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.

Mineralocorticoid Receptor Antagonist (Potassium Canrenoate) Does Not Influence Outcome in the Treatment of COVID-19-Associated Pneumonia and Fibrosis-A Randomized Placebo Controlled Clinical Trial.

In December 2019 the SARS-CoV-2 virus appeared in the world, mainly presenting as an acute infection of the lower respiratory tract, namely pneumonia. Nearly 10% of all patients show significant pulmonary fibrotic changes after the infection. The aim of this study was to evaluate the effectiveness and safety of potassium canrenoate in the treatment of COVID-19-associated pneumonia and pulmonary fibrosis. We performed a randomized clinical trial (RCT) of potassium canrenoate vs placebo. A total of 55 patients were randomized and 49 were included in the final analysis (24 allocated to the intervention group and 25 allocated to the control group). Patients were assessed by physical examination, lung ultrasound, CT imaging and blood samples that underwent biochemical analysis. This RCT has shown that the administration of potassium canrenoate to patients with COVID-19 induced pneumonia was not associated with shorter mechanical ventilation time, shorter passive oxygenation, shorter length of hospitalization or less fibrotic changes on CT imaging. The overall mortality rate was not significantly different between the two groups. Adverse events recorded in this study were not significantly increased by the administration of potassium canrenoate. The negative outcome of the study may be associated with the relatively small number of patients included. Any possible benefits from the use of potassium canrenoate as an antifibrotic drug in COVID-19 patients require further investigation.

Atypical Pupil Reactions in Brain Dead Patients.

BACKGROUND: During routine diagnosis of brain death, changes in pupil diameter in response to the stimulation of peripheral nerves are sometimes observed. For example, pupillary dilation after diagnosed brain death is described in the literature as the ciliospinal reflex. However, pupil constriction creates diagnostic doubts. OBJECTIVE: The pupillometric analysis of pupil response to stimulation of the cervicothoracic spinal cord in patients with diagnosed brain death. METHODS: Instrumental tests to confirm the arrest of cerebral circulation were performed in 30 adult subjects (mean age 53.5 years, range 26-75 years) with diagnosed brain death. In addition, a pupillometer was used to measure the change in pupil diameter in response to neck flexion. INTERVENTION: Flexion of the neck and measuring the response in change of the pupil with the use of the pupillometer. RESULTS: The change in the pupil was observed in the examined group of patients. Difference in pupil size ≥ 0.2 mm was observed in 14 cases (46%). In five cases (17%), pupil constriction was found (from 0.2 to 0.7 mm). Measurement error was +/- 0.1 mm. CONCLUSIONS: Both pupillary constriction and dilatation may occur due to a ciliospinal reflex in patients with brain death. This phenomenon needs further research in order to establish its pathophysiology.

Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review.

Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20-30%) and twelve (15-25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.

COVID-19: The Potential Treatment of Pulmonary Fibrosis Associated with SARS-CoV-2 Infection.

In December 2019, a novel coronavirus, SARS-CoV-2, appeared, causing a wide range of symptoms, mainly respiratory infection. In March 2020, the World Health Organization (WHO) declared Coronavirus Disease 2019 (COVID-19) a pandemic, therefore the efforts of scientists around the world are focused on finding the right treatment and vaccine for the novel disease. COVID-19 has spread rapidly over several months, affecting patients across all age groups and geographic areas. The disease has a diverse course; patients may range from asymptomatic to those with respiratory failure, complicated by acute respiratory distress syndrome (ARDS). One possible complication of pulmonary involvement in COVID-19 is pulmonary fibrosis, which leads to chronic breathing difficulties, long-term disability and affects patients' quality of life. There are no specific mechanisms that lead to this phenomenon in COVID-19, but some information arises from previous severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS) epidemics. The aim of this narrative review is to present the possible causes and pathophysiology of pulmonary fibrosis associated with COVID-19 based on the mechanisms of the immune response, to suggest possible ways of prevention and treatment.

Validation of the behavioral pain scale to assess pain intensity in adult, intubated postcardiac surgery patients: A cohort observational study - POL-BPS.

Patients after cardiac surgery experience significant pain, but cannot communicate effectively due to opioid analgesia and sedation. Identification of pain with validated behavioral observation tool in patients with limited abilities to self-report pain improves quality of care and prevents suffering. Aim of this study was to validate Polish version of behavioral pain scale (BPS) in intubated, mechanically ventilated patients sedated with dexmedetomidine and morphine after cardiac surgery.Prospective observational cohort study included postoperative cardiac surgery patients, both sedated with dexmedetomidine and unsedated, observed at rest, during a nociceptive procedure (position change) and 10 minutes after intervention. Pain control was achieved using morphine infusion and nonopioid coanalgesia. Pain intensity evaluation included self-report by patient using numeric rating scale (NRS) and BPS assessments carried out by 2 blinded observers.A total of 708 assessments were performed in 59 patients (mean age 68 years), predominantly men (44/59, 75%). Results showed very good interrater correlation between raters (interrater correlation scores >0.87). Self-report NRS scores were obtained from all patients. Correlation between NRS and BPS was relatively strong during nociceptive procedures in all patients for rater A and rater B (Spearman R > 0.65, P < .001). Both mean NRS and BPS scores were significantly higher during nociceptive procedures as compared to assessments at rest, in both sedated and unsedated patients (P < .001).The results of this observational study show that the Polish translation of BPS can be regarded as a useful and validated tool for pain assessment in adult intubated patients. This instrument can be used in both unsedated and sedated cardiac surgery patients with limited communication abilities.

Predisposition of functional genetic variants of A-kinase anchoring protein 10 toward acquired repolarization disorders in high-risk vascular surgery patients.

PURPOSE: We aimed at assessing the predisposition of A-kinase anchoring protein 10 (AKAP10) polymorphism toward acquired repolarization disorders in high-risk vascular surgery patients. PATIENTS AND METHODS: One hundred adult patients (age =44-85 years), scheduled for an elective high-risk "open" vascular surgery procedure, were recruited. The electrocardiogram Holter monitor was used to assess repolarization stability from the beginning of the operation up to 24 hours afterward. The AKAP10 gene rs203462 polymorphism and cardiac complications were analyzed. RESULTS: Repolarization disturbances defined as QT interval duration corrected for heart rate (QTc) interval prolongation >500 ms and QTc interval dispersion >65 ms were recorded in 46 patients. A model of multivariate logistic regression showed that only the presence of allele G of the AKAP10 polymorphism was an independent risk factor for repolarization disturbances in the perioperative period (odds ratio =14.35; 95% CI =4.65-44.23; p<0.0001). CONCLUSION: When the acquired QTc interval prolongation or QTc dispersion is associated with AKAP10 polymorphism, it may remain clinically silent.

Validation of the Polish version of the Critical Care Pain Observation Tool (CPOT) to assess pain intensity in adult, intubated intensive care unit patients: the POL-CPOT study.

INTRODUCTION: Pain in the critically ill affects nearly 50% of patients. In patients unable to self-report pain, behavioural scales are used. The aim of this study was to validate the Polish version of the Critical Care Pain Observation Tool (CPOT). MATERIAL AND METHODS: The prospective observational cohort study included patients observed during non-nociceptive and nociceptive procedures, at rest, during the intervention, and 15 min after each intervention. Assessments included self-report by patients and CPOT assessment carried out by two blinded observers. RESULTS: A total of 71 patients were included in the study (mean age: 66 years), predominantly males (50/71, 70%), mean APACHE II score 26.04 ±10.56. Results showed an excellent inter-rater correlation (ICC) between raters (ICC scores > 0.97). Self-report NRS (numeric rating scale) scores were available from 58/71 patients (82%). Patients' self-reported pain and CPOT showed a very strong correlation (Spearman's R > 0.85, p < 0.0001). The CPOT has high diagnostic value for detection of presence of patients' self-reported pain (ROC AUC = 0.938 for rater A and 0.951 for rater B, p < 0.0001). CPOT score ≥ 2 is an optimal cut-off to detect pain during a nociceptive procedure. A significantly higher mean CPOT score during a nociceptive procedure as compared to a non-nociceptive procedure or at rest was found (p < 0.0001). CONCLUSIONS: This study shows that the Polish version of the CPOT can be used to assess pain in critically ill patients with no hypnotic, opioid-based analgo-sedation. Polish CPOT scores correlated well with patients' self-reported presence of pain and showed excellent inter-rater reliability. This makes the Polish version of the CPOT a reliable pain assessment tool.

Characteristics of peripheral immune cell subsets in patients with carotid atherosclerosis undergoing carotid endarterectomy.

INTRODUCTION: The role of circulating immune cells in the pathophysiology of cerebrovascular accidents is currently under debate. The aim of this study was to characterize peripheral immune cell subsets in patients undergoing carotid endarterectomy (CEA). MATERIAL AND METHODS: We conducted a prospective observational study in a group of 124 patients with significant carotid stenosis undergoing carotid endarterectomy, both symptomatic and asymptomatic. We compared the percentages of circulating immune cells: B lymphocytes, T lymphocytes, T helper, cytotoxic T, CD4+/CD8+ ratio, T regulatory, monocytes and NK cells before CEA and 6 h after the procedure. RESULTS: Total lymphocyte count and cytotoxic T lymphocyte count decreased 6 h after CEA in both subgroups. The NK cell level decrease was statistically significant only in the symptomatic subgroup (19.41 ±9.30 before CEA and 16.52 ±9.37 after CEA; p = 0.0044), but not in the asymptomatic subgroup (17.88 ±9.14 before CEA and 15.91 ±9.51 after CEA; p = 0.0886). The T lymphocyte level showed a statistically significant increase only in symptomatic patients (69.74 ±10.16 before CEA vs. 71.45 ±9.77 after CEA; p = 0.0462), and not in the asymptomatic subgroup (70.08 ±11.19 prior to CEA and 70.21 ±12.35; p = 0.9048). B lymphocyte, helper T lymphocyte and regulatory T (Treg) lymphocyte (CD4+/CD25+) levels showed a significant increase after CEA. CONCLUSIONS: This is the first study to compare circulating immune cells in patients undergoing carotid endarterectomy. Only the symptomatic subgroup experienced a significant decrease in the NK cell level and an increase in the T lymphocyte count after CEA. This study enriches our understanding of immune cell kinetics during carotid endarterectomy.

Multicenter assessment of sedation and delirium practices in the intensive care units in Poland - is this common practice in Eastern Europe?

BACKGROUND: The majority of critically ill patients experience distress during their stay in the Intensive Care Unit (ICU), resulting from systemic illness, multiple interventions and environmental factors. Providing humane care should address concomitant treatment of pain, agitation and delirium. The use of sedation and approaches to ICU delirium should be monitored according to structured guidelines. However, it is unknown to what extent these concepts are followed in Eastern European countries like Poland. The aim of this study was to evaluate sedation and delirium practices in ICUs in Poland, as a representative of the Eastern European block, particularly the implementation of sedation and ICU delirium screening tools, availability of written sedation guidelines, choice of sedation and delirium treatment agents. METHODS: A national postal survey was conducted in all Polish ICUs in early 2016. RESULTS: A total of 165 responses out of 436 addressed units were received (37.8%). Out of responding ICUs delirium is monitored in only 11.9% of the units in Poland. Sedation monitoring tool is used in only 46.1% of units. Only 19.4% of ICUs have written protocols for sedation and 32.1% do not practice daily sedation interruption. The most frequently used agents for short-term sedation (<24 h) were propofol and fentanyl infusions and benzodiazepines (midazolam) and morphine for longer sedation (>24 h). The preferred agents for delirium treatment were haloperidol (77.6%), dexmedetomidine (43.6%) and quetiapine (19.4%). Close to one-third (32.7%) of respondents chose a benzodiazepine (diazepam) for ICU delirium treatment. Non-pharmacological treatment for ICU delirium was reported by only 45% of the respondents. CONCLUSIONS: A majority of Polish ICUs do not adhere to international guidelines regarding sedation and delirium practices. There continues to be inadequate use of sedation and delirium monitoring tools. High usage of benzodiazepines for sedation and ICU delirium treatment reveals persistence of non-evidence-based practice. This study should prompt further assessment of other Eastern Europe countries and help generate a collective response to update these aspects of patient safety and comfort.

Methods of pain assessment in adult intensive care unit patients - Polish version of the CPOT (Critical Care Pain Observation Tool) and BPS (Behavioral Pain Scale).

Many patients treated in the intensive care unit (ICU) experience pain that is a source of suffering and leaves a longterm imprint (chronic pain, post-traumatic stress disorder). Nearly 30% of patients experience pain at rest, while the percentage increases to 50% during nursing procedures. Pain in ICU patients can be divided into four categories: continuous ICU treatment-related pain/discomfort, acute illness-related pain, intermittent procedural pain and pre-existing chronic pain present before ICU admission. As daily nursing procedures and interventions performed in the ICU may be a potential source of pain, it is crucial to use simple pain monitoring tools. The assessment of pain intensity in ICU patients remains an everyday challenge for clinicians, especially in sedated, intubated and mechanically ventilated patients. Regular assessment of pain intensity leads to improved outcome and better quality of life of patients in the ICU and after discharge from ICU. The gold standard in pain evaluation is patient self-reporting, which is not always possible. Current research shows that the two tools best validated for patients unable to self-report pain are the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT). Although international guidelines recommend the use of validated tools for pain evaluation, they underline the need for translation into a given language. The authors of this publication obtained an official agreement from the authors of the two behavioral scales - CPOT and BPS - for translation into Polish. Validation of these tools in the Polish population will aid their wider use in pain assessment in ICUs in Poland.

Peripheral Blood Lymphocyte Subsets (CD4+, CD8+ T Cells, NK Cells) in Patients with Cardiovascular and Neurological Complications after Carotid Endarterectomy.

BACKGROUND: The aim of the study was to evaluate the differences in the circulating immune cells' subgroups after the atherosclerotic plaque removal in patients presenting with postoperative complications as compared to the patients without complications after carotid endarterectomy (CEA). METHODS: Patients with significant carotid atherosclerosis (n=124, age range: 44 to 87 years) who underwent CEA were enrolled in a prospective study. The immunology study using flow cytometry was performed to determine the percentages of peripheral blood T cells (CD4+, CD8+, Treg-CD4+/CD25+) and NK (natural killer) cells before and after the procedure. The data were expressed as the percentage of total lymphocytes±the standard error of mean. RESULTS: The mean percentage of lymphocytes (61.54%±17.50% vs. 71.82%±9.68%, p=0.030) and CD4 T lymphocytes (T helper, 38.13%±13.78% vs. 48.39%±10.24%, p=0.027) was significantly lower six hours after CEA in patients with postoperative 30-day cardiovascular and neurological complications as compared to the group without complications. On the other hand the mean NK level in the group with complications was significantly higher (21.61%±9.00% vs. 15.80%±9.31%, p=0.048). CONCLUSIONS: The results of this study suggest that after carotid endarterectomy the percentages of circulating immune cells subsets differ in patients with and without postoperative complications.

Electrophysiological, hemodynamic, and metabolic response to open procedure or endovascular repair of infrarenal aortic aneurysms.

BACKGROUND: The occurrence of cardiovascular diseases in the group of patients undergoing vascular surgery because of abdominal aorta aneurysm is very high. Endovascular procedures are regarded as hemodynamically safer for the patients. The aim of this study was to compare the changes in electrophysiological, hemodynamic, and metabolic parameters depending on the type of operation, using invasive hemodynamic monitoring and Holter electrocardiography recording. METHODS: A prospective, observational, nonrandomized study was conducted to compare dynamic changes of electrophysiological parameters (dominant rhythm, arrhythmia, corrected QT interval (QTc), invasive blood pressure, electrolytes, and acid-base balance in defined points during perioperative time in 2 groups: vascular prosthesis implantation group (91 patients) and stent-graft implantation group (83 patients). RESULTS: The study group comprised 174 consecutive adult Caucasian patients (mean age 64.4 ± 8.9 years in stent-graft group and 70.0 ± 7.5 years in vascular prosthesis implantation group). Although patients in the stent-graft implantation group were younger, they were diagnosed with lower limbs vascular atherosclerosis, type 2 diabetes mellitus, and a lower left ventricle ejection fraction more often than patients in the open procedure group. During the open procedure, higher blood pressure amplitudes (P = 0.00009), higher decrease in pH (P = 0.049), increase in the arterial lactate level (P = 0.00002), prolonged QTc values (P = 0.001), more frequent ventricular extrasystoles (P = 0.005), and cardiovascular deaths were observed, when compared with those observed during the endovascular aneurysm repair. CONCLUSIONS: When compared with the chosen techniques, the one for infrarenal abdominal aneurysm was found to be associated with significant differences in electrophysiological, hemodynamic, and metabolic parameters.

Association of the rs10918594 of nitric oxide synthase 1 adaptor protein (NOS1AP) polymorphisms with the graft function after kidney transplantation.

BACKGROUND: The purpose of this study was to investigate the relationship of nitric oxide synthase 1 adaptor protein (NOS1AP) polymorphism with serum creatinine level and occurrence of delayed graft function (DGF) in kidney transplant recipients. MATERIAL/METHODS: This prospective observational study included 75 kidney transplantations. The data from 40 kidney donors (8 females, 32 males) included sex, age, and cause of death. Donors fully met multi-organ transplantation criteria. Recipient data included sex, age, cause of renal insufficiency, and time and number of hemodialyses prior to transplantation. Applying polymerase chain reaction restriction fragments length polymorphism method, we investigated rs10918594 NOS1AP polymorphism among the 75 kidney recipients. The function of every transplanted kidney was correlated with this polymorphism. We defined DGF as requirement for at least 1 hemodialysis after kidney transplantation. We investigated the association of NOS1AP polymorphism with the recipient serum creatinine levels at day 1 and 180 days after kidney transplantation and the occurrence of DGF. RESULTS: The analysis of variance showed higher serum creatinine levels in kidney recipients with GG genotype compared with the CC_CG genotype at day 1 and at day 180 post-transplantation. Occurrence of DGF in the post-operative period in kidney recipients with the variant genotypes CG compared with the GG_CC genotype was higher, although these differences were no statistically significant. CONCLUSIONS: Our data suggests no statistically significant association of the rs10918594 polymorphism of nitric oxide synthase 1 adaptor protein (NOS1AP) with the graft function after kidney transplantation.

Factors influencing QTc interval prolongation during kidney transplantation.

BACKGROUND: During renal transplantation, factors causing disturbances of the repolarization process, defined by the QT interval, may lead to ventricular arrhythmias. The aim of this study was to determine a relationship between QT interval prolongation and metabolic homoeostasis, and durations of cold ischemia time (CIT) and warm ischemia time (WIT) during renal transplantation. MATERIAL/METHODS: From among 198 consecutive renal transplant patients, 68 (mean age 45 ± 12 years) were included in a prospective observational pilot study. Prior to the procedure, arterial blood gas analysis was performed, and digital Holter ECG monitoring was applied and continued for 12 hours. Subsequent arterial blood gas analysis was performed 30 minutes after graft reperfusion. RESULTS: QTc changed dynamically and significantly during the perioperative period. Ventricular arrhythmias were observed only during graft reperfusion. Recordings showed that 33 out of 68 patients had ventricular extrasystoles, and non-sustained ventricular tachycardia was observed in 2 patients. No patients presented with hemodynamic instability. There was no statistical correlation between CIT or WIT and the difference (delta) between the final and initial values of the pH, potassium and lactate levels, QTc range, maximal QTc or QTc measured at the predefined time points. CONCLUSIONS: The renal transplantation procedure carries a high risk of ventricular repolarization period disturbances that can lead to life-threatening tachyarrhythmias despite optimal hemodynamic or metabolic status and independent of CIT and WIT.

[Cefepim in empiric therapy of ventilator-associated pneumonia]. / Empiryczne zastosowanie cefepimu u chorej z respiratorowym zapaleniem pluc.

BACKGROUND: The most common infection following surgical treatment, when mechanical ventilation and tracheal intubation are used, is ventilator-associated pneumonia (VAP) induced by Gram-negative and Gram-positive bacteria. Its treatment is difficult due to increasingly high antimicrobial drug resistance observed recently. CASE REPORT: A 73-year-old patient was admitted to undergo coronary artery bypass grafting and cardiac aneurysm excision. Additionally, chronic circulatory insufficiency (NYHA 2) with ejection fraction of 30% together with hypertension and type 2 diabetes were diagnosed. After extracorporeal circulation, she was given adrenaline/noradrenaline and intra-aortic balloon pump. Postoperatively, elevated levels of CRP (70 mg L(-1)) and of procalcitonin (22.4 ng mL(-1)) were detected. Empiric therapy with cefepime 1 g x 2 iv was started. X-ray revealed atelectasis in the middle left lung lobe and Enterobacter cloacae was isolated from the bronchial tree. Patient was intubated and mechanically ventilated. Antibiotic therapy with cefepime was continued for 10 days and resulted in improvement of patient's general condition. On postoperative day 7, she was transferred from ITU to the cardiac surgery ward. CONCLUSION: Cefepime applied empirically to a VAP patient can effectively treat the lung infection and improve his/her general condition.