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Stephen Trzeciak

Publications and source records attributed to Stephen Trzeciak.

12 recordsLinked to original sources
PubMed2006

Severe sepsis and septic shock: review of the literature and emergency department management guidelines.

Severe sepsis and septic shock are as common and lethal as other acute life-threatening conditions that emergency physicians routinely confront such as acute myocardial infarction, stroke, and trauma. Recent studies have led to a better understanding of the pathogenic mechanisms and the development of new or newly applied therapies. These therapies place early and aggressive management of severe sepsis and septic shock as integral to improving outcome. This independent review of the literature examines the recent pathogenic, diagnostic, and therapeutic advances in severe sepsis and septic shock for adults, with particular relevance to emergency practice. Recommendations are provided for therapies that have been shown to improve outcomes, including early goal-directed therapy, early and appropriate antimicrobials, source control, recombinant human activated protein C, corticosteroids, and low tidal volume mechanical ventilation.

Adrenal Cortex Hormones↗
PubMed2006

Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department.

OBJECTIVE: Early goal-directed therapy (EGDT) has been shown to decrease mortality in patients with severe sepsis and septic shock. Consensus guidelines now advocate EGDT for the first 6 h of sepsis resuscitation. However, EGDT has not yet been widely adopted in practice. A need for effective collaboration between emergency medicine and critical care medicine services has been identified as an obstacle for implementation. We aimed to determine if EGDT end points could reliably be achieved in real-world clinical practice. METHODS: EGDT was implemented as a collaborative emergency medicine/critical care quality improvement initiative. EGDT included the following: i.v. fluids (IVF) targeting central venous pressure > or = 8 mm Hg, vasopressors targeting mean arterial pressure > or = 65 mm Hg, and (if necessary) packed RBCs (PRBCs) and/or dobutamine targeting central venous oxygen saturation > or = 70%. A retrospective analysis was performed of emergency department (ED) patients with persistent sepsis-induced hypotension (systolic BP < 90 mm Hg despite 1.5 L of IVF) treated with EGDT during the first year of the initiative. Primary outcome measures included successful achievement of EGDT end points and time to achievement. A secondary analysis was performed comparing EGDT cases to historical control cases (nonprotocolized control subjects without invasive monitoring). RESULTS: All end points were achieved in 20 of 22 cases (91%). The median time to reach each end point was < or = 6 h. In the secondary analysis, patients (n = 38; EGDT, n = 22; pre-EGDT, n = 16) had similar age, do-not-resuscitate status, severity scores, hypotension duration, and vasopressor requirement (p = not significant). In the ED, EGDT used more IVF and included PRBC/dobutamine utilization, without any impact on the overall use of these therapies through the first 24 h in the ICU. EGDT was associated with decreased ICU pulmonary artery catheter (PAC) utilization (9.1% vs 43.7%, p = 0.01). CONCLUSIONS: With effective emergency medicine/critical care collaboration, we demonstrate that EGDT end points can reliably be achieved in real-world sepsis resuscitation. ED-based EGDT appears to decrease ICU PAC utilization.

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PubMed2005

Clinical manifestations of disordered microcirculatory perfusion in severe sepsis.

Microcirculatory dysfunction plays a pivotal role in the development of the clinical manifestations of severe sepsis. Prior to the advent of new imaging technologies, clinicians had been limited in their ability to assess the microcirculation at the bedside. Clinical evidence of microcirculatory perfusion has historically been limited to physical examination findings or surrogates that could be derived from global parameters of oxygen transport. This review explores: (1) the clinical manifestations of severe sepsis that can be linked to microcirculatory dysfunction; (2) the relationship between conventional hemodynamic parameters and microcirculatory blood flow indices; (3) the incorporation of microcirculatory function into the definition of 'shock' in the sepsis syndrome; (4) the role of the microcirculation in oxygen transport; and (5) the potential impact of novel sepsis therapies on microcirculatory flow. Although the study of the microcirculation has long been the domain of basic science, newly developed imaging technologies, such as orthogonal polarization spectral imaging, have now given us the ability to directly visualize and analyze microcirculatory blood flow at the bedside, and see the microcirculatory response to therapeutic interventions. Disordered microcirculatory flow can now be associated with systemic inflammation, acute organ dysfunction, and increased mortality. Using new technologies to directly image microcirculatory blood flow will help define the role of microcirculatory dysfunction in oxygen transport and circulatory support in severe sepsis.

Hemodynamics↗
PubMed2005

Critical care medicine training and certification for emergency physicians.

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Critical care is a continuum that includes out-of-hospital, emergency department (ED), and ICU care teams. Both emergency medicine and critical care medicine require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of critical care medicine fellowships do not accept emergency medicine residents, and those who do successfully complete a fellowship do not have access to a US certification examination in critical care medicine. Despite these barriers, interest in critical care medicine training among emergency physicians is increasing. Dual emergency medicine- and critical care medicine-trained physicians will not only help alleviate the intensivist shortage but also strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to critical care medicine certification for emergency physicians who complete a critical care fellowship.

Certification↗
PubMed2005

Critical care medicine training and certification for emergency physicians.

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine (EM) and critical care medicine (CCM). Critical care is a continuum that includes prehospital, emergency department (ED), and intensive care unit (ICU) care teams. Both EM and CCM require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of CCM fellowships do not accept EM residents, and those who successfully complete a fellowship do not have access to a U.S. certification exam in CCM. Despite these barriers, interest in CCM training among EM physicians is increasing. Dual EM/CCM-trained physicians not only will help alleviate the intensivist shortage but also will strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to CCM certification for emergency physicians who complete a critical care fellowship.

Certification↗
PubMed2005

Inclusion criteria for clinical trials in sepsis: did the American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions of sepsis have an impact?

BACKGROUND: Over the last 25 years, a growing number of clinical trials have evaluated novel sepsis therapies. To promote uniformity in inclusion criteria for patient enrollment, the American College of Chest Physicians and Society of Critical Care Medicine first published consensus conference definitions for sepsis in 1992. STUDY OBJECTIVES: To characterize (1) the utilization of specific criteria for patient enrollment in sepsis clinical trials and (2) the impact that the consensus conference definitions have had on these criteria. DESIGN: We used MEDLINE to identify clinical trials in sepsis from 1976 to 2001. Clinical trials published after the consensus conference (ACC; from 1993 to 2001) were compared with trials published before the consensus conference (BCC; from 1976 to 1992). RESULTS: We identified 176 clinical trials (ACC, 119 trials; BCC, 57 trials). Clinical trials published ACC were more likely to utilize or reference a previously published standard for inclusion criteria (65% vs 11%, respectively; p < 0.001). The consensus conference definitions were the standards used in 69% of these trials. The utilization of specified values for WBC count, temperature (T), heart rate (HR), and respiratory rate (RR) was significantly increased in the ACC group compared to the BCC group, as follows: WBC count, 62% vs 26%, respectively (p < 0.001); T, 89% vs 56%, respectively (p < 0.001); HR, 77% vs 26%, respectively (p < 0.001); and RR, respectively 76% vs 28% (p < 0.001). ACC, clinical trials were less likely to require blood culture positivity (4 of 119 trials [3%] vs 9 of 57 trials [16%], respectively; p < 0.006) and were more likely to incorporate markers of acute organ dysfunction (81 of 119 trials [68%] vs 28 of 57 trials [49%], respectively; p < 0.03) in the inclusion criteria. CONCLUSIONS: (1) Since 1992 there has been a significant increase in the utilization of predefined sepsis criteria for patient enrollment in clinical trials, and this increase can be attributed to the existence of consensus conference definitions. (2) Compared to inclusion criteria BCC, inclusion criteria ACC were less reliant on blood culture positivity and were more likely to incorporate markers of organ dysfunction.

Clinical Trials as Topic↗
PubMed2004

Clinical review: Emergency department overcrowding and the potential impact on the critically ill.

Critical care constitutes a significant and growing proportion of the practice of emergency medicine. Emergency department (ED) overcrowding in the USA represents an emerging threat to patient safety and could have a significant impact on the critically ill. This review describes the causes and effects of ED overcrowding; explores the potential impact that ED overcrowding has on care of the critically ill ED patient; and identifies possible solutions, focusing on ED based critical care.

Critical Care↗
PubMed2004

Infections and severe sepsis in solid-organ transplant patients admitted from a university-based ED.

The objective was to provide a descriptive analysis of infectious processes in transplant patients admitted from the emergency department (ED). A database of all adult transplant patients at a university medical center was cross-referenced with a computerized record of all ED visits over an 18-month period. ED charts, inpatient records, and microbiology data were retrospectively reviewed. Final diagnoses and outcomes were analyzed. There were 352 ED visits by transplant patients (kidney 66%, kidney/pancreas 15%, liver 13%, lung 3%, heart 3%). Infections were the most common indications for admission (77/217, 35%). Urinary tract infection and pneumonia were the most common infections. Nine of 77 patients (11.7%) with documented infections developed severe sepsis, which was the most common reason for ICU utilization. Thirty-five percent of transplant patients admitted from the ED had acute infections, and 11.7% of these patients had severe sepsis. The emergency physician must have a high index of suspicion for infections when evaluating organ transplant recipients.

Adult↗
PubMed2004

Lac-time?

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Biomarkers↗
PubMed2004

Other supportive therapies in sepsis: an evidence-based review.

OBJECTIVE: In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for other supportive therapies in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN: The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS: The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION: Patients with severe sepsis should be treated with deep-vein thrombosis prophylaxis. Low-dose unfractionated heparin or low molecular weight heparin is preferred. Use of graduated compression devices is recommended in septic patients with contraindication to the use of heparin or combined with heparin in very high-risk patients. Stress ulcer prophylaxis should be given to all patients with severe sepsis. Histamine-2 receptor antagonists are more effective than sucralfate in decreasing bleeding risk and transfusion requirements. Proton pump inhibitors have not been assessed in a direct comparison with histamine-2 receptor antagonists but do demonstrate equivalency and ability to increase gastric pH.

Consensus Statements as Topic↗
PubMed2002

Variation in patient management based on ECG interpretation by emergency medicine and internal medicine residents.

This study was performed to determine the impact of electrocardiogram (ECG) interpretation on urgent patient care decisions by internal medicine (IM) and emergency medicine (EM) resident physicians. Six clinical scenarios and ECGs were given to 31 IM residents and 31 EM residents at a university medical center. Based on the ECG interpretation, the residents were asked to select the best patient management from a list of choices. IM and EM residents were equally likely to choose the correct management for complete heart block (90% IM v 97% EM, P = NS), and pulseless ventricular tachycardia (VT) (94% IM v 97% EM, P = NS). IM residents were less likely to choose the correct management for acute posterior wall myocardial infarction (MI) (26% IM v 74% EM, P <.0001) and unstable supraventricular tachycardia (SVT) (87% IM v 100% EM, P <.05). Residents in both programs were equally likely to misinterpret left ventricular hypertrophy (LVH) (23% IM and 16% EM, P = NS) and benign early repolarization (BER) (48% IM and 52% EM, P = NS) as acute myocardial ischemia when presented with a clinical history not suggestive of cardiac ischemia. IM and EM residents were equally likely to choose the correct management for complete heart block and pulseless VT. Compared with EM residents, IM residents were less likely to choose the correct management of posterior wall MI and unstable SVT. Both IM and EM residents were prone to misinterpreting LVH and BER as acute myocardial ischemia. Resident education in both specialties should focus on ECG interpretation skills to improve patient management decisions.

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