Dr. Stephen Trzeciak is a world renowned research and clinical expert in the management of sepsis and post-cardiac arrest care.  A large amount of his work has been incorporated into the Surviving Sepsis campaign as well as a research network that studies the critical interventions that are made from  the time they hit the emergency department all the way through their ICU stay. In this talk, Dr. Trzeciak addresses some of the critical steps we should all be considering the next time we manage not only the obviously shocked patient, but also the ones with subtle signs of shock.  His work includes a large volume of research dedicated to microcirculatory dysfunction – which may in fact prove to be one of the most important resuscitation endpoints of the future.
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Pearls
Early intervention defines the patient’s trajectory
— Dr. Stephen Trzeciak
- For the patient in circulatory shock, macrocirculatory goals often include a MAP > 65 mmHg, however it is critically important to trend the microcirculatory surrogates such as lactate & ScvO2 to make sure the patient’s systemic perfusion is adequate.  PRESSURE is not equivalent to FLOW.
- 7 manifestations of circulatory shock:
- Hypotension
- Tachycardia
- Oliguria
- Encephalopathy
- Peripheral perfusion abnormalities
- Metabolic acidosis
- Respiratory distress
Microcirculation
- Defined: The network of arterioles, capillaries, & post-capillary venules that are responsible for tissue perfusion.
- Primary site & chief regulator of O2 transport
- Largest endothelial surface in the body
- Site of microthrombi, neutrophil aggregation during shock
- Can be visualized through sublingual sidestream darkfield imaging, gastric tonometry
- Which is better? Lactic acid or ScVO2: It appears that these resuscitation markers are equivalent, however – peripheral lactate doesn’t need a CVC.  If it is abnormal, one measurement should beget another.  Trending is key to monitor the effectiveness of your resuscitation.
- Cryptic Shock:  Beware of the patient with normal hemodynamics and an elevated lactate – they may “look good” but they actually have a similar mortality as those in overt shock.  These patients NEED aggressive care and resuscitation.
- Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-93. [PubMed]
- Process Commentary/Response [Comment re Protocol-Based Care for Early Septic Shock – Trzeciak – N Engl J Med.371.4_ 2014]
- Arnold RC, Sherwin R, Shapiro NI, et al. Multicenter observational study of the development of progressive organ dysfunction and therapeutic interventions in normotensive sepsis patients in the emergency department. Acad Emerg Med. 2013;20(5):433-40. [PubMed]
- Trzeciak S, Glaspey LJ, Dellinger RP, et al. Randomized Controlled Trial of Inhaled Nitric Oxide for the Treatment of Microcirculatory Dysfunction in Patients With Sepsis. Crit Care Med. 2014. [PubMed]
