Early goal directed therapy: where do we stand after the individual patient’s meta-analysis?

In the recent years, the issue of early goal directed therapy (EGDT) has led to many debate. EGDT became popular after the Rivers’ trial (1). In that single center trial including 263 patients with septic shock, EGDT application in the emergency department (ED) resulted in an important decrease in 28-day mortality from 46.5% to 30.5% (P<0.01). Even though the main difference in hemodynamic goal was the target of central venous oxygen saturation (ScvO2) that has to be maintained above 70%, the entire package, including maintenance of mean arterial pressure (MAP) ≥65 mmHg, central venous pressure (CVP) between 8-12 mmHg and urine output ≥0.5 mL/kg.h, was adopted in resuscitation guidelines (2). The trial was heavily criticized. Many of the criticisms were directed to the targets, and especially CVP as CVP is not an excellent indicator of fluid responsiveness, as well as to some of the interventions used to increase ScvO2 and in particular to the frequent use of red blood cell transfusions. Also the incidence of low ScvO2 at baseline was higher than in subsequent observational trials. All these factors raised the issue of the external validity of the trial.