Goal-directed therapy

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## Overview

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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.[1] 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.[2] Further more, 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]

Early Goal-Directed Therapy is most likely to benefit patients in institutions where the mortality rate for septic shock is high.[5]

Shown below is a the Forest plot depicting the different trials that evaluated Goal-Directed Therapy for septic shock.

## Elements

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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

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1. ↑ Gordon A, Russell J, Crit Care. 2005; 9(6): 647–648. Published online 2005 November 23. doi: 10.1186/cc3951.
2. ↑ 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
3. ↑ Rossi AF, Khan D, Clin Biochem. 2004 Jun;37(6):456-61.
4. ↑ Rivers, 2001 http://scalpel.stanford.edu/articles/Goal directed therapy.pdf
5. ↑ openMetaAnalysis Contributors. Early goal directed therapy for septic shock: a living systematic review. GitHub. Available at http://openmetaanalysis.github.io/Early-goal-directed-therapy-for-septic-shock/. Accessed February 24, 2014.

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Health Science * Medicine * Medical specialities * Intensive care medicine / Critical care medicine and Critical care nursing

General terms|

Intensive care unit (ICU) * Neonatal intensive care unit (NICU) * Pediatric intensive care unit (PICU) * Coronary care unit (CCU) * Critical illness insurance

Conditions|

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Diagnosis|

Arterial blood gas * Arterial catheter * Blood cultures * Central venous catheter * Pulmonary artery catheter * Screening cultures

Life supporting treatments|

Airway management * Chest tube * Dialysis * Enteral feeding * Goal-directed therapy * Induced coma * Mechanical ventilation * Therapeutic hypothermia * Total parenteral nutrition

Drugs|

Analgesics * Antibiotics * Antithrombotics * Inotropes * Intravenous fluids * Neuromuscular-blocking drugs * Recombinant activated protein C * Sedatives * Stress ulcer prevention drugs * Vasopressors

ICU scoring systems|

APACHE II * Glasgow Coma Scale * PIM2 * SAPS II * SAPS III * SOFA

Organisations|

Society of Critical Care Medicine * Surviving Sepsis Campaign

Related specialties|

Anesthesia * Cardiology * Internal medicine * Neurology * Pediatrics * Pulmonology * Surgery * Traumatology

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