance.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: In the past 3 years, Dr Rivers has received funding from the National Institutes of Health, Aggennix AG, and Alere Corporation. He has been a one-time consultant for Aggennix AG; Eisai Co, Ltd; Idaho Technologies Inc; AstraZeneca; Massimo; and Sangard. He is a consultant to the Institute of Medicine, National Academies. The EGDT study was performed without external industry support or funding of any kind. Any intellectual properties associated with Dr Rivers’ research are exclusively owned by Henry Ford Hospital. Dr Rivers holds no past or present intellectual properties and has never received royalties or stock interest related to technologies in EGDT research and practice. Dr Elkin has received funding from the Gordon and Betty Moore Foundation, been a one-time consultant for Eisai Co, Ltd, and participated on the speaker’s bureau for Edwards Lifesciences LLC on three occasions. Dr Cannon has been a one-time consultant for Aggennix AG and Eisai Co, Ltd.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: In the past 3 years, Dr Rivers has received funding from the National Institutes of Health, Aggennix AG, and Alere Corporation. He has been a one-time consultant for Aggennix AG; Eisai Co, Ltd; Idaho Technologies Inc; AstraZeneca; Massimo; and Sangard. He is a consultant to the Institute of Medicine, National Academies. The EGDT study was performed without external industry support or funding of any kind. Any intellectual properties associated with Dr Rivers’ research are exclusively owned by Henry Ford Hospital. Dr Rivers holds no past or present intellectual properties and has never received royalties or stock interest related to technologies in EGDT research and practice. Dr Elkin has received funding from the Gordon and Betty Moore Foundation, been a one-time consultant for Eisai Co, Ltd, and participated on the speaker’s bureau for Edwards Lifesciences LLC on three occasions. Dr Cannon has been a one-time consultant for Aggennix AG and Eisai Co, Ltd.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: In the past 3 years, Dr Rivers has received funding from the National Institutes of Health, Aggennix AG, and Alere Corporation. He has been a one-time consultant for Aggennix AG; Eisai Co, Ltd; Idaho Technologies Inc; AstraZeneca; Massimo; and Sangard. He is a consultant to the Institute of Medicine, National Academies. The EGDT study was performed without external industry support or funding of any kind. Any intellectual properties associated with Dr Rivers’ research are exclusively owned by Henry Ford Hospital. Dr Rivers holds no past or present intellectual properties and has never received royalties or stock interest related to technologies in EGDT research and practice. Dr Elkin has received funding from the Gordon and Betty Moore Foundation, been a one-time consultant for Eisai Co, Ltd, and participated on the speaker’s bureau for Edwards Lifesciences LLC on three occasions. Dr Cannon has been a one-time consultant for Aggennix AG and Eisai Co, Ltd.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Chest. 2011;140(6):1408-1413. doi:10.1378/chest.11-2563
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In 2001, early goal-directed therapy (EGDT) resulted in a 16% reduction in hospital mortality and, post hoc, a higher lactate clearance in severe sepsis and septic shock.1 Multiple studies have confirmed the validity and generalizability of EGDT, resulting in its adoption into the Surviving Sepsis Campaign Guidelines.2,3 Nguyen et al4,5 examined early lactate clearance and found a significant retrospective association with inflammation, apoptosis, coagulation, organ dysfunction, and mortality. Following this rationale, Jones et al6 modified the EGDT protocol in 2010 using a noninferiority study design and concluded that lactate clearance is equivalent to central venous oxygen saturation (Scvo2) in the management of individual patients.

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