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Heart rate variability (HRV) is a measure that shows the variation in time between consecutive heartbeats – a physiological phenomenon controlled by the autonomic nervous system. Over the years the analysis of this parameter has been used in many fields of medicine, including anaesthesiology, for scientific and research purposes. We carried out a review of the available literature on the applicability of HRV assessment in anaesthesiology. Several potential applications of HRV in clinical anaesthesia have been identified and proven feasible. As a non-invasive and relatively easy method to gauge the autonomic nervous system, HRV analysis can provide the anaesthesiologist with additional datapoints, potentially useful in assessing efficacy of a blockade and adequacy of analgesia, and in predicting adverse events. However, interpretation of HRV and generalizability of research findings can be problematic due to the multiplicity of factors that influence this parameter and bias in methods introduced by the researchers.

In recent years commensal microorganisms are not just “passive occupants”, but important element of homeostasis. There are numerous reports documenting the composition and role of the gut, skin or vagina microbiome but the role of commensal organisms living in the lungs is relatively unknown. Pulmonary microbiome impact on the immune response of the host organism and may indicate new therapeutic directions. Lung microbiome, by modulating the expression of innate immunity genes, causes an increase in the concentration of IL-5, IL-10, IFNγ and CCL11, affects the TLR4 dependent response of pulmonary macrophages and modulate the production of antibacterial peptides contained in the mucus. It is documented that disorders of the lung microbiome contribute to asthma or chronic obstructive pulmonary disease. However it is known that pulmonary dysbiosis also occurs in critically ill patients. It is possible, therefore, that microbiota-targeted therapy may constitute the future therapeutic direction in ICU.

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.

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.

Various opioids are added to local anesthetic solutions for spinal anesthesia. This may change the final density of the local anestetic (LA) mixture. This effect regarding current concepts in spinal anesthesia needs to be re-evaluated. In order to re-evaluate such effects, hyperbaric and isobaric local anesthetic (LA) solutions were mixed with opioid adjuvants (A) using the equipment available in the operating room. Ten density measurements for each composition (LA-A) were performed. The density change of 0.0006 g/mL was regarded as significant. Measured densities were also compared with theoretical values calculated using Hare’s. As a result, the addition of an opioid adjuvant caused a significant reduction in the final density of the LA-A solution. In hyperbaric LA mixtures, it did not change the baricity from hyperbaric to isobaric. However, the addition of highly hypobaric fentanyl 0.99360 g/mL (SD ± 0.00004) changes all isobaric LA solutions baricity to hypobaric. The comparison of measured and theoretical densities revealed significant differences (p > 0.05). However, the absolute reduction reached 0.0006 g/mL in only two LA-A compositions. We conclude that the addition of fentanyl to isobaric LA results in a hypobaric solution that may affect the distribution of the block. The inadequacy of LA-A in a clinical setting is unlikely to influence block characteristics.

Working Group: Prof. Łukasz Krzych, MD, PhD – Chairman of the Working Group, Chairman of the Intensive Care Section of the Polish Society of Anaesthesiology and Intensive Therapy Assistant Prof. Alicja Bartkowska-Śniatkowska, MD, PhD – Deputy Chairwoman of the Paediatric Section of the Polish Society of Anaesthesiology and Intensive Therapy Prof. Piotr Knapik, MD, PhD – Chairman of the Scientific and Educational Section of the Polish Society of Anaesthesiology and Intensive Therapy Assistant Prof. Marzena Zielińska, MD, PhD – Chairwoman of the Paediatric Section of the Polish Society of Anaesthesiology and Intensive Therapy Assistant Prof. Dariusz Maciejewski, MD, PhD – Intensive Therapy Section of the Polish Society of Anaesthesiology and Intensive Therapy Maciej Cettler, MD – Paediatric Section of the Polish Society of Anaesthesiology and Intensive Therapy Prof. Radosław Owczuk, MD, PhD – President-Elect of the Polish Society of Anaesthesiology and Intensive Therapy Prof. Krzysztof Kusza, MD, PhD – Outgoing President of the Polish Society of Anaesthesiology and Intensive Therapy Expert Group (in alphabetical order): Representatives of the Board of the Society of Anaesthesiology and Intensive Therapy: Alicja Bartkowska-Śniatkowska, Piotr Knapik, Łukasz Krzych, Krzysztof Kusza, Romuald Lango, Agnieszka Misiewska-Kaczur, Mariusz Piechota Representatives of the sections and branches of the Polish Society of Anaesthesiology and Intensive Therapy: Paweł Andruszkiewicz, Maciej Cettler, Tomasz Czarnik, Mirosław Czuczwar, Michał Domagała, Anna Dylczyk-Sommer, Krzysztof Kobylarz, Waldemar Machała, Dariusz Maciejewski, Irena Ożóg-Zabolska, Andrzej Piotrowski, Beata Rybojad, Katarzyna Sierlikakowska, Wojciech Szczek, Bułat Tuyakov, Marzena Zielińska, Maciej Żukowski Regional consultants in the field of anaesthesiology and intensive therapy: Stanisław Lech Czaban, Wojciech Dąbrowski, Tomasz Gaszyński, Beata Kościałkowska, Łukasz Krzych, Andrzej Małek, Dariusz Onichimowski, Wojciech Serednicki, Karina Stefańska-Wronka, Wiesław Świtała, Janusz Trzebicki

Objectives Presenting outcomes of patients hospitalised for COVID-19 should be put in context and comparison with other facilities. However, varied methodology applied in published studies can impede or even hinder a reliable comparison. The aim of this study is to share our experience in pandemic management and highlight previously under-reported factors affecting mortality. We present outcomes of COVID-19 treatment in our facility that will allow for an intercentre comparison. We use simple statistical parameters—case fatality ratio (CFR) and length of stay (LOS).Setting Large clinical hospital in northern Poland serving over 120 000 patients annually.Participants Data were collected from patients hospitalised in COVID-19 general and intensive care unit (ICU) isolation wards from November 2020 to June 2021. The sample consisted of 640 patients—250 (39.1 %) were women and 390 (60.9 %) were men, with a median age of 69 (IQR 59–78) years.Results Values of LOS and CFR were calculated and analysed. Overall CFR for the analysed period was 24.8%, varying from 15.9 % during second quarter 2021 to 34.1% during fourth quarter 2020. The CFR was 23.2% in the general ward and 70.7% in the ICU. All ICU patients required intubation and mechanical ventilation, and 44 (75.9 %) of them developed acute respiratory distress syndrome. The average LOS was 12.6 (±7.5) days.Conclusions We highlighted the importance of some of the under-reported factors affecting CFR, LOS and thus, mortality. For further multicentre analysis, we recommend broad analysis of factors affecting mortality in COVID-19 using simple and transparent statistical and clinical parameters.

Background: Critically ill patients frequently require continuous renal replacement therapy (CRRT). During CRRT, particles up to 10 kDa in size, such as enoxaparin, may be removed. The aim of this study was to determine if patients receiving prophylactic doses of enoxaparin and treated with continuous veno-venous hemodiafiltration (CVVHDF) reach prophylactic values of anti-Xa factor activity. Methods: In this observational trial, we compared two groups: 20 patients treated with CVVHDF and 20 patients not treated with CVVHDF. All of them received prophylactic doses of 40 mg of enoxaparin subcutaneously. Anti-Xa factor activity was determined on the third day of receiving a prophylactic dose of enoxaparin. The first blood sample was taken just before the administration of enoxaparin, and other samples were taken 3 h, 6 h, and 9 h after the administration of a prophylactic dose of enoxaparin. Results: At 3 and 6 h after administration of enoxaparin in both groups, we observed a significant increase in anti-Xa factor activity from baseline, with the peak after 3 h of administration. There were no significant differences in the numbers of patients who had anti-Xa factor activity within the prophylactic range between CVVHDF and control groups. Conclusion: CVVHDF has only a mild effect on the enoxaparin prophylactic effect measured by anti-Xa factor activity. Thus, it seems there is no need to increase the dose of enoxaparin for patients requiring CVVHDF.

Abstract Background Fasting prior to anesthesia is considered aspiration prophylaxis. However, prolonged food and drink restrictions may increase the risk of other complications. The aim of this study was to assess whether a carbohydrate-enriched drink (Nutricia™ preOp®), recommended by the enhanced recovery after surgery (ERAS) protocol, can improve body hydration in fasting healthy individuals. Methods Measurements were done with the bioelectric impedance analysis with a Fresenius body composition monitor. Body composition, total body water, water distribution, and hemodynamic parameters were measured at the beginning of the study and after 10 h and 12 h of fasting. Patients fasted for 10 h and then were divided into two groups: the control (n = 40) and the pre-op group (n = 41). The pre-op group received 400 mL of Nutricia™ preOp®, as suggested in the ERAS guidance. The two-tailed Student’s t test was used to compare two groups with normally distributed data and homogenous variances; if variances were heterogeneous, Welch’s test was used. The Mann-Whitney U test was used to compare two groups with non-normal data distribution. p

Dexmedetomidine, a central α-2 agonist, is used for procedural sedation and for conscious sedation influences on heart rate and blood pressure. Authors verified whether it is possible to predict bradycardia and hypotension with the use of heart rate variability (HRV) analysis for an autonomic nervous system (ANS) activity assessment. The study included adult patients of both sexes with an ASA score of I or II scheduled for ophthalmic surgery to be performed under sedation. The loading dose of dexmedetomidine was followed by a 15 min infusion of the maintenance dose. The frequency domain heart rate variability parameters from the 5-min Holter electrocardiogram recordings before dexmedetomidine administration were used for the analysis. The statistical analysis also included pre-drug heart rate and blood pressure as well as patient age and sex. The data from 62 patients were analysed. There was no relationship between the decrease in heart rate (42% of cases) and initial HRV parameters, haemodynamic parameters or sex and age of patients. In multivariate analysis, the only risk factor for a decrease in mean arterial pressure (MAP) > 15% from the pre-drug value (39% of cases) was the systolic blood pressure before dexmedetomidine administration as well as for a >15% decrease in MAP sustained at more than one consecutive time point (27% of cases). The initial condition of the ANS did not correlate with the incidence of bradycardia or hypotension; HRV analysis was not helpful in predicting the abovementioned side effects of dexmedetomidine.

ObjectiveHere we looked for possible mechanisms regulating the progression of type 1 diabetes mellitus (T1DM). In this disease, autoaggressive T cells (T conventional cells, Tconvs) not properly controlled by T regulatory cells (Tregs) destroy pancreatic islets.Research design and methodsWe compared the T-cell compartment of patients with newly diagnosed T1DM (NDT1DM) with long-duration T1DM (LDT1DM) ones. The third group consisted of patients with LDT1DM treated previously with polyclonal Tregs (LDT1DM with Tregs). We have also looked if the differences might be dependent on the antigen specificity of Tregs expanded for clinical use and autologous sentinel Tconvs.ResultsPatients with LDT1DM were characterized by T-cell immunosenescence-like changes and expansion of similar vβ/T-cell receptor (TCR) clones in Tconvs and Tregs. The treatment with Tregs was associated with some inhibition of these effects. Patients with LDT1DM possessed an increased percentage of various proinsulin-specific T cells but not GAD65-specific ones. The percentages of all antigen-specific subsets were higher in the expansion cultures than in the peripheral blood. The proliferation was more intense in proinsulin-specific Tconvs than in specific Tregs but the levels of some proinsulin-specific Tregs were exceptionally high at baseline and remained higher in the expanded clinical product than the levels of respective Tconvs in sentinel cultures.ConclusionsT1DM is associated with immunosenescence-like changes and reduced diversity of T-cell clones. Preferential expansion of the same TCR families in both Tconvs and Tregs suggests a common trigger/autoantigen responsible. Interestingly, the therapy with polyclonal Tregs was associated with some inhibition of these effects. Proinsulin-specific Tregs appeared to be dominant in the immune responses in patients with T1DM and probably associated with better control over respective autoimmune Tconvs.Trial registration numberEudraCT 2014-004319-35.

We on the Editorial Board of “Anaesthesiology Intensive Therapy” are committed to continuous improvement of the quality of our journal, and thus we are excited that two excellent clinician-scientists have joined us in this endeavour. It is our great honour to announce that Doctor Thomas Kander of Lund University (Sweden) and Doctor Dan Drzymal­ski of Tufts Medical Center (Boston, Massachusetts) have become members of the Advisory Editorial Board of “Anaesthesio­logy Intensive Therapy”.