LETTERS

Early goal-directed therapy for all UK emergency departments? I read with great interest the article by Lyon et al1 on early goal-directed therapy (EGDT) in Scottish emergency departments (ED). While I would commend any effort to instigate early optimisation and critical care for patients with severe sepsis and septic shock, Iwould suggest a note of caution before any ED in the UK adopts the use of EGDT.2 The application of the results found in the single-centre randomised controlled trial conducted in the USA by Rivers et al2 remains controversial. For this reason, EGDT received a grade 1C recommendation (ie, ‘strong’ recommendation with ‘low level ’ of evidence) in the 2008 Surviving Sepsis Campaign guide-lines.3 The two major concerns in the work of Rivers et al2 was the 46.5 % mortality in the control arm and the mean central venous oxygen saturation (ScvO2) of 48.9 % found in their sample population. Large, multicentre studies since conducted in Europe and Australasia, where EGDT is not widely prac-tised, have reportedmortality rates lower than both the control and interventional arm of the Rivers study,4e6 despite comparable APACHE II scores. As a result of these discrepancies and lack of good quality evidence, the Australian and New Zealand Intensive Care Society (ANZICS) choosenot to endorse fully the2008 Surviving Sepsis Campaign guidelines, espe-cially with regard to EGDT.