Echo vs. EGDT in Severe Sepsis and Septic Shock

Inclusion Criteria: * At least 18 years of age * Suspected infection * Two or more systemic inflammatory response syndrome (SIRS) criteria * White blood cell count less than 4,000 per mm3, greater than 12,000 per mm3, or differential with greater than 10% immature forms * Heart rate greater than 90 beats per minute * Respiratory rate greater than 20 breaths per minute or paCO2 less than 32 mmHg * Temperature less than 36°C or greater than 38°C * Evidence of refractory hypoperfusion attributed to sepsis (one or more of the following): * Systolic blood pressure less than 90 mmHg despite an intravenous fluid challenge of at least 30ml/kg (a portion of this may be albumin equivalent) * Blood lactate level at least 4 mmol/L. * Intention to place an arterial catheter. * Intention to place a central venous catheter. Exclusion criteria: * Known pregnancy * Requirement for immediate surgery * Hypotension attributed to alternative cause * Treating physician deems the patient is moribund * Treating physician deems aggressive care is unsuitable * Contraindication to central venous catheterization or arterial catheterization * Advanced directives restricting implementation of the protocol * Significant pathology of the chest or abdominal wall that would make transthoracic echocardiography impossible (burns, chest trauma, etc.) * Children under the age of 18 will not be included in this study