Goal-directed therapy

Goal-Directed Therapy is a technique used in critical care medicine involving intensive monitoring and aggressive management of perioperative hemodynamics in patients with a high risk of morbidy and mortality. [Gordon A, Russell J, Crit Care. 2005; 9(6): 647–648. Published online 2005 November 23. doi: 10.1186/cc3951.] In cardiac surgery, GDT has proved effective when commenced after surgery. The combination of goal-directed therapy and Point-of-Care Testing has demonstrated a marked decrease in mortality for patients undergoing congenital heart surgery. [Rossi AF, Khan DM, Hannan R, Boliver J, Zaidenweber M, Burke R, Intensive Care Med. 2005 Jan;31(1):98-104. Epub 2004 Dec 1] Further more, a reduction in morbidity and mortality has been associated with GDT techniques when used in conjunction with an electronic medical record. [Rossi AF, Khan D, Clin Biochem. 2004 Jun;37(6):456-61.]

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. [Rivers, 2001 http://scalpel.stanford.edu/articles/Goal%20directed%20therapy.pdf]

Elements

In the event of hypotension and/or lactate > 4 mmol/L, then deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent).

Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.

In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl):
*Achieve central venous pressure (CVP) of > 8 mm Hg
*Achieve central venous oxygen saturation (ScvO2) of > 70%

References