Early goal-directed therapy (EGDT or EGDT) was introduced by Emanuel P. Rivers in ''

The New England Journal of Medicine ''The New England Journal of Medicine'' (''NEJM'') is a weekly medical journal published by the Massachusetts Medical Society. Founded in 1812, the journal is among the most prestigious peer-reviewed medical journals. Its 2023 impact factor w ...

'' in 2001 and is a technique used in

critical care medicine Intensive care medicine, usually called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. It includes ...

involving intensive monitoring and aggressive management of

perioperative The perioperative period is the period of a patient's surgical procedure. It commonly includes ward admission, anesthesia, surgery, and recovery. Perioperative may refer to the three phases of surgery: preoperative, intraoperative, and postoperat ...

hemodynamics in patients with a high risk of

morbidity A disease is a particular abnormal condition that adversely affects the structure or function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical conditions that are asso ...

and mortality. 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. Furthermore, a reduction in morbidity and mortality has been associated with GDT techniques when used in conjunction with an

electronic medical record An electronic health record (EHR) is the systematized collection of electronically stored patient and population health information in a digital format. These records can be shared across different health care settings. Records are shared thro ...

. Early goal-directed therapy is a more specific form of therapy used for the treatment of severe

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

and

septic shock Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International C ...

. This approach involves adjustments of

cardiac The heart is a muscular organ found in humans and other animals. This organ pumps blood through the blood vessels. The heart and blood vessels together make the circulatory system. The pumped blood carries oxygen and nutrients to the tissu ...

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 Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...

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: * a transient increase in

central venous pressure Central venous pressure (CVP) is the blood pressure in the venae cavae, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system. CVP ...

(CVP) * a decrease in heart rate 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 *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 Dobutamine is a medication used in the treatment of cardiogenic shock (as a result of inadequate tissue perfusion) and severe heart failure. It may also be used in certain types of cardiac stress tests. It is given by IV only, as an injection ...

infusion (maximum 20 μg/kg/min) or transfusion of packed

red blood cell Red blood cells (RBCs), referred to as erythrocytes (, with -''cyte'' translated as 'cell' in modern usage) in academia and medical publishing, also known as red cells, erythroid cells, and rarely haematids, are the most common type of blood cel ...

s to a

hematocrit The hematocrit () (Ht or HCT), also known by several other names, is the volume percentage (vol%) of red blood cells (RBCs) in blood, measured as part of a blood test. The measurement depends on the number and size of red blood cells. It is nor ...

≥ 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% *Achieve

mean arterial pressure In medicine, the mean arterial pressure (MAP) is an average calculated blood pressure in an individual during a single cardiac cycle. Although methods of estimating MAP vary, a common calculation is to take one-third of the pulse pressure (the d ...

(MAP) ≥ 65mmHg The presence of

atherosclerosis Atherosclerosis is a pattern of the disease arteriosclerosis, characterized by development of abnormalities called lesions in walls of arteries. This is a chronic inflammatory disease involving many different cell types and is driven by eleva ...

or pre-existing uncontrolled hypertension may necessitate a higher MAP target. *Achieve

urine Urine is a liquid by-product of metabolism in humans and many other animals. In placental mammals, urine flows from the Kidney (vertebrates), kidneys through the ureters to the urinary bladder and exits the urethra through the penile meatus (mal ...

output ≥ 0.5 mL/kg/h

References

{{Intensive care medicine Intensive care medicine