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Abstract Background ICU patients are particularly susceptible to vitamin D3 deficiencies. This can be due to the severity of their underlying disease, the type of treatment they are on, and malnutrition before and inadequate nutrition during the hospitalization preceding ICU admission as well as advanced age. Literature provides no guidance on how to supplement vitamin D3 in severely deficient patients who are undergoing continuous renal replacement therapy (CRRT). Most serum 25(OH)D3 is bound with vitamin D binding protein in a complex whose molecular weight is 10 kDa. This means it can be removed during CRRT via convection mechanism. Critically ill patients undergoing CRRT can therefore be particularly prone to develop severe vitamin D3 deficiency. Methods As the trial design, a randomized controlled, single blinded, multicenter, parallel group approach was chosen to compare a single administration of 750,000 IU of vitamin D3 via the enteral or oral route in ICU patients with severe vitamin D3 deficiency (measured serum 25(OH)D3 levels ≤ 12.5 ng/ml) undergoing CRRT with a single administration of 500,000 IU of vitamin D3. The trial will be performed in up to five university hospitals in Poland. The primary outcome is the percentage of patients that achieved serum 25(OH)D3 levels ≥ 30 ng/ml on days 3 and 7 following vitamin D3 administration. Assuming a drop-out rate of approximately 10%, the number of recruited patients should be 138. Discussion Considering the potential pathophysiological mechanisms underlying hypovitaminosis D in critically ill patients under CRRT, it seems conceivable that these patients will require greater supplementation doses to correct severe deficiency. The study is meant to help answer the question whether increasing the supplementation dose by 50% will ensure a more effective replenishment of vitamin D3 in critically ill patients undergoing CRRT. Trial registration ClinicalTrials.gov Identifier: NCT05657678, registered: December 12 2022, https://clinicaltrials.gov/study/NCT05657678?cond=NCT05657678&rank=1 .

Substantial efforts have been undertaken to identify and minimise factors responsible for the development of ventilator-induced lung injury. A novel approach to this problem addresses energy dissipated in lung tissue during the breathing cycle as one of the key problems. Flow-controlled ventilation is a new modality of mechanical ventilation based on a constant flow during both inspiration and expiration. This review aims to evaluate the current evidence available regarding flow-controlled ventilation. Lastly, three cases of flow-controlled ventilation application are presented: ventilation with a small lumen tube during tracheal resection, one-lung ventilation during thoracoscopic lobectomy, and ventilation of a critically ill patient with acute respiratory distress syndrome in an intensive care unit setting.

Abstract Background Incidence of difficult endotracheal intubation ranges between 3 and 10%. Bougies have been recommended as an airway adjunct for difficult intubation, but reported success rates are variable. A new generation flexible tip bougie appears promising but was not investigated so far. We therefore compared the new flexible tip with a standard bougie in simulated normal and difficult airway scenarios, and used by experienced anesthesiologists. Methods We conducted a observational, randomized, cross-over simulation study. Following standardized training, experienced anesthesiologists performed endotracheal intubation using a Macintosh blade and one of the bougies in six different airway scenarios in a randomized sequence: normal airway, tongue edema, pharyngeal obstruction, manual cervical inline stabilization, cervical collar stabilization, cervical collar stabilization and pharyngeal obstruction. Overall success rate with a maximum of 3 intubation attempts was the primary endpoint. Secondary endpoints included number of intubation attempts, time to intubation and dental compression. Results Thirty-two anesthesiologist participated in this study between January 2019 and May 2019. Overall success rate was similar for the flexible tip bougie and the standard bougie. The flexible tip bougie tended to need less intubation attempts in more difficult airway scenarios. Time to intubation was less if using the flexible tip bougie compared to the standard bougie. Reduced severity of dental compression was noted for the flexible tip bougie in difficult airway scenarios except cervical collar stabilization. Conclusion In this simulation study of normal and difficult airways scenarios, overall success rate was similar for the flexible tip and standard bougie. Especially in more difficult airway scenarios, less intubation attempts, and less optimization maneuvers were needed if using the flexible tip bougie. Trial registration clinicaltrials.gov Identifier: NCT03733158 . 7th November 2018.

Abstract Background Electrical impedance tomography (EIT) is a tool to monitor regional ventilation distribution in patient’s lungs under general anesthesia. The objective of this study was to assess the regional ventilation distribution using different driving pressures (DP) during high frequency jet ventilation (HFJV). Methods Prospective, observational, cross-over study. Patients undergoing rigid bronchoscopy were ventilated HFJV with DP 1.5 and 2.5 atm. Hemodynamic and ventilation parameters, as well as ventilation in different regions of the lungs in percentage of total ventilation, assessed by EIT, were recorded. Results Thirty-six patients scheduled for elective rigid bronchoscopy. The final analysis included thirty patients. There was no significant difference in systolic, diastolic and mean arterial blood pressure, heart rate, and peripheral saturation between the two groups. Peak inspiratory pressure, mean inspiratory pressure, tidal volume, and minute volume significantly increased in the second, compared to the first intervention group. Furthermore, there were no statistically significant differences between each time profiles in all ROI regions in EIT. Conclusions In our study intraoperative EIT was an effective method of functional monitoring of the lungs during HFJV for rigid bronchoscopy procedure. Lower driving pressure was as effective in providing sufficient ventilation distribution through the lungs as the higher driving pressure but characterized by lower airway pressure. Trial registration The study was registered on ClinicalTrials.gov under no. NCT02997072.

BACKGROUND:Predicting difficult intubation is of high clinical interest. METHODS:237 patients aged ≥18 years were included in the study. Preoperative airway evaluation included: Mallampati test, thyromental distance, sternomental distance and thyromental height test. During direct laryngoscopy Cormack & Lehane classification was graded. We calculated the ROC AUC, sensitivity and specificity for thyromental height test as a primary end point of our study. RESULTS:Only thyromental height test and Cormack-Lehane scale proved significant on occurrence of difficult intubation. The optimal sensitivity and specificity values of thyromental height test were met with a cut off value of 50 mm. With 1 mm increase in thyromental height test, risk of difficult intubation decreased by 7%. CONCLUSION:Thyromental height test is a simple, easy to perform and non-invasive test to predict difficult intubation in patients scheduled for elective double lumen tube intubation during thoracic surgical procedures. With 1 mm above 50 mm increase in thyromental height test the risk of difficult intubation decreased by 7%. TRIAL REGISTRATION:Clinicaltrials.gov Identifier: NCT02988336.

Throughout the past decades ultrasonography did not prove to be a procedure of choice if regarded as part of the routine bedside examination. The reason was the assumption defining the lungs and the bone structures as impenetrable by ultrasound. Only during the recent several years has the approach to the use of such tool in clinical daily routines changed dramatically to offer so-called point-of-care ultrasonography (POCUS). Both vertical and horizontal artefacts became valuable sources of information about the patient’s clinical condition, assisting therefore the medical practitioner in differential diagnosis and monitoring of the patient. What is important is that the information is delivered in real time, and the procedure itself is non-invasive. The next stage marking the progress made in this area of diagnostic imaging is the development of arti­ficial intelligence (AI) based on machine learning algorithms. This article is intended to present the available, innovative solutions of the ultrasound systems, including Smart B-line technology, to ensure automatic identification process, as well as interpretation of B-lines in the given lung area of the examined patient. The article sums up the state of the art in ultrasound artefacts and AI applied in POCUS.

Breast surgeries belong to the most frequently performed procedures and are often associated with a high intensity of pain in the postoperative period. Regional anesthesia techniques, and paravertebral block, have been the gold standard of postoperative pain management for major breast cancer surgeries. In recent years, the development of new techniques of regional anesthesiology, which is due to the extensive implementation of ultrasound imaging, has enabled the use of a number of new blockades. The “new players” in regional anesthesiology include numerous fascial plane blocks. Fascial plane blocks are often technically easier and less invasive compared to, for example, paravertebral blockade. The core mechanism of action in fascial blocks consists in blocking the nerve structures that supply a certain area of the trunk after deposition of local anesthetic (LA) within the fascial and fasciomuscular compartments. In addition to direct nerve blockade, there are other potential mechanisms of analgesia such as systemic effects. This idea differs from the traditional concept of nerve and plexus blocks, but it should be remembered that the final effect of a fascial plane block and its extent can be extremely variable across individual cases. According to the current state of knowledge, an alternative to paravertebral blockade may be PECS blockade. The available options also include erector spinae plane block (ESPB) and serratus plane block (SPB), however their recommendation in breast surgery requires more extensive scientific evidence.

Core body temperature is strictly regulated (± 0.2 °C) and coordinated at the level of central nervous system located in the hypothalamus via several protective effector mechanisms that prevent overcooling and overheating. The central regulation permits both circadian and monthly variations of even 1°C; under normal conditions, however, the activation of effective protective mechanisms prevents even the slightest overcooling and core temperature elevation at any moment of the day.

Abstract Simulation sessions can produce high-fidelity emergency situations that facilitate the learning process. These sessions may also generate a complex stress response in the learners. This prospective observational study assessed psychological, physiological, immunological, and humoral levels of stress during high-fidelity simulation training. Fifty-six undergraduate medicine students who took part in a medical simulation session were assigned team roles (physician, nurse or assistant). Subsequently, each participant was assessed before the scenario (T0), after the procedure (T1), and two hours later (T2). Psychological stress and anxiety were measured at T0 and T1, using the State-Trait Anxiety Inventory (STAI) and Dundee Stress State Questionnaire (DSSQ). Cortisol, testosterone, secretory immunoglobulin class A (sIgA), alpha-amylase, and oxygen saturation level were measured at T0, T1, and T2, as was the physiological response indicated by heart rate (HR) and blood pressure (BP). It was found that the onset of task performance was related to increased anticipatory worry and higher oxygen saturation. The participants reported decreased worry, followed by increased emotional distress after the simulation training (T1). Participants trait anxiety predicted the intensity of worry, distress and task engagement. In contrast, no clear relationships were found between trait anxiety and biological stress markers. Testosterone levels were growing significantly in each phase of measurement, while physiological responses (BP, HR) increased at T1 and declined at T2. The levels of stress markers varied depending on the assigned roles; however, the trajectories of responses were similar among all team members. No evidence for prolonged cortisol response (T1, T2) was found based on psychological stress at the onset of simulation (T0). Regression analysis followed by receiver operating characteristics analyses showed uncertain evidence that initial state anxiety and worry predicted the levels of sIgA. Medical students are relatively resilient in terms of stress responses to medical simulation. The observed stress patterns and interrelationships between its psychological, physiological, hormonal, and immunological markers are discussed in accordance with theoretical concepts, previous research work, and further recommendations.

Abstract The development of the SARS‐CoV‐2 pandemic caused a common appearance of severe pulmonary complications, rarely seen as a result of the other infections. These are pneumothorax, pneumomediastinum, emphysematous bullae, cavitary lung lesions, or subcutaneous emphysema. Their formation is influenced by both—the natural course of the disease and the treatment strategy adopted.

Abstract Background In pursuit of improvement in cardiopulmonary resuscitation (CPR), new technologies for the measurement and assessment of CPR quality are implemented. In our study, we assessed the kinematics of the rescuer during continuous chest compression (CCC–CPR). The proper performance of the procedure is a survival predictor for patients with cardiac arrest (CA). The purpose of the study was a prospective assessment of the kinematics of the rescuer’s body with consideration given to the depth and rate of chest compression (CC) as the indicator of properly performed CC maneuver by professional and non-professional rescuers during a simulation of a 10-min CCC using a manikin. Methods Forty participants were enrolled in the study. CCC–CPR was performed in accordance with the 2015 AHA guidelines on a manikin positioned on the floor. Kinematic data on the movement were obtained from the measuring system (X-sens MVN Biomech) transmitting information from 17 inertial sensors. Measurement data were imported to the author’s program RKO-Kinemat written in the Matlab and C # environments. Two groups of results were distinguished: Group I—results of CC with the depth of ≥ 40 mm and Group 2—CC results with the depth of

Osiemnastoletnia pacjentka została przeniesiona z oddziału psychiatrycznego. Od 2. roku życia była leczona z powodu padaczki z objawami częściowymi złożonymi z wtórnym uogólnieniem. Etiologia padaczki nieznana. Wielokrotnie hospitalizowana z powodu lekooporności i dwa razy z powodu stanów padaczkowych wtórnie uogólnionych. W październiku bieżącego roku zwiększyła się ilość napadów padaczkowych, którym towarzyszyły zaburzenia zachowania. Zmiana leków przeciwpadaczkowych nie przyniosła efektu. Chora była hospitalizowana na oddziałach neurologicznym i psychiatrycznym. Z powodu licznych napadów częściowych złożonych wtórnie uogólniających się została przyjęta do Kliniki Neurologii, gdzie rozwinął się stan padaczkowy. Badaniem neurologicznym stwierdzono asymetrię odruchów ścięgnistych l>p, tomografia komputerowa głowy była prawidłowa. Nie zdołano przerwać stanu padaczkowego za pomocą zalecanych, maksymalnych dawek diazepamu, klonazepamu, walproinianu sodu, fenytoiny, fenobarbitalu, lidokainy, midazolamu i prowadzonej przez 2 dni śpiączki tiopentalowej. Równocześnie podawano przez sondę żywienie i wcześniej stosowane leki przeciwpadaczkowe: TGB, VPA, TPH. Pomimo intensywnego leczenia obserwowano do 50 napadów na dobę w postaci zwrotu gałek ocznych w górę, mrugania, ślinotoku, bradykardii, niepokoju ruchowego ust, barków i przegięcia głowy. W zapisie EEG stwierdzono uogólnioną patologię napadową. Wykonano badanie płynu mózgowo-rdzeniowego, w któ- rym jedynie poziom białka był podwyższony. Włączono propofol dożylnie oraz lewetiracetam w sondzie, uzyskując ustą- pienie napadów w ciągu godziny i poprawę zapisu EEG. Terapii propofolem towarzyszyły spadki ciśnienia tętniczego wymagające podawania amin presyjnych przez 4 dni. W 14. dobie leczenia chorą ekstubowano. Stan neurologiczny był dobry, nie stwierdzono regresji intelektualnej. W ciągu 4 tygodni napadów padaczkowych nie obserwowano.