Early goal-directed and lactate-guided therapy in adult patients with severe sepsis and septic shock: a meta-analysis of randomized controlled trials

Study on Assessing Serum Lactate as an Early Prognostic Determinant in Sepsis Outcome

BACKGROUND

Apart from being one of the main causes of death, sepsis has recently been considered a chronic critical illness. This has resulted in the implementation of standard treatment recommendations for management, with a focus on the initial phases of treatment. Early detection of sepsis and prognostic grading are now crucial for management. Despite the fact that sequential organ failure assessment score (SOFA), acute physiology, and chronic health evaluation II score (APACHE II) have been widely used in sepsis, there have been shortcomings such as feasibility and many lab parameters involved. As a result, this study was conducted to evaluate the role of serum lactate as an early marker and to compare it to current scoring systems for determining the outcome of sepsis.

METHODS AND MATERIAL

This was an observational hospital-based study with 60 individuals recruited over a one-year period from July 2021 to June 2022. Serum lactate, as well as the other laboratory tests required for the computation of SOFA and APACHE II, were performed. The baseline data and the trend of lactate vs standard scores were examined in the first 48 hours, as well as their impact on outcomes in sepsis patients (as measured by mortality rates- patients were followed up for 28 days). The diagnostic accuracy of these scores was calculated using the area under the receiver operating characteristic (ROC) curve (AUROC).

RESULTS

The study enrolled 60 people out of a total of 162 people who were screened. The mean age was 48.4 years, with the highest mortality occurring between the ages of 41 and 60 years. Of the total 60 participants, 34 (56.6%) were male, with the respiratory tract being the most common source of infection for sepsis (36.67%). In our study, 46 patients survived while 14 patients died. The mean lactate on admission was 3.1 mmol/L in survivors and 4 mmol/L in non-survivors, whereas APACHE II was 9 and 12.36, and SOFA was 3.63 and 7.79, respectively, in survivors and non-survivors. Serum lactate and prognosis scores were compared in the survivor and non-survivor groups, and the difference in diagnostic accuracy was found to be statistically significant.

CONCLUSIONS

Serum lactate can be used as an early recognition marker in patients with a probability of sepsis and serial lactate monitoring has a similar diagnostic accuracy in predicting outcomes as the traditional prognostic scoring systems SOFA and APACHE II.

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

DECREASE IN THE PLATELET-TO-LYMPHOCYTE RATIO IN DAYS AFTER ADMISSION FOR SEPSIS CORRELATES WITH IN-HOSPITAL MORTALITY

ABSTRACT

Background: A previous study has linked an increase in platelet-to-lymphocyte ratio (PLR) to a poor prognosis; however, the relationship between early change in PLR and outcomes in sepsis patients is unclear. Methods : The Medical Information Mart for Intensive Care IV database was for this retrospective cohort analysis on patients meeting the Sepsis-3 criteria. All the patients meet the Sepsis-3 criteria. The platelet-to-lymphocyte ratio (PLR) was calculated by dividing the platelet count by the lymphocyte count. We collected all PLR measurements that were available within 3 days of admission for analysis of longitudinal changes over time. Multivariable logistic regression analysis was used to determine the relationship between the baseline PLR and in-hospital mortality. After correcting for possible confounders, the generalized additive mixed model was used to examine the trends in PLR over time among survivors and nonsurvivors. Results: Finally, 3,303 patients were enrolled, and both low and high PLR levels were significantly associated with higher in-hospital mortality in the multiple logistic regression analysis (tertile 1: odds ratio, 1.240; 95% confidence interval, 0.981-1.568 and tertile 3: odds ratio, 1.410; 95% confidence interval, 1.120-1.776, respectively). The generalized additive mixed model results revealed that the PLR of the nonsurvival group declined faster than that of the survival group within 3 days after intensive care unit admission. After controlling for confounders, the difference between the two groups steadily decreased and increased by an average of 37.38 daily. Conclusions : There was a U-shaped relationship between the baseline PLR and in-hospital mortality of sepsis patients, and there was a significant difference between the nonsurvival and survival groups in the change in PLR over time. The early decrease in PLR was related to an increase in in-hospital mortality.

Association Between Lactate and 28-Day Mortality in Elderly Patients with Sepsis: Results from MIMIC-IV Database

INTRODUCTION

This study aimed to explore the association of serum lactate with clinical outcomes in elderly patients with sepsis based on data from the MIMIC-IV database.

METHODS

All elderly patients with sepsis (age ≥ 65 years) were included. Different models were constructed for exploring the relationships between lactate and 28-day mortality. A two-segment linear regression model was performed to verify the threshold effects of lactate on clinical outcomes and smooth curve fitting was performed.

RESULTS

A total of 4199 elderly patients with sepsis were included. The 28-day mortality was 32.22% (n = 1395). After adjustment for all potential cofounders, for each 1 mmol/l increment in lactate, the odds ratio (OR) of 28-day mortality was 1.23 (95% CI 1.18-1.28, P < 0.0001). Smooth fitting curves indicated a non-linear positive relationship between lactate and 28-day mortality. The turning point of lactate level was 5.7 mmol/l: at ≤ 5.7 mmol/l, with each 1 mmol/l increment in lactate, the risk of 28-day mortality increased significantly (OR 1.32, 95% CI 1.25-1.38, P < 0.0001); the significantly positive relationship was still present at lactate > 5.7 mmol/l (OR 1.10, 95% CI 1.04-1.18, P = 0.0019). The area under the ROC curve (AUC) of lactate was 0.618 (95% CI 0.599-0.635) and the cutoff value of lactate was 2.4 mmol/l with a sensitivity of 0.483 and a specificity of 0.687.

CONCLUSION

In elderly patients with sepsis, a non-linear positive relationship was discovered between serum lactate and 28-day mortality. Physicians should be alert to lactate assessment at admission and pay more attention to those patients with higher levels of lactate.

Construction of a lactate-related prognostic signature for predicting prognosis after surgical repair for acute type a aortic dissection

Background: Serum lactate is commonly measured in the perioperative period in patients who have undergone surgery for an acute type A aortic dissection (ATAAD). However, conflicting data has been reported as to whether lactate elevation is associated with short-term prognosis. The aim of the current study was to determine the association between perioperative arterial lactate levels and postoperative 30-day mortality. Methods: Patients who underwent repair of a ATAAD at our institution were retrospectively screened and those with comprehensive measurements of serum lactate before surgery and at 0, 1, 3, 6, 12, and 24 h after surgery in the intensive care unit (ICU) were selected for the analysis. Patients' demographic features and outcomes were reviewed to determine risk factors associated with 30-day mortality using logistic regression modeling. The association between serum lactate levels at different time points and 30-day mortality were analyzed by receiver-operating characteristic curves. Results: 513 patients were identified and retrospectively analyzed for this study including 66 patients (12.9%) who died within 30 days after surgery. Patients who died within 30 days after surgery had elevated lactate levels measured before surgery and at 0, 1, 3, 6, 12, and 24 h after their ICU stay. Lactate measured at 24 h post ICU admission (odds ratio, 2.131; 95% confidence interval, 1.346-3.374; p = 0.001) was a predictor of 30-day mortality. The area under the curve (AUC) for 30-day mortality with lactate levels at 12 h and 24 h post ICU stay were 0.820 and 0.805, respectively. Conclusion: Early elevation of lactate level is correlated with increased 30-day mortality in patients who received ATAAD surgical repair.

Septic Shock: Phenotypes and Outcomes

INTRODUCTION

Sepsis is a heterogeneous syndrome that results in life-threatening organ dysfunction. Our goal was to determine the relevant variables and patient phenotypes to use in predicting sepsis outcomes.

METHODS

We performed an ancillary study concerning 119 patients with septic shock at intensive care unit (ICU) admittance (T0). We defined clinical worsening as having an increased sequential organ failure assessment (SOFA) score of ≥ 1, 48 h after admission (ΔSOFA ≥ 1). We performed univariate and multivariate analyses based on the 28-day mortality rate and ΔSOFA ≥ 1 and determined three patient phenotypes: safe, intermediate and unsafe. The persistence of the intermediate and unsafe phenotypes after T0 was defined as a poor outcome.

RESULTS

At T0, the multivariate analysis showed two variables associated with 28-day mortality rate: norepinephrine dose and serum lactate concentration. Regarding ΔSOFA ≥ 1, we identified three variables at T0: norepinephrine dose, lactate concentration and venous-to-arterial carbon dioxide difference (P(v-a)CO₂). At T0, the three phenotypes (safe, intermediate and unsafe) were found in 28 (24%), 70 (59%) and 21 (18%) patients, respectively. We thus suggested using an algorithm featuring norepinephrine dose, lactate concentration and P(v-a)CO₂ to predict patient outcomes and obtained an area under the curve (AUC) of 74% (63-85%).

CONCLUSION

Our findings highlight the fact that identifying relevant variables and phenotypes may help physicians predict patient outcomes.

Does lactate enhance the prognostic accuracy of the quick Sequential Organ Failure Assessment for adult patients with sepsis? A systematic review

OBJECTIVES

To investigate whether adding lactate to the quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) improves the prediction of mortality in adult hospital patients, compared with qSOFA alone.

DESIGN

Systematic review in accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies guidelines.

DATA SOURCES

Embase, Medline, PubMed, SCOPUS, Web of Science, CINAHL and Open Grey databases were searched in November 2020.

ELIGIBILITY CRITERIA

Original research studies published after 2016 comparing qSOFA in combination with lactate (LqSOFA) with qSOFA alone in adult patients with sepsis in hospital. The language was restricted to English.

DATA EXTRACTION AND SYNTHESIS

Title and abstract screening, full-text screening, data extraction and quality assessment (using Quality Assessment of Diagnostic Accuracy Studies-2) were conducted independently by two reviewers. Extracted data were collected into tables and diagnostic test accuracy was compared between the two tests.

RESULTS

We identified 1621 studies, of which 11 met our inclusion criteria. Overall, there was a low risk of bias across all studies. The area under the receiver operating characteristic (AUROC) curve for qSOFA was improved by the addition of lactate in 9 of the 10 studies reporting it. Sensitivity was increased in three of seven studies that reported it. Specificity was increased in four of seven studies that reported it. Of the six studies set exclusively within the emergency department, five published AUROCs, all of which reported an increase following the addition of lactate. Sensitivity and specificity results varied throughout the included studies. Due to insufficient data and heterogeneity of studies, a meta-analysis was not performed.

CONCLUSIONS

LqSOFA is an effective tool for identifying mortality risk both in adult inpatients with sepsis and those in the emergency department. LqSOFA increases AUROC over qSOFA alone, particularly within the emergency department. However, further original research is required to provide a stronger base of evidence in lactate measurement timing, as well as prospective trials to strengthen evidence and reduce bias.

PROSPERO REGISTRATION NUMBER

CRD42020207648.

Prognostic role of elevated lactate in acute pulmonary embolism: A systematic review and meta-analysis

BACKGROUND

Previous studies have shown elevated lactate was a good predictor for the prognosis of pulmonary embolism (PE). However, due to low number of patients and different expression of blood lactate in separate study, these results are inconsistent. Therefore, the aim of this meta-analysis is to evaluate the relationship between increased lactate levels and adverse outcome in acute PE.

METHOD

The literatures search was conducted in PubMed, Web of Science, and EMBASE until May 29, 2021.

RESULTS

Finally, 6 studies with 1706 patients were included in our meta-analysis. High lactate levels were markedly associated with overall mortality both in unselected PE patients (OR 5.13, 95% CI: 3.36-7.86, p < .00,001) and normotensive PE patients (OR 4.54, 95% CI: 2.64-7.80, p < .00,001), and PE-related short-term mortality in patients with elevated lactate was significantly higher than that in patients with normal levels (OR 9.05, 95% CI :4.08-20.10, p < .00,001). The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of lactate for predicting overall mortality in patients with acute PE were 0.67 (95% CI: 0.43-0.85), 0.73 (95% CI: 0.60-0.83), 2.5 (95% CI: 2.0-3.1), and 0.45 (95% CI: 0.26-0.78), respectively. The area under SROC curve (AUC) was 0.76 (95% CI: 0.73-0.80).

CONCLUSION

The result of our meta-analysis indicate that elevated blood lactate is a good predictor for overall mortality and short-term mortality in patients with acute PE, and can be routinely measured in risk stratification, but its prognostic role in patients with different risk classes still need to be verified.

What Is the Utility of Measuring Lactate Levels in Patients with Sepsis and Septic Shock?

Elevations in blood lactate concentrations have been studied in sepsis and other disease states for decades and are well known to be associated with increased mortality. Many studies have also demonstrated the prognostic accuracy of serial lactate levels, and some have suggested that lactate clearance may be a useful therapeutic target for resuscitation. Lactate measurements have therefore gained an increasingly prominent role in sepsis definitions, screening protocols, management guidelines, and quality measures over the past two decades. The heavy emphasis on lactate monitoring, however, has also generated controversy and concerns. Lactate is not specific to infection and its frequent use for sepsis screening and diagnosis may therefore trigger unnecessary broad-spectrum antibiotic use in some patients. Because hyperlactatemia does not always reflect fluid-responsive hypoperfusion, titrating resuscitation to lactate clearance can also lead to unnecessary fluid and volume overload. More broadly, there is a lack of high-quality evidence demonstrating that initial and serial lactate monitoring leads to better patient-centered outcomes. Indeed, a recent randomized controlled trial comparing resuscitation strategies based on lactate clearance versus normalizing capillary refill time showed no benefit and potential harm with lactate-guided therapy. In this article, we review the basic pathobiology of lactate metabolism and delineate why the traditional paradigm that hyperlactatemia reflects tissue hypoxia is overly simplistic and incomplete. We then review the evidence behind the diagnostic, prognostic, and therapeutic uses of lactate monitoring and place this in the context of evolving sepsis diagnosis and management guidelines.

Comparison of Intermittent versus Continuous Superior Venal Caval Oxygen Saturation Monitoring in Early Goal Directed Therapy in Septic Shock: A Systematic Review

Early goal directed therapy (EGDT) is a bundle of care (monitoring ScvO2 and lactate along with clinical parameters and instituting therapy) that has shown to improve outcomes in patients with septic shock. We conducted a systematic review of clinical trials and observational studies to compare intermittent versus continuous monitoring of ScvO2. We did major database searches till August 2020. Hospitalized children (>2 months age) and adults with septic shock were included. The intervention was “intermittent ScvO2 monitoring,” and the comparator was “continuous ScvO2 monitoring.” The primary outcome is “all-cause mortality.” Of 564 citations, 3 studies (n = 541) including both children and adults were included in the analysis. There was no significant difference in the “overall/all-cause mortality” (two randomized controlled trials; 258 participants) between the “intermittent” and “continuous” ScvO2 monitoring groups (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.8–1.24). However, a single observational study (283 participants) showed a significant increase in mortality in the intermittent group (RR: 1.46; 95% CI: 1.03–2.05). The GRADE evidence generated for “overall/all-cause mortality” was of “moderate certainty.” To conclude, the present meta-analysis did not find any significant difference between “intermittent” and “continuous” ScvO2 monitoring in patients with septic shock.

An explainable machine learning algorithm for risk factor analysis of in-hospital mortality in sepsis survivors with ICU readmission

BACKGROUND AND OBJECTIVE

Patients who survive sepsis in the intensive care unit (ICU) (sepsis survivors) have an increased risk of long-term mortality and ICU readmission. We aim to identify the risk factors for in-hospital mortality in sepsis survivors with later ICU readmission and visualize the quantitative relationship between the individual risk factors and mortality by applying machine learning (ML) algorithm.

METHODS

Data were obtained from the Medical Information Mart for Intensive Care III (MIMIC-III) database for sepsis and non-sepsis ICU survivors who were later readmitted to the ICU. The data on the first day of ICU readmission and the in-hospital mortality was combined for the ML algorithm modeling and the SHapley Additive exPlanations (SHAP) value of the correlation between the risk factors and the outcome.

RESULTS

Among the 2970 enrolled patients, in-hospital mortality during ICU readmission was significantly higher in sepsis survivors (n = 2228) than nonsepsis survivors (n = 742) (50.4% versus 30.7%, P<0.001). The ML algorithm identified 18 features that were associated with a risk of mortality in these groups; among these, BUN, age, weight, and minimum heart rate were shared by both groups, and the remaining mean systolic pressure, urine output, albumin, platelets, lactate, activated partial thromboplastin time (APTT), potassium, pCO2, pO2, respiration rate, Glasgow Coma Scale (GCS) score for eye-opening, anion gap, sex and temperature were specific to previous sepsis survivors. The ML algorithm also calculated the quantitative contribution and noteworthy threshold of each factor to the risk of mortality in sepsis survivors.

CONCLUSION

14 specific parameters with corresponding thresholds were found to be associated with the in-hospital mortality of sepsis survivors during the ICU readmission. The construction of advanced ML techniques could support the analysis and development of predictive models that can be used to support the decisions and treatment strategies made in a clinical setting in critical care patients.

Predicting 30-days mortality for MIMIC-III patients with sepsis-3: a machine learning approach using XGboost

Background

Sepsis is a significant cause of mortality in-hospital, especially in ICU patients. Early prediction of sepsis is essential, as prompt and appropriate treatment can improve survival outcomes. Machine learning methods are flexible prediction algorithms with potential advantages over conventional regression and scoring system. The aims of this study were to develop a machine learning approach using XGboost to predict the 30-days mortality for MIMIC-III Patients with sepsis-3 and to determine whether such model performs better than traditional prediction models.

Methods

Using the MIMIC-III v1.4, we identified patients with sepsis-3. The data was split into two groups based on death or survival within 30 days and variables, selected based on clinical significance and availability by stepwise analysis, were displayed and compared between groups. Three predictive models including conventional logistic regression model, SAPS-II score prediction model and XGBoost algorithm model were constructed by R software. Then, the performances of the three models were tested and compared by AUCs of the receiver operating characteristic curves and decision curve analysis. At last, nomogram and clinical impact curve were used to validate the model.

Results

A total of 4559 sepsis-3 patients are included in the study, in which, 889 patients were death and 3670 survival within 30 days, respectively. According to the results of AUCs (0.819 [95% CI 0.800–0.838], 0.797 [95% CI 0.781–0.813] and 0.857 [95% CI 0.839–0.876]) and decision curve analysis for the three models, the XGboost model performs best. The risk nomogram and clinical impact curve verify that the XGboost model possesses significant predictive value.

Conclusions

Using machine learning technique by XGboost, more significant prediction model can be built. This XGboost model may prove clinically useful and assist clinicians in tailoring precise management and therapy for the patients with sepsis-3.

Combined Use of CytoSorb and ECMO in Patients with Severe Pneumogenic Sepsis

BACKGROUND

High morbidity and mortality are frequently reported in intensive care patients suffering from severe sepsis with systemic inflammation. With the development of severe respiratory failure, extracorporeal membrane oxygenation (ECMO) is often required. In this study, cytokine adsorption therapy in combination with ECMO is applied in patients with acute respiratory distress syndrome (ARDS) due to severe pneumogenic sepsis. The efficacy of this therapy is evaluated compared with a historical cohort without hemoadsorption therapy.

METHODS

Between January and May 2018, combined high-flow venovenous ECMO and CytoSorb therapy (CytoSorb filter connected to ECMO circuit) was applied in patients (n = 13) with pneumogenic sepsis and ARDS. These patients were prospectively included (CytoSorb group). Data from patients (n = 7) with pneumogenic sepsis and ECMO therapy were retrospectively analyzed (control group).

RESULTS

All patients survived in the CytoSorb group, where the 30-day mortality rate reached 57% in the control group. After CytoSorb therapy, we instantly observed a significant reduction in procalcitonin (PCT) and C-reactive protein (CRP) levels compared with the control group. Within 48 hours, the initial high doses of catecholamine could be weaned off only in the CytoSorb group.

CONCLUSIONS

Our results indicate that CytoSorb in combination with ECMO is an effective therapy to prevent escalation of sepsis with rapid weaning off high-dose catecholamine infusions and quick reduction in PCT and CRP levels. Optimal timing of immunomodulatory therapy and impact on ECMO-related inflammation still need to be furtherly investigated.

Effect of magnesium supplementation on lactate clearance in critically ill patients with severe sepsis: a randomized clinical trial

OBJECTIVES

In this study, changes in lactate clearance following magnesium supplementation were evaluated in critically ill patients with severe sepsis.

METHODS

Fifty-eight patients with severe sepsis were randomly assigned to receive either magnesium (n = 30) or placebo (n = 28). Patients in the magnesium group received intravenous magnesium sulfate to maintain serum magnesium level around 3 mg/dL for 3 days. The placebo group received the same volume of normal saline. Change in lactate clearance was considered primary outcome of the study.

RESULTS

Mean increase in the lactate clearance in the magnesium group was significantly higher than the placebo group on day 2 (27.53% vs. 23.79% respectively, p < 0.001) and day 3 (49.83% vs. 37.02% respectively, p < 0.001). Time to lactate clearance was also significantly shorter in the magnesium group than the placebo group (47.28 ± 20.59 vs. 61.20 ± 24.31 h respectively, p = 0.03). Sepsis-related mortality was not significantly different but median length of ICU stay was significantly shorter in the magnesium group than the placebo group (8 vs. 15 days respectively, p < 0.01).

CONCLUSIONS

Magnesium supplementation increased lactate clearance in critically ill patients with severe sepsis. Optimizing serum magnesium level near the upper limit of the normal range may improve severe sepsis outcomes.

'Intermittent' versus 'continuous' ScvO2 monitoring in children with septic shock: a randomised, non-inferiority trial

PURPOSE

To compare the effect of 'intermittent' central venous oxygen saturation (ScvO₂) monitoring with 'continuous' ScvO₂ monitoring on shock resolution and mortality in children with septic shock.

METHODS

Primary outcome was the achievement of therapeutic goals or shock resolution in the first 6 h. We randomly assigned children < 17 years' age with septic shock to 'intermittent ScvO₂' or 'continuous ScvO₂' groups. All children were subjected to subclavian/internal jugular line insertion and managed as per Surviving Sepsis Campaign Guidelines. To guide resuscitation, we used ScvO₂ estimated at other clinical and laboratory parameters were monitored similarly in both groups.

RESULTS

We enrolled 75 and 77 children [median (IQR) age: 6 (1.5-10) years] in the 'intermittent' and 'continuous' groups, respectively. Baseline characteristics were comparable between the groups. When compared to the 'continuous' group, fewer children in the 'intermittent' group achieved shock resolution within first 6 h [19% vs. 36%; relative risk (RR) 0.51; 95% CI 0.29-0.89; risk difference - 18.0%; 95% CI - 32.0 to - 4.0]. The lower bound of confidence interval, however, crossed the pre-specified non-inferiority margin. There was no difference in the proportion of children attaining shock resolution within 24 h (63% vs. 69%; RR 0.86; 95% CI 0.68-1.08) or risk of mortality between the groups (47% vs. 43%; RR 1.06; 95% CI 0.74-1.51).

CONCLUSIONS

Given that a greater proportion of children attained therapeutic end points in the first 6 h, continuous monitoring of ScvO₂ should preferably be used to titrate therapy in the first few hours in children with septic shock. In the absence of such facility, intermittent monitoring of ScvO₂ can be used to titrate therapy in these children, given the lack of difference in the proportion of patients achieving shock resolution at 24 h or in risk of mortality between the intermittent and continuous groups.