Goal directed therapy: how long can we wait?

Haemodynamic monitoring and manipulation are cornerstones of critical care management. In this issue of Critical Care, Pearse et al. report two interesting related studies in this area, examining the effectiveness of postoperative goal directed therapy following major surgery [1] and the use of central venous saturation (ScvO2) monitoring in these patients [2].As the authors at St George's Hospital, London, point out, despite their own work [3] and that of others [4,5] demonstrating the benefit of preoperative goal directed therapy (GDT) for high risk surgery patients, GDT has not become routine practice. One can speculate why this might be. A lack of intensive care beds to allow preoperative admission may be responsible for not instituting GDT; however, a study from York, UK, found that preoperative GDT did not increase overall intensive care use [5]. GDT is a bundle of care that includes intensive care unit (ICU) monitoring, fluids, blood transfusion and inotropes, and it is difficult to know if the benefits of GDT are due to all or just some of these components. Of note for practitioners, the safety of the pulmonary artery (PA) catheter has been questioned [6] and this was a core technology to measure cardiac output in earlier GDT studies.Pearse and colleagues have taken the pragmatic view that if the intensive care community will not take up preoperative GDT, then perhaps postoperative GDT is more palatable, and so they studied the efficacy of the latter. They demonstrated that even when only applied postoperatively for the first eight hours, GDT (as defined by their protocol) significantly reduced complication rates and hospital length of stay [1]. The two groups received similar volumes of crystalloid and blood but the GDT group received on average an extra 700 ml of colloid and, as dictated by the protocol, more patients in the GDT group achieved the oxygen delivery goal of 600 ml min-1 m-2. Mortality rates were similar in both groups.This was a well conducte