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February 17, 2019

How Best to Resuscitate Patients With Septic Shock?

Author Affiliations
  • 1University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Associate Editor, JAMA
JAMA. 2019;321(7):647-648. doi:10.1001/jama.2019.0070

What is the best approach for resuscitation of a patient with septic shock? Despite considerable investigation over several decades, this important question still has no clear answer. There is agreement that resuscitation should proceed quickly, for the longer the delay, the greater the physiologic stress and end-organ injury. However, treatment options are principally intravenous fluids and vasoactive agents, which have the capacity to both help or harm the patient. Thus, these therapies must be titrated in response to markers of the adequacy of resuscitation. The 2016 Surviving Sepsis Guidelines advocate that the principal marker of the adequacy of resuscitation is serum lactate.1 Serum lactate level is elevated when the body relies on anaerobic metabolism. As such, an elevated serum lactate level is a reflection of tissue hypoperfusion and thus considered axiomatic of shock. However, serum lactate level can be elevated in conditions other than shock and yet may not always be elevated in some shock states. Furthermore, lactate clearance is often considered too slow to provide timely feedback to clinicians regarding the consequences of their treatment decisions. Moreover, not all patients with shock can be cared for in settings with access to rapid-turnaround serum lactate assays.