Nutritional management in critically ill patients with COVID-19: a retrospective multicentre study.

INTRODUCTION: Although nutritional treatment is an established pillar of multidisciplinary care provided in critical illness, there are many concerns regarding this issue in severe COVID-19. This observational, retrospective, multicentre study aimed to analyse the approach to nutritional treatment among selected intensive care units (ICUs) in Poland. MATERIAL AND METHODS: The medical records of 129 patients hospitalized in five units due to respiratory failure following COVID-19 were analysed in terms of nutritional management on the eighth day of the ICU stay. The Harris-Benedict equation (HB), Mifflin St. Jeor equation (MsJ) and ESPEN formula (20 kcal kg -1 body weight) were used to estimate the energy target for each patient, and two ESPEN formulas determined the protein target (1 g kg -1 body weight and 1.3 g kg -1 body weight). RESULTS: Evaluation of nutritional therapy was performed in 129 subjects. The fulfilment of caloric requirement considering the HB, MsJ and ESPEN formula was 66%, 66.7% and 62.5%, respectively. Two clinical centres managed to provide 70% or more of daily caloric requirements. According to the ESPEN formula, the implementation of the protein target was 70%; however, one of the investigated units provided a median of 157% of the protein demand. The nutritional management varied in the preferred route of nutrition administration. Neither method nor grade of nutrition supply influenced biochemical parameters on the 8th day of ICU stay. CONCLUSIONS: Significant differences in nutritional treatment of critically ill COVID-19 patients in Polish ICUs were noted, which underlines the importance of setting up clear guidelines regarding this issue.

Occupational hazards in anaesthesiology during the COVID-19 pandemic.

According to the Occupational Safety and Health Administration of the Department of Labor of the United States, the exposure risk for anaesthesiologists working with COVID-19 patients can be classified as high or very high. This is mostly due to fact that the anaesthesiologists work in close contact with patients' airways, and the aerosol-generating nature of some procedures they perform. Fortunately, despite the occupational hazard, the incidence of COVID-19 among anaesthesiologists and intensivists remains relatively low. Current evidence suggests that the majority of SARS-CoV-2 infections in this group were either contracted outside of the work environment or can be attributed to personal protective equipment (PPE) malfunction. This article focuses on different aspects of anaesthesiologists' safety, risks connected with different clinical scenarios and procedures, issues related to testing and screening, as well as modifiable and non-modifiable risk factors for severe illness or from COVID-19. This analysis is accompanied by a review of guidelines dedicated to mitigating said risks. Educating the personnel, introducing appropriate procedures, and proper utilisation of PPE are essential to the safety of all parties involved in hospital care, particularly those with significant exposure risk.

Dysphagia. Part 1: General issues.

Dysphagia is a common problem among ICU patients. The frequency of dysphagia increases with age and sometimes symptoms can be difficult to recognise. But the consequences of dysphagia can be very serious, including aspiration and subsequently aspiration pneumonia. Therefore, knowing mechanisms and symptoms causing dysphagia is very important and should be well recognised. Proper diagnosis allows one to prevent further complications. However, both the diagnosis and treatment can be very complicated, especially among the patients who do not cooperate. In many cases, the implementation of an appropriate nutrition strategy and proper rehabilitation can alleviate the symptoms of dysphagia and avoid the most severe complications.

Dysphagia. Part 2: Dysphagia in intensive care patients.

Dysphagia is a common problem among ICU patients. The frequency of dysphagia increases with age and sometimes symptoms can be difficult to recognise. But the con-sequences of dysphagia can be very serious, including aspiration and subsequently aspiration pneumonia. Therefore, knowing mechanisms and symptoms causing dysphagia is very important and should be well recognised. Proper diagnosis allows one to prevent further complications. However, both the diagnosis and treatment can be very complicated, especially among the patients who do not cooperate. In many cases, the implementation of an appropriate nutrition strategy and proper rehabilitation can alleviate the symptoms of dysphagia and avoid the most severe complications.

COVID-19 - what should anaethesiologists and intensivists know about it?

Over the past three months, the world has faced an unprecedented health hazard. The World Health Organization has announced a pandemic infection with an unknown species of coronavirus called SARS-CoV-2. Spreading mainly through the droplet route, the virus causes mild symptoms in the majority of cases, the most common being: fever (80%), dry cough (56%), fatigue (22%) and muscle pain (7%); less common symptoms include a sore throat, a runny nose, diarrhea, hemoptysis and chills. A life-threatening complication of SARS-CoV-2 infection is an acute respiratory distress syndrome (ARDS), which occurs more often in older adults, those with immune disorders and co-morbidities. Severe forms of the infection, being an indication for treatment in the intensive care unit, comprise acute lung inflammation, ARDS, sepsis and septic shock. The article presents basic information about etiology, pathogenesis and diagnostics (with particular emphasis on the importance of tomocomputer imaging), clinical picture, treatment and prevention of the infection. It goes on to emphasize the specific risks of providing anesthesiology and intensive care services. Due to the fact that effective causal treatment is not yet available and the number of infections and deaths increases day by day, infection prevention and strict adherence to recommendations of infection control organizations remain the basis for fighting the virus.

The influence of epidural blockade on gut permeability in patients undergoing open surgical repair of abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic clamping during aneurysm repair may cause a decrease in splanchnic blood flow and deterioration of gut barrier integrity. Epidural blocks have beneficial effects on vital organs during abdominal surgery, but sparse data are available on the influence on gut permeability during open aortic surgery. The aim of this study was to verify the hypothesis that epidural blocks may have beneficial effects on intestine permeability changes. METHODS: Seventy individuals undergoing elective open abdominal aortic aneurysm repair were randomly assigned to receive either balanced anaesthesia (continuous epidural and general anaesthesia, group E&G) or only general anaesthesia (group G). For group E&G, an epidural catheter was inserted into the epidural space before the induction of general anaesthesia. Ropivacaine was used for intraoperative and postoperative blocks. For both groups general anaesthesia was maintained with sevoflurane. For group G, analgesia was provided with remifentanil. The assessments of gut function were based on measurements of the absorption and percentages of urinary excretion of four sugars (m 3-O-methyl-D-glucose, D-xylose, L-rhamnose and lactulose) and the lactulose/rhamnose (L/R) ratio. RESULTS: No intergroup differences were observed for sugar recovery or L/R ratio. Significant decreases in 3-O-methyl-D-glucose, D-xylose, and L-rhamnose recoveries were revealed in both examined groups when comparing the results obtained at 12 and 24 hours following the administration of anaesthesia. The rate of blood pressure decrease was significantly higher in group E&G. CONCLUSIONS: Aortic clamping during open abdominal aortic repair led to unfavorable changes in intestinal permeability. Epidural block did not attenuate this deterioration.

The influence of low flow anaesthesia on renal function in cancer patients previously treated with nephrotoxic chemotherapeutic agents.

BACKGROUND: The aim of this study was to assess renal morbidity, associated with the use of low flow anaesthesia (LFA), in cancer patients previously treated with nephrotoxic chemotherapeutic agents. METHODS: Seventy-five patients, aged 30-70 years, scheduled for elective surgery, were randomly allocated to three groups: Group A included those patients who had received nephrotoxic chemotherapeutic agents (cisplatin, carboplatin, methotrexate or cyclophosphamide) within 90 days before surgery, and who were anaesthetised with low flow (0.8(-1) L min(-1)) air-oxygen-sevoflurane (1-3 MAC) anaesthesia; Group B included similar patients who received high flow (6 L min-1) anaesthesia. Non-cancer patients receiving low flow anaesthesia served as controls. Blood was sampled for serum creatinine, BUN, cistatin C, and electrolytes (Na(+), K(+), Cl(-), Ca(2+), P(3+), Mg(2+)) before anaesthesia, and one, three and five days after. RESULTS: There were no statistically significant differences between the groups. CONCLUSIONS: The use of low flow sevoflurane anaesthesia is not associated with an increased risk of nephrotoxicity in those previously exposed to nephrotoxic chemotherapeutic agents.

[The incidence of postoperative hypoxaemia during transportation to the recovery area]. / Incydenty hipoksji w bezposrednim okresie pooperacyjnym w czasie transportu chorych z sali operacyjnej do oddzialu wybudzen.

BACKGROUND: Transportation to the recovery room after surgery can be associated with significant hypoxaemia, if a portable oxygen source and a pulse oximeter are not used. We analysed the condition of patients on admission to recovery after being transported from the operating room without additional oxygen and monitoring. METHODS: One hundred and thirty-one ASA II and III patients, aged 58.2 ± 15.96 years, were enrolled to the study. SaO2 readings immediately before transportation, and on arrival in recovery, were compared. Additionally, blood-gas analysis was performed 10 min after admission to the recovery room. The duration times of transport (T1), lack of monitoring (T2) and breathing with room air (T3) were measured. RESULTS: The mean SaO2 before transportation was 96.9 ± 10.55%, and on arrival in the recovery room was 93.0% ± 6.35. The mean T values were: T1 - 90.0 ± 94.2 s, T2 - 152.6 ± 86.6 s, and T3 - 122.9 ± 86.8 s. Although the length of transport time was relatively short, mild hypoxaemia was observed in all patients, with the SaO2 returning to normal after 10 min on 40% oxygen. Blood gas analysis revealed mild respiratory acidosis in 73% of cases. CONCLUSION: Additional oxygen via face mask and appropriate monitoring should be provided to all patients during transportation from the operating room to the recovery area.

[Does the time of admission to ITU affect mortality?]. / Czy na smiertelnosc w oddziale intensywnej terapii ma wplyw czas przyjecia chorych do oddzialu?

BACKGROUND: Among many factors that may affect mortality among ITU patients, the time of admission has been reported to play some, but ill-defined role. In the retrospective study, we analysed the time of admission, severity of the underlying disease, clinical status on admission and mortality among adult patients treated in a single ITU over a six-year period. METHODS: We compared the mortality of patients who were admitted during daytime (7 a.m. to 6:59 p.m.) and at night (7 p.m. to 6:59 a.m.). We also compared those admitted on weekdays (Monday 7 p.m. to Friday 6:59 a.m.) to those admitted during weekends (Friday 7 p.m. to Monday 7 a.m.). The patients condition was assessed using the APACHE II scale. Brain dead organ donors and readmissions were excluded from the analysis. RESULTS: The retrospective study involved the data of 1789 patients. Mortality was higher in patients who were admitted during the night and during weekends, when compared to daytime and weekdays, respectively. Mortality was also higher in patients admitted directly from the operating theatre after emergency surgery, but only during nights and weekends. The following independent factors in ITU mortality have been identified: length of ITU stay (OR 1.015; % CI 1.005-1.024), admission from a hospital ward (OR 1.39; 95% CI 1.04-1.86) and APACHE II score (OR 1.177; 95% CI 1.156-1.198). CONCLUSION: Time of admission has not been identified as a single independent factor of ITU mortality, but admissions at night and during weekends were associated with higher mortality, probably because of emergency conditions.

Tracheal tube cuff pressure depends on the anaesthesiologist's experience. A follow-up study.

BACKGROUND: Excessive tracheal tube cuff pressure can cause ischemia of the tracheal mucosa, and possible serious complications, such as tracheal stenosis, formation of tracheo-oesophageal fistula or even life-threatening haemorrhage. Inadequate cuff pressure increases the risk of aspiration of gastric contents. METHODS: The cuff pressures were analysed on the basis of the anaesthesiologists' experience. The results were compared to those obtained during the previous study which had been conducted seven years earlier (2002). The physicians were divided into three groups, according to their experience: group I - less than 2 years of practice; group II--2 to 10 years of practice; and group III--over 10 years of practice. High-volume, low-pressure tubes were used for intubation. The anaesthesiologists were not informed of the planned audit. RESULTS: Statistical analysis demonstrated significant differences between cuff pressure readings in the respective study groups. Cuff pressures in group II (p < 0.05) and group III (p < 0.0005) were greater than those in group I. In 2002, no statistically significant differences had been observed between the three groups (p = 0.1156). When comparing results from 2002 and present one differences were observed inside individual groups, concerning group II (p < 0.05) and group III (p < 0.0005). CONCLUSION: There is a tendency to overinflation of endotracheal tube cuffs in all groups. This problem is more common in the group of highly experienced anaesthesiologists, and is more more prevalent at present than in 2002.

Ondansetron given intravenously attenuates arterial blood pressure drop due to spinal anesthesia: a double-blind, placebo-controlled study.

BACKGROUND AND OBJECTIVES: Side effects of spinal anesthesia include arterial hypotension and bradycardia. Both of them may be induced by sympathetic nerve blockade as well as by the Bezold-Jarisch reflex, which may be mediated by peripheral serotonin receptors (5-HT(3) type). The aim of this study was to verify the hypothesis that blockade of type 3 serotonin receptors by intravenous ondansetron administration might reduce hypotension and bradycardia induced by spinal anesthesia. METHODS: Seventy-one patients participated in the study; 36 in the ondansetron group (receiving 8 mg intravenous ondansetron), and 35 in the placebo group (receiving isotonic NaCl solution). Measurements of heart rate and arterial blood pressure were taken every 5 minutes after spinal anesthesia was performed with 4 mL 0.5% hyperbaric bupivacaine solution. RESULTS: Decreases in mean, systolic, and diastolic arterial pressure as well as in heart rate, compared with baseline values were observed in both groups. Minimal systolic and mean blood pressure values obtained over a 20-minute observation period were significantly higher in the ondansetron group. There were no significant differences in diastolic blood pressure and heart rate values between the groups. CONCLUSIONS: Ondansetron given intravenously attenuates the fall of systolic and mean blood pressure, but does not have an influence on diastolic blood pressure or heart rate.