Early goal-directed therapy (EGDT or EGDT) 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.[1] In cardiac surgery, goal-directed therapy 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.[2] Furthermore, a reduction in morbidity and mortality has been associated with GDT techniques when used in conjunction with an
electronic medical record.[3]
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.[4]
Three trials published in 2014/2015 have shown that early goal directed therapy should be abandoned.[5]
Evidence
EGDT, as compared to usual modern care, does not appear to improve outcomes but results in greater expense.[5]
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.[6] Crystalloid solutions are recommended over colloid solutions given the cost and lack in difference of mortality benefit.[6] 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:
Achieve CVP of 8-12 mmHg. Mechanical ventilation, increased abdominal pressure, and preexisting impaired ventricular compliance may require higher CVP targets of 12-15 mmHg[6]
Achieve superior vena cava oxygen saturation (ScvO2) of > 70% OR mixed venous oxygen saturation (SvO2) of > 65%. If initial fluid resuscitation fails to achieve adequate oxygen saturation, additional options include
dobutamine infusion (maximum 20 μg/kg/min) or transfusion of packed
red blood cells to a
hematocrit ≥ 30%. If a ScvO2 is unavailable, lactate normalization may be used as a surrogate marker. A reduction in lactate by ≥ 10% is noninferior to achieving a ScvO2 of ≥ 70% [7]