A consensus committee of 55 international experts representing 25 international organizations was convened in 2016 to provide an update to the 2012 Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock.
Mean arterial pressure (MAP) is the driving pressure of tissue perfusion. Below a threshold MAP, perfusion of critical organs such as the brain or kidney becomes inadequate. Plasma lactate is not a direct measure of tissue perfusion. Increases in plasma lactate concentration may represent tissue hypoxia, accelerated aerobic glycolysis driven by excess beta-adrenergic stimulation, or other causes such as liver failure. Regardless of the source, increased lactate levels are associated with worse outcomes.
Five randomized controlled trials (647 patients) have evaluated lactate-guided resuscitation of patients with septic shock. A significant reduction in mortality was seen in lactate-guided resuscitation compared to resuscitation without lactate monitoring (RR 0.67; 95% CI 0.53–0.84; low quality). There was no evidence for difference in ICU length of stay (mean difference −1.51 days; 95% CI −3.65 to 0.62; low quality). Two other meta-analyses of these same 647 patients demonstrated moderate evidence for reduction in mortality when an early lactate clearance strategy was used, compared with either usual care or with a Scvo2 normalization strategy.
Based on this evidence, updated Surviving Sepsis guidelines continue to recommend measurement of plasma lactate levels to guide resuscitation.
Rhodes, A., Evans, L.E., Alhazzani, W. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med (2017). doi:10.1007/s00134-017-4683-6
Levy B (2006) Lactate and shock state: the metabolic view. Curr Opin Crit Care. 12(4):315–321
Casserly B, Phillips GS, Schorr C et al (2015) Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database. Crit Care Med 43(3):567–573