In this issue of JAMA, Jones et al1 report the results of a randomized, noninferiority trial comparing 2 strategies for guiding the use of inotropes and red blood cell transfusions during early goal-directed therapy for patients with severe sepsis or septic shock. Early goal-directed therapy is a multifaceted strategy for titrating intravenous fluids, pressors, inotropes (ie, dobutamine), and transfusions to rapidly correct the physiological derangements associated with severe sepsis. In a single-center randomized trial, the use of early goal-directed therapy was associated with a decrease in mortality from 46.5% to 30.5%.2 Early goal-directed therapy is a key element of the treatment bundle suggested by the Surviving Sepsis Campaign, is widely believed to be effective, and has been implemented to varying degrees in emergency departments across the country.3- 6 However, the validity of the initial trial has been questioned by some, and the benefits of early goal-directed therapy and its components are currently being reevaluated in a number of large prospective clinical trials.7
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