Pan Jianzhen, Peng Milin, Liao Chao, Hu Xia, Wang Aimin, Li Xiangmin
Department of Emergency Medicine.
Department of Critical Care Medicine, Xiang Ya Hospital, Central South University, Changsha, Hunan, China.
Medicine (Baltimore). 2019 Feb;98(8):e14453. doi: 10.1097/MD.0000000000014453.
Compelling evidence has shown that aggressive resuscitation bundles are one of the cornerstones of the successful treatment of patients with sepsis. Recent studies suggest that lactate normalization during resuscitation is a more powerful indicator of resuscitative adequacy; however, early lactate clearance-guided therapy is still not recommended. We performed this meta-analysis to evaluate the effect of early lactate clearance-directed therapy as a potentially more effective resuscitation target.
Studies were identified using PubMed, Embase, and the Cochrane Library without region, publication type, or language restrictions. Randomized trials were included when they compared the efficacy and safety of lactate clearance-guided resuscitation versus central venous oxygen saturation (ScvO2)-guided therapy. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) stay, length of hospital stay, mechanical ventilation time, Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score, and Sepsis-related Organ Failure Assessment (SOFA) score.
Seven randomized controlled trials encompassing 1301 cases were reviewed. Compared with guided ScvO2 therapy, early lactate clearance-directed therapy was associated with decreased in-hospital mortality (relative ratio [RR] 0.68, 95% confidence interval [CI] 0.56 to 0.82), shorter ICU stay (mean difference [MD] -1.64 days, 95% CI -3.23 to -0.05), shorter mechanical ventilation time (MD -10.22 hours, 95% CI -15.94 to -4.5), and lower APACHE-II scores (MD -4.47, 95% CI -7.25 to -1.69). However, patients undergoing early lactate clearance-guided therapy had similar lengths of hospital stay and similar SOFA scores.
As a specific indicator of resuscitation outcome, lactate clearance alone is superior to ScvO2 alone during a standard resuscitation paradigm. The optimal or desired rate of lactate clearance is still a contentious area. To guide resuscitation and normalize lactate levels in patients, repeating lactate measurements every 2 hours until the patient has met a lactate clearance of 10% or greater may be helpful.
PROSPERO CRD42018100515.
有力证据表明，积极的复苏集束化治疗是脓毒症患者成功治疗的基石之一。近期研究提示，复苏过程中乳酸水平正常化是复苏充分性的一个更强有力的指标；然而，仍不推荐早期乳酸清除率指导的治疗。我们开展此项荟萃分析以评估早期乳酸清除率导向治疗作为一个可能更有效的复苏目标的效果。
通过PubMed、Embase和Cochrane图书馆检索研究，无地域、发表类型或语言限制。纳入比较乳酸清除率指导的复苏与中心静脉血氧饱和度（ScvO2）指导的治疗的疗效和安全性的随机试验。主要结局为死亡率，次要结局为重症监护病房（ICU）住院时间、住院时长、机械通气时间、急性生理与慢性健康状况评分系统II（APACHE-II）评分以及脓毒症相关器官功能衰竭评估（SOFA）评分。
回顾了7项随机对照试验，共1301例病例。与ScvO2指导的治疗相比，早期乳酸清除率导向治疗与住院死亡率降低（相对比[RR]0.68，95%置信区间[CI]0.56至0.82）、ICU住院时间缩短（平均差[MD]-1.64天，95%CI-3.23至-0.05）、机械通气时间缩短（MD-10.22小时，95%CI-15.94至-4.5）以及APACHE-II评分降低（MD-4.47，95%CI-7.25至-1.69）相关。然而，接受早期乳酸清除率指导治疗的患者住院时长和SOFA评分相似。
作为复苏结局的一个特定指标，在标准复苏模式中单独的乳酸清除率优于单独的ScvO2。乳酸清除的最佳或期望速率仍是一个有争议的领域。为指导患者复苏并使乳酸水平正常化，可以每2小时重复测量乳酸，直至患者达到10%或更高的乳酸清除率。
PROSPERO CRD42018100515。
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