Early goal-directed therapy

Early goal-directed therapy was introduced by Emanuel P. Rivers in "The New England Journal of Medicine" in 2001 and is a technique used in critical care medicine involving intensive monitoring and aggressive management of perioperative hemodynamics in patients with a high risk of morbidity and mortality. In cardiac surgery, goal directed therapy (GDT) has proved effective when commenced after surgery. The combination of GDT and Point-of-Care Testing has demonstrated a marked decrease in mortality for patients undergoing congenital heart surgery. Furthermore, a reduction in morbidity and mortality has been associated with GDT techniques when used in conjunction with an electronic medical record.
Early goal-directed therapy is a more specific form of therapy used for the treatment of severe sepsis and septic shock. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with an increased oxygen demand before surgery.
Three trials published in 2014/2015 have shown that early goal directed therapy should be abandoned.
Evidence.
EGDT, as compared to usual modern care, does not appear to improve outcomes but results in greater expense.
Elements.
In the event of hypotension and/or lactate greater than 4 mmol/L, initial management includes a minimum fluid challenge of 30 ml/kg of crystalloid solution. Crystalloid solutions are recommended over colloid solutions given the cost and lack in difference of mortality benefit. Albumin may be considered if large amounts of crystalloid solution is needed.
Indications of a positive response to fluid resuscitation may include:
If hypotension persists despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl), goals in the first 6 hours of resuscitation include: 