An article in American Journal of Emergency Medicine by two intensivists challenges the science behind Rivers’ early goal-directed therapy (EGDT) protocol for severe sepsis / septic shock. In a nutshell:

• Rivers’ study was small (n = 263), nonblinded, industry-supported and single-center
• early fluids and antibiotics are a sound idea, but other components of EGDT are flawed
• targeting a CVP is meaningless and could result in hypovolaemia or pulmonary oedema; dynamic markers of preload responsiveness such as pulse pressure variation or IVC diameter variation are better guides to fluid resuscitation
• ScvO2 may be normal or elevated in septic shock patients; the low average ScvO2 in Rivers’ study has not been reproduced in subsequent studies.
• packed cells have significant side effects and their non-deformability, pro-inflammatory and pro-thrombotic effects may impair microvascular perfusion and paradoxically worsen tissue oxygen delivery
• dobutamine can potentially further worsen the haemodynamic status of patients with hypovolaemia, vasodilation, or a hyperdynamic circulation, which cannot be differentiated using CVP and ScvO2

Early goal-directed therapy: on terminal life support?
Am J Emerg Med. 2010 Feb;28(2):243-5
I like this paper, mainly because I have been uncomfortable with the chasing of arbitrary targets for some time. My own practice is to try to improve markers of organ hypoperfusion (such as lactate, urine output, mental status, and skin perfusion as well as blood pressure) by early antibiotics, fluid resuscitation guided by clinical and sonographic (IVC) signs, and vasoactive drugs guided by clinical and sonographic (basic echo) findings. I place a central venous catheter for access for the vasoactive drugs, rather than to get a CVP reading. I do measure ScvO2 with a central venous blood gas, but have rarely seen one below 70% even in severely shocked patients – I’m far more interested in clearing the lactate, as are these guys.