I read Dr. Paul Marik's recent review article "The demise of early goal-directed therapy for severe sepsis and septic shock" (Acta Anaesthesiol Scand. 2015 Feb 6. doi: 10.1111/aas.12479) with great interest, and once again return to what may be the major lessons from both the initial success of EGDT and the dramatic reductions in sepsis mortality: do it right; do it fast – use the right antibiotics to quickly attack the infectious microorganisms (c.f. Barochia AV et al., Bundled care for septic shock: an analysis of clinical trials. Crit Care Med 2010; 38: 668–78) and support perfusion to prevent multi-organ failure, and death before the infection is eliminated.
As Dr. Marik (2015) concludes "Accumulating data suggest that the major components of the 6-h sepsis resuscitation bundle lack high-quality evidence. Early identiﬁcation and treatment with appropriate antibiotics remains the most important elements in the treatment of patients with sepsis. Patients with sepsis should be resuscitated according to an individualized physiological-based approach. A conservative ﬂuid strategy and the early use of norepinephrine may further improve the outcome of this common disorder." (emphasis mine).
Drs. Marik and R. Bellomo (Re-thinking resuscitation goals: an alternative point of view! Critical Care 2013, 17:458.Critical Care 2013, 17:458) "consider that the ﬁrst step in the resuscitation of patients with septic shock is to achieve an MAP of at least 60 to 65 mm Hg with the use of vasoactive agents (norepinephrine) and small volumes of balanced ﬂuid."
In view of the ProCESS and ARISE trials, accumulating evidence for role of early antibiotics, and evidence for a conservative fluid strategy, let me conclude by presenting a challenge: how do we best individualize sepsis care for the benefit of the patient? As you, intensive care physicians and others treating sepsis patients, address this challenge, in the words of Dr. Marik (2015), let us all "acknowledge [our] mentors, colleagues, students and patients who have taught [us] everything [we] know ..." in the search for further improvements in sepsis resuscitation, management and outcomes.