Goal-directed therapy represents an attempt to adjust the cardiac preload, afterload, and contractility to balance systemic oxygen delivery with oxygen demand. In patients with severe sepsis and septic shock, such an approach would seem eminently reasonable as part of general supportive measures to restore and maintain adequate cellular perfusion and to prevent organ dysfunction. In the setting of the ICU, however, supranormal and normal approaches have met with little or no success [23, 24] . It is possible that, by the time these therapies are applied in the ICU, any such intervention may have been too late. Hence, the focus has shifted towards hemodynamic optimization in the early presentation of disease, such as in the emergency department.