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Critical Care Medicine

Answer 3
  1. Transfusion of packed RBCs to achieve hematocrit > 35% if Svo2 < 70%. Therapy targeting a specific blood pressure and oxygen delivery has been tried unsuccessfully in many critical care diseases. However, goal-directed therapy, directed by continuous measurement of central Svo2, has been shown to reduce mortality of patients with severe sepsis when initiated early in their hospital course.7 The initiation and continuation of EGDT in the ED for 6 hours resulted in a 16% absolute and 34% relative reduction in hospital mortality (46.5% versus 30.5%) as compared with standard care. EGDT patients received protocolized care consisting of the following (in sequence): (1) placement of a central venous line able to continuously monitor Svo2; (2) IV volume resuscitation using crystalloids or colloids to achieve a CVP of 8 to 12 cm H2O; and (3) initiation of vasopressor agents to maintain MAP greater than 65 mm Hg or vasodilator agents to maintain MAP less than 90 mm Hg. Once the patient reached a CVP of 8 to 12 cm H2O and MAP of 65 to 90 mm Hg, care was directed using Svo2. Patients with Svo2 less than 70% were transfused with packed RBCs to achieve hematocrit values above 30%. If the hematocrit was above 30% but the Svo2 remained below 70%, dobutamine infusion was initiated.

    7. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77.

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