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Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation

H Bryant Nguyen12*, Win Sen Kuan3, Michael Batech4, Pinak Shrikhande5, Malcolm Mahadevan3, Chih-Huang Li67, Sumit Ray8, Anna Dengel9 and the ATLAS (Asia Network to Regulate Sepsis care) Investigators

Author Affiliations

1 Department of Emergency Medicine, Loma Linda University, 11234 Anderson Street, Loma Linda, CA 92354, USA

2 Department of Medicine, Division of Pulmonary and Critical Care, Loma Linda University, 11234 Anderson Street, Loma Linda, CA 92354, USA

3 Department of Emergency Medicine, National University Health System, Street 5 Lower Kent Ridge Road, Singapore 119074, Singapore

4 Department of Epidemiology and Biostatistics, Loma Linda University, 24951 North Circle Drive, Nichol Hall 1708, Loma Linda, CA 92350, USA

5 Department of Critical Care Medicine, Fortis Flt. Lt. Rajan Dhall Hospital, Sector B, Pocket-1, Vasant Kunj, New Delhi 110070, India

6 Department of Emergency Medicine, Chang-Gung Memorial Hospital, Linkou Medical Center, No. 5, Fu-Shing Street, Taoyuan 333, Taiwan, ROC

7 Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang-Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 333, Taiwan, ROC

8 Department of Critical Care & Emergency Medicine, Sir Gangaram Hospital, Rajinder Nagar, New Delhi 110060, India

9 Department of Medicine, Loma Linda University, 11234 Anderson Street, Loma Linda, CA 92354, USA

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Critical Care 2011, 15:R229  doi:10.1186/cc10469

Published: 27 September 2011



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.


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.


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.


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.