Monitoring critically ill patients can be a daunting task even for experienced clinicians. Goal-directed therapy is a technique involving intensive monitoring and aggressive management of hemodynamics in patients with high risk of morbidity and mortality. The aim of goal-directed therapy is to ensure adequate tissue oxygenation and survival. This article reviews commonly used diagnostics in critical care medicine and what the information gathered signifies and discusses clinical decision making on the basis of diagnostic test results. One example is early goal-directed therapy for severe sepsis and septic shock. The components and application of goals in early goal-directed therapy are discussed.

Article Outline

• Macrovascular versus microvascular monitoring parameters
• Macrovascular monitoring
• • Central Venous Pressure
  • Blood Pressure
  • Urine Output
• Microvascular monitoring
• • Lactate and Lactate Clearance
  • Central Venous Oxygen Saturation
  • Base Excess
• Advanced monitoring
• • Early Goal-Directed Therapy
  • The EGDT Bundle, Step-by-Step
  • • Step 1: identification of a severe sepsis or septic shock patient
    • Step 2: identification of a high-risk patient
    • Step 3: target CVP of 8 to 12 mm Hg
    • Step 4: target MAP greater than 65 mm Hg and less than 90 mm Hg
    • Step 5: target Scvo2 greater than 70%
    • Step 6: sedation and mechanical ventilation
  • Other Goals and Adjunctive Therapies for EGDT
  • • Urine output greater than 0.5 mL/kg/h
    • Early source control
    • Early antibiotic therapy
• Summary
• References

Chapter Outline

• Monitoring
• Perfusion
• Fluid and Electrolyte Disturbances
• Complications
• References

Myocardial dysfunction is commonly encountered in humans, and presumably in dogs with sepsis and critical illness. This dysfunction contributes to increased mortality. With management of the underlying diseases and an understanding of the processes contributing to myocardial dysfunction, steps may be taken to mitigate the consequences of cardiac impairment. Clinical findings, proposed pathophysiologic mechanisms, and current treatment considerations are discussed. Further study is needed to find practical ways to identify myocardial dysfunction and to determine whether timed interventions intended to augment cardiac performance will reduce mortality in this patient population.

Article Outline

• Cardiac performance in septic shock
• • Humans
  • Dogs
• Proposed mechanisms of sepsis-induced myocardial dysfunction
• Toll-like receptors and innate immunity
• Cascade of events from trigger to myocardial dysfunction
• Additional contributing factors leading to poor outcome
• Therapeutic potentials
• References