Early Goal-Directed Therapy in Sepsis

In 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:

• CVP of 8-12 mmHg. Mechanical ventilation, increased abdominal pressure, and preexisting impaired ventricular compliance may require higher CVP targets of 12-15 mmHg^[5]

• Superior vena 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 infusion (maximum 20 µg/kg/min) or transfusion of packed red blood cells to a hematocrit ≥ 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% ^[6]

• Achieve MAP ≥ 65mmHg^[5] The presence of atherosclerosis or pre-existing uncontrolled hypertension may necessitate a higher MAP target.
• Achieve Urine output ≥ 0.5 mL/kg/h^[5]

Successful targeting the above goals in the first 6-hour period results in a 15.9% absolute reduction in 28-day mortality rate.