title: Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation.
abstract: BACKGROUND
  Implementation of the Surviving Sepsis Campaign (SSC) guidelines has been associated with improved outcome in patients with severe sepsis. Resolution of lactate elevations or lactate clearance has also been shown to be associated with outcome. The purpose of the present study was to examine the compliance and effectiveness of the SSC resuscitation bundle with the addition of lactate clearance.
  
  
  METHODS
  This was a prospective cohort study over 18 months in eight tertiary-care medical centers in Asia, enrolling adult patients meeting criteria for the SSC resuscitation bundle in the emergency department. Compliance and outcome results of a multi-disciplinary program to implement the Primary SSC Bundle with the addition of lactate clearance (Modified SSC Bundle) were examined. The implementation period was divided into quartiles, including baseline, education and four quality improvement phases.
  
  
  RESULTS
  A total of 556 patients were enrolled, with median (25th to 75th percentile) age 63 (50 to 74) years, lactate 4.1 (2.2 to 6.3) mmol/l, central venous pressure 10 (7 to 13) mmHg, mean arterial pressure (MAP) 70 (56 to 86) mmHg, and central venous oxygen saturation 77 (69 to 82)%. Completion of the Primary SSC Bundle over the six quartiles was 13.3, 26.9, 37.5, 45.9, 48.8, and 54.5%, respectively (P <0.01). The Modified SSC Bundle was completed in 10.2, 23.1, 31.7, 40.0, 42.5, and 43.6% patients, respectively (P <0.01). The ratio of the relative risk of death reduction for the Modified SSC Bundle compared with the Primary SSC Bundle was 1.94 (95% confidence interval = 1.45 to 39.1). Logistic regression modeling showed that the bundle items of fluid bolus given, achieve MAP >65 mmHg by 6 hours, and lactate clearance were independently associated with decreased mortality - having odds ratios (95% confidence intervals) 0.47 (0.23 to 0.96), 0.20 (0.07 to 0.55), and 0.32 (0.19 to 0.55), respectively.
  
  
  CONCLUSIONS
  The addition of lactate clearance to the SSC resuscitation bundle is associated with improved mortality. In our study patient population with optimized baseline central venous pressure and central venous oxygen saturation, the bundle items of fluid bolus administration, achieving MAP >65 mmHg, and lactate clearance were independent predictors of outcome.
authors.affiliation: Department of Emergency Medicine, Loma Linda University, 11234 Anderson Street, Loma Linda, CA 92354, USA. hbnguyen@llu.edu
authors.forename: H Bryant
authors.initials: HB
authors.lastname: Nguyen
authors.forename: Win Sen
authors.initials: WS
authors.lastname: Kuan
authors.forename: Michael
authors.initials: M
authors.lastname: Batech
authors.forename: Pinak
authors.initials: P
authors.lastname: Shrikhande
authors.forename: Malcolm
authors.initials: M
authors.lastname: Mahadevan
authors.forename: Chih-Huang
authors.initials: CH
authors.lastname: Li
authors.forename: Sumit
authors.initials: S
authors.lastname: Ray
authors.forename: Anna
authors.initials: A
authors.lastname: Dengel
mesh_terms: D000368:Aged; D001208:Asia; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D019344:Lactic Acid / Q000493:pharmacokinetics*; D008297:Male; D008657:Metabolic Clearance Rate; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D018805:Sepsis / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D019344:Lactic Acid