Goal-Directed Therapy

Since the publication of the landmark paper by Dr. Emanuel Rivers in The New England Journal of Medicine in 2001, the world of critical care massively adopted his protocol for the resuscitation of severe sepsis and/or septic shock—which was named “early goal-directed therapy” [1]. The concept of goal-directed therapy rapidly arose from sepsis and was applied to shock in general in the intensive care unit. Goal-directed therapy is a bundle of care that embraces the use of fluids, blood transfusion, and inotropes aiming to precise hemodynamic targets [2]. In case of hypotension or lactate raise, a fluid challenge of 30 ml/kg of crystalloid solution is administered to the patient. Fluid responsiveness is assessed in terms of low central venous pressure (CVP) and decreases in heart rate. In the following hours, hemodynamic targets include: a CVP of 8–12 mmHg, a superior vena cava oxygen saturation (ScvO2) >70% or a mixed venous oxygen saturation (SvO2) >65%, a mean arterial pressure (MAP) ≥65 mmHg, and a urine output ≥0.5 mL/kg/h. Strategies to achieve these target involve additional fluids, transfusion of packed red blood cells or inotrope infusion. In the original study, the application of this protocol reduced mortality by more of one third and halved that of patients with severe sepsis [1].