Predictors of outcomes of patients ≥ 80 years old admitted to intensive care units in Poland - a post-hoc analysis of the VIP2 prospective observational study.

INTRODUCTION: Elderly patients pose a significant challenge to intensive care unit (ICU) clinicians. In this study we attempted to characterise the population of patients over 80 years old admitted to ICUs in Poland and identify associations between clinical features and short-term outcomes. MATERIAL AND METHODS: The study is a post-hoc analysis of the Polish cohort of the VIP2 European prospective observational study enrolling patients > 80 years old admitted to ICUs over a 6-month period. Data including clinical features, clinical frailty scale (CFS), geriatric scales, interventions within the ICU, and outcomes (30-day and ICU mortality and length of stay) were gathered. Univariate analyses comparing frail (CFS > 4) to non-frail patients and survivors to non-survivors were performed. Multivariable models with CFS, activities of daily living score (ADL), and the cognitive decline questionnaire IQCODE as predictors and ICU or 30-day mortality as outcomes were formed. RESULTS: A total of 371 patients from 27 ICUs were enrolled. Frail patients had significantly higher ICU (58% vs. 44.45%, P = 0.03) and 30-day (65.61% vs. 54.14%, P = 0.01) mortality compared to non-frail counterparts. The survivors had significantly lower SOFA score, CFS, ADL, and IQCODE than non-survivors. In multivariable analysis CFS (OR 1.15, 95% CI: 1.00-1.34) and SOFA score (OR 1.29, 95% CI: 1.19-1.41) were identified as significant predictors for ICU mortality; however, CFS was not a predictor for 30-day mortality ( P = 0.07). No statistical significance was found for ADL, IQCODE, polypharmacy, or comorbidities. CONCLUSIONS: We found a positive correlation between CFS and ICU mortality, which might point to the value of assessing the score for every patient admitted to the ICU. The older Polish ICU patients were characterised by higher mortality compared to the other European countries.

Practice Guidelines for Monitoring Neuromuscular Blockade-Elements to Change to Increase the Quality of Anesthesiological Procedures and How to Improve the Acceleromyographic Method.

Neuromuscular blocking agents are a crucial pharmacological element of general anesthesia. Decades of observations and scientific studies have resulted in the identification of many risks associated with the uncontrolled use of neuromuscular blocking agents during general anesthesia or an incomplete reversal of neuromuscular blockade in the postoperative period. Residual relaxation and acute postoperative respiratory depression are the most serious consequences. Cyclic recommendations have been developed by anesthesiology societies from many European countries as well as from the United States and New Zealand. The newest recommendations from the American Society of Anesthesiologists and the European Society of Anesthesiology were published in 2023. These publications contain very detailed recommendations for monitoring the dosage of skeletal muscle relaxants in the different stages of anesthesia-induction, maintenance and recovery, and the postoperative period. Additionally, there are recommendations for various special situations (for example, rapid sequence induction) and patient populations (for example, those with organ failure, obesity, etc.). The guidelines also refer to pharmacological drugs for reversing the neuromuscular transmission blockade. Despite the development of several editions of recommendations for monitoring neuromuscular blockade, observational and survey data indicate that their practical implementation is very limited. The aim of this review was to present the professional, technical, and technological factors that limit the implementation of these recommendations in order to improve the implementation of the guidelines and increase the quality of anesthesiological procedures and perioperative safety.

Are There Any Advantages of the Low Opioid Anaesthesia and Non-Opioid Postoperative Analgesia Protocol: A Clinical Observational Study.

Purpose: The methods of perioperative analgesia and pain control have changed. The principle of opioid-based analgesia has been modified to multimodal analgesia, followed by LOA (low opioid anaesthesia) and OFA (opioid-free anaesthesia). The aim was to describe the effects of LOA on nausea, vomiting, and pain control during general anaesthesia and postoperative period after laparoscopic cholecystectomy. Patients and Methods: The protocol included the study group-40 patients received low-opioid anaesthesia (LOA), and the control group-40 patients received general anaesthesia with opioid analgesia (OA). The scheme of LOA was based on ketamine, lidocaine, magnesium sulfate, paracetamol, and metamizole. The OA was based on standard opioid (fentanyl) administration in induction and maintenance phase due to clinical observation. Postoperative analgesia included 1g of paracetamol and 1g of metamizol intravenously, with a 6-hour interval between doses. Results: Significant differences in the pain score in the periods of 2-6, 6-12, and 12-24 hours after anaesthesia between the groups were noticed (p < 0.001). Moreover, a significant difference in the frequency of nausea (p = 0.005) and vomiting (p = 0.04) between groups were presented. Nausea occurred in 54.05% of OA group, while in the LOA group, it occurred in a 23.08%. Vomiting occurred in 32.43% of control group, while in the study group, it occurred in 12.82% of patients. Conclusion: The LOA protocol was more beneficial in reducing nausea and vomiting than the opioid-based method of anaesthesia. The LOA protocol of general anaesthesia during laparoscopic cholecystectomy and non-opioid postoperative analgesia have better outcomes in pain control, as well as nausea and vomiting, and improve postoperative patient comfort. The LOA protocol during anaesthesia and non-opioid postoperative analgesia should be considered in routine practice.

Prevalence of life-sustaining treatment limitations in Polish very old intensive care patients (VIPs). A post-hoc analysis of two prospective observational studies.

PURPOSE: Several initiatives have recently focused on raising awareness about limitations of treatment in Poland. We aimed to assess if the propensity to limit LST among elderly patients in 2018-2019 increased compared to 2016-2017. METHODS: We analysed Polish cohorts from studies VIP1 (October 2016 - May 2017) and VIP2 (May 2018 - May 2019) that enrolled critical patients aged >80. We collected data on demographics, clinical features limitations of LST. Primary analysis assessed factors associated with prevalence of limitations of LST, A secondary analysis explored differences between patients with and without limitations of LST. RESULTS: 601 patients were enrolled. Prevalence of LST limitations was 16.1% in 2016-2017 and 20.5% in 2018-2019. No difference was found in univariate analysis (p = 0.22), multivariable model showed higher propensity towards limiting LST in the 2018-2019 cohort compared to 2016-2017 cohort (OR 1.07;95%CI, 1.01-1.14). There was higher mortality and a longer length of stay of patients with limitations of LST compared to the patients without limitations of LST. (11 vs. 6 days, p = 0.001). CONCLUSIONS: The clinicians in Poland have become more proactive in limiting LST in critically ill patients ≥80 years old over the studied period, however the prevalence of limitations of LST in Poland remains low.

Opioid Therapy and Implications for Oxidative Balance: A Clinical Study of Total Oxidative Capacity (TOC) and Total Antioxidative Capacity (TAC).

BACKGROUND: Opioids are used in pharmacotherapy for chronic pain. The phenomenon of their influence on the oxidative-antioxidant balance is poorly understood. Additionally, little is known about the oxidative status in patients receiving chronic opioid noncancer pain therapy. METHODS: The primary goal was to explore oxidative status using the total oxidative capacity (TOC) and total antioxidative capacity (TAC) in patients with chronic lower back pain (LBP) treated with opioids. The secondary task was to present the risk factors connected with the duration of therapy or anthropometric parameters. Plasma TOC and TAC were analyzed in the study group (n = 28), i.e., patients with chronic LBP treated with opioids, and in the control group (n = 11), i.e., healthy volunteers. RESULTS: The TAC was significantly lower in the study group compared to the control group (p < 0.05), while the TOC did not differ significantly. A statistically lower TOC for buprenorphine compared to oxycodone (p = 0.019) and tramadol (p = 0.036) was observed. The TOC did not differ between tramadol and oxycodone. The highest TAC was described for oxycodone, while the TAC for buprenorphine and tramadol was significantly lower in comparison with oxycodone (p = 0.007 and p = 0.016). The TOC/TAC ratio was higher in patients with nicotinism in both groups. CONCLUSIONS: Patients receiving chronic opioid therapy presented a lower antioxidative capacity. There were differences in opioid-induced oxidative imbalance, which is very important clinically. Nicotinism increases the oxidative-antioxidative imbalance. The least oxidative capacity was associated with buprenorphine, while oxycodone showed the greatest antioxidant activity. The most favorable TOC/TAC ratio was observed for buprenorphine. It is suggested that buprenorphine or oxycodone has the best profile, and there is no correlation with the duration of opioid therapy or the opioid dose. However, all opioid substances can potentially enhance the oxidative-antioxidative status.

What do we know about perioperative hypersensitivity reactions and what can we do to improve perioperative safety?

Hypersensitivity reactions are an important aspect of perioperative care and are a crucial interdisciplinary issue in anaesthesiological practice, as well as allergological and laboratory diagnostics. This phenomenon was observed as early as the 1980s and 1990s in Western European countries, and knowledge on this subject has grown significantly over time. Although hypersensitivity reactions are not frequent events (the incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency - 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations), their courses are unfortunately serious and life-threatening. It should also be noted that there is no information regarding the occurrence of perioperative hypersensitivity reactions in many countries. Hence, global assessment of the problem is underestimated. The primary source of actual knowledge comes from epidemiological studies, which indicate an increasing frequency of hypersensitivity reaction occurrence and changes in aetiological factors. The first report from France (1984 to 1989) described two main causes - neuromuscular blocking agents and hypnotic agents. The following years confirmed an increase in perioperative hypersensitivity reactions associated with latex and antibiotics. The most recent data from the National Audit Project 6 indicated increased participation of antibiotics, chlorhexidine, and contrast agents. The results of epidemiological analyses are the basis of medical management guidelines and practice modification. Thanks to the activity of many organisations monitoring the intensity and nature of perioperative hypersensitivity reactions, guidelines for diagnostics and management have been developed. This article presents the results of numerous studies, including the first and the most recent, from various geographical regions. The clinical significance, pathogenesis mechanisms are also discussed. This publication also presents important directions for further scientific and epidemiological research on perioperative hypersensitivity reactions.Key messagesThe incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency - 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations.Reactions may occur during the first episode of anaesthesia, most frequently in the induction of general anaesthesia, and much less frequently during postoperative follow-up.The first reports of perioperative hypersensitivity reaction come from the 1990s, and knowledge on this subject has grown significantly over time.In many countries, multidisciplinary teams and organisations have been established to identify, monitor the occurrence of this phenomenon, and have set the directions of medical activities and have changed the rules and recommendations.There is no information about the occurrence of perioperative hypersensitivity reactions in many countries, and global assessment of the problem is underestimated. Additionally, there is a great need to develop a system to monitor their occurrence in other countries.The long-term epidemiologic studies have demonstrated variability in pharmacologic triggers. However, the main pharmacological substances (antibiotics, muscle relaxants, disinfectans, contrast agents) are related to aspects of patient safety during anaesthesia.

Impact of COVID-19 pandemic on bariatric patients in Podlaskie Voivodeship in Poland.

The research shows that despite the pandemic and higher risk of mortality and complications after SARS-CoV-2 infection, bariatric patients declare a high level of willingness to undergo the bariatric procedure, and the impact of COVID-19 pandemic does not play an important role in their decision-making process concerning the bariatric procedure. </br> </br> Due to the noticeable lifestyle changes during the pandemic such as greater food intake and decrease in physical activity among the bariatric patients, the process of qualification to the bariatric procedure should be conducted very meticulously and the recommended values for weight loss should be implemented to increase patients' motivation before and after the procedure. As the research shows, bariatric patients tend to neglect their strive for healthy lifestyle, even in the presence of the pandemic. Therefore, weight gain prior to the bariatric procedure can lead to more frequent complications during surgery and deterioration of the expected results of bariatric surgery. In conclusion, the group of bariatric patients is a high-risk group not only because of greater mortality due to COVID-19 infection, but also because they do not attach much importance to the external factors such as global pandemic.

Effect of body mass index and rocuronium on serum tryptase concentration during volatile general anesthesia: an observational study.

OBJECTIVE: Female sex, body mass index (BMI), and neuromuscular blocking agents are risk factors of perioperative hypersensitivity reactions. This study aimed to investigate the effect of rocuronium on serum tryptase concentrations during general anesthesia in overweight and obese women. METHODS: The study was conducted in two groups: Group I (n=66) underwent volatile anesthesia with rocuronium and group II (n=60) underwent volatile anesthesia without any muscle relaxant. Serum tryptase concentration (STC) measurements were performed at baseline (STC 0) and postoperatively (STC 1). ClinicalTrials.gov: NCT04035707 RESULTS: The highest median value of STC 0 was seen in obese patients (3.44 µg L-1) and it was significantly higher than in overweight (p=0.01) and underweight patients (p=0.03). The maximum STC 0 was observed in overweight patients (20.4 µg L-1). In group I, STC 0 in obese patients presented the highest median value (4.49 µg L-1), and was significantly higher than in overweight patients (p=0.03), and had significantly higher STC 1 than patients with normal BMI (p=0.04). STC 0 and STC 1 in overweight and obese female patients did not differ significantly between groups. STC 1 did not correlate with rocuronium doses. In group I, BMI positively correlated with the duration of rocuronium infusion (rho=0.37) and STC 1 positively correlated with BMI (rho=0.32). CONCLUSION: Excess weight and obesity predispose to higher preoperative serum tryptase values. Postoperative STC is not linked to rocuronium doses. BMI is the main determinant factor of STC during combined volatile general anesthesia.

Opioid-induced immunosuppression and carcinogenesis promotion theories create the newest trend in acute and chronic pain pharmacotherapy.

Opioids are the main group of pharmacological agents used during the perioperative period and provide a sedative and analgesic component. The observations of opioid consumption in West Europe indicate that this group of drugs is widely used in chronic noncancer pain therapy. Nearly 20 years ago, the first publications indicating that opioids, as an element of perioperative pharmacotherapy in oncologic patients, increase the risk of tumor recurrence and affect further prognosis were presented. The actual publications suggest that there are multifactorial, complex mechanisms underlying the immunological impact and carcinogenesis promotion of opioids and that the intensity varies depending on the type of opioid. There are also questions about the immunosuppressive effects among patients receiving opioids in the treatment of chronic noncancer pain. The aim of the review article is to present information about the action of opioids on the immune system in carcinogenic settings and to define the clinical usefulness of this pharmacological phenomenon.

Effect of body mass index and rocuronium on serum tryptase concentration during volatile general anesthesia: an observational study

OBJECTIVE: Female sex, body mass index (BMI), and neuromuscular blocking agents are risk factors of perioperative hypersensitivity reactions. This study aimed to investigate the effect of rocuronium on serum tryptase concentrations during general anesthesia in overweight and obese women. METHODS: The study was conducted in two groups: Group I (n=66) underwent volatile anesthesia with rocuronium and group II (n=60) underwent volatile anesthesia without any muscle relaxant. Serum tryptase concentration (STC) measurements were performed at baseline (STC 0) and postoperatively (STC 1). ClinicalTrials.gov: NCT04035707 RESULTS: The highest median value of STC 0 was seen in obese patients (3.44 μg L-1) and it was significantly higher than in overweight (p=0.01) and underweight patients (p=0.03). The maximum STC 0 was observed in overweight patients (20.4 μg L-1). In group I, STC 0 in obese patients presented the highest median value (4.49 μg L-1), and was significantly higher than in overweight patients (p=0.03), and had significantly higher STC 1 than patients with normal BMI (p=0.04). STC 0 and STC 1 in overweight and obese female patients did not differ significantly between groups. STC 1 did not correlate with rocuronium doses. In group I, BMI positively correlated with the duration of rocuronium infusion (rho=0.37) and STC 1 positively correlated with BMI (rho=0.32). CONCLUSION: Excess weight and obesity predispose to higher preoperative serum tryptase values. Postoperative STC is not linked to rocuronium doses. BMI is the main determinant factor of STC during combined volatile general anesthesia.

Opioid-induced immunosuppression and carcinogenesis promotion theories create the newest trend in acute and chronic pain pharmacotherapy

Opioids are the main group of pharmacological agents used during the perioperative period and provide a sedative and analgesic component. The observations of opioid consumption in West Europe indicate that this group of drugs is widely used in chronic noncancer pain therapy. Nearly 20 years ago, the first publications indicating that opioids, as an element of perioperative pharmacotherapy in oncologic patients, increase the risk of tumor recurrence and affect further prognosis were presented. The actual publications suggest that there are multifactorial, complex mechanisms underlying the immunological impact and carcinogenesis promotion of opioids and that the intensity varies depending on the type of opioid. There are also questions about the immunosuppressive effects among patients receiving opioids in the treatment of chronic noncancer pain. The aim of the review article is to present information about the action of opioids on the immune system in carcinogenic settings and to define the clinical usefulness of this pharmacological phenomenon.

[The role of tryptase assay in recognition of anaphylactic reaction to muscle relaxants]. / Rola tryptazy w diagnostyce reakcji alergicznych na srodki zwiotczajace.

The incidence of allergic reactions during anaesthesia has been estimated to be from 1:3500 to 1:20000, with muscle relaxants being the most common allergens. Symptoms may involve all organs and systems with various intensities--from mild skin reactions to bronchospasm and cardiovascular collapse in the most severe cases. In a case of suspected perioperative allergic reaction, the management should not be limited to resuscitation and restoration of basic life functions, but must include careful investigation of potential allergens. An appropriate diagnostic strategy is essential for confirmation of an allergic reaction, identification of the allergen, and recommendations for future prevention. In this review, the various aspects of anaphylaxis and anaphylactoid reactions to muscle relaxants are discussed, including the role of tryptase and its assay in the diagnostic regimen.

[Intraoperative identification of the recurrent laryngeal nerves in thyroid surgery]. / Zastosowanie sródoperacyjnej elektroidentyfikacji nerwów krtaniowych wstecznych w chirurgii tarczycy - punkt widzenia anestezjologa.

Accidental injury to the recurrent laryngeal nerve is a common complication of thyroid surgery. Different mechanisms of injury have been described, such as mechanical, electrical, or thermal. Retrosternal operations, secondary bleeding requiring wound revision, or neoplastic tumors are also frequent causes of this complication. Intraoperative direct stimulation of suspected nerve structures as well as vagal nerve stimulation have been proposed to avoid the injury. The effect of stimulation can be assessed by direct observation of the vocal cords (direct laryngoscopy or fiberoscopy via a laryngeal mask airway), or electromyography of the posterior cricoarytenoid muscle. All of these methods limit the use of muscle relaxants during anaesthesia. Details of anaesthetic management are presented.