Over many decades, spinal (intrathecal) opioid administration has become a proven method of analgesia forthe perioperative period. However, in clinical practice, it is confronted with concerns about potential complications, the need for increased postoperative monitoring, and the unavailability of a relevant commercial product on the Czech market. Pathophysiological interpretation of adverse effects and their potential prevention is evolving as research continues. The implementation of spinal opioids in clinical practice is likewise changing. When used appropriately, it is a safe method to improve the postoperative course of the full spectrum of surgical procedures across age groups. Thus, healthcare facilities with in- dividually prepared morphine for intrathecal administration can enjoy the benefits of not only quality patient analgesia but also the minimization of peripheral adverse effects of opioids. This article aims to highlight new findings on the use of spinal morphine. It also focuses on the preventability of its adverse effects and the specifics of its use in the elderly population.

As in the previous year, very few original prospective clinical papers concerning respiratory failure and pulmonary lung support, including artificial lung ventilation and veno-venous form of extracorporeal membrane oxygenation, have been published so far over this year, 2024. In the first part, the manuscript focuses on selected pathophysiological aspects of acute hypoxemic respiratory failure. In the second part, the text continues with a description of several publications that deal with the issue of the use of invasive ventilation support in the form of artificial lung ventilation. The third part deals with a non-invasive form of ventilation support. In the final part, two papers concerning the prone position in conscious patients (awake proning) and one that deals with the length of pronation in patients on artificial lung ventilation are described.

Only a few original papers on respiratory issues have been published so far in 2023. The vast majority are systematic reviews and meta-analyses of already published studies. In March 2023, the European Society for Intensive Care Medicine (ESICM) issued recommendations for the management of acute respiratory distress syndrome (ARDS). In the first part of this text, a very basic summary of recommendations according to individual domains is described. Extracorporeal membrane oxygenation (ECMO) is an intervention that has received much attention in recent years, mainly due to the COVID-19 pandemic. The last randomized trial (EOLIA trial) did not confirm a mortality benefit [1]. However, the subsequent Bayesian analysis of the data of this study brought a posterior probability of a mortality benefit of ECMO support compared to conventional therapy in a selected subgroup of patients with early use of ECMO in patients with severe ARDS [2]. In the second part of the article, we summarize publications related to the effect of ECMO support on several specific groups of diseases. These are patients with polytrauma, life-threatening bronchial asthma, burn trauma, and kidney transplant patients. The third part of the article deals with various aspects of anticoagulant therapy used in ECMO support, including its monitoring and comparison of the effect of heparin and bivalirudin. The fourth part describes a publication evaluating the effectiveness of extracorporeal CO2 removal (ECCO2R) from the point of view of enabling ultraprotective mechanical ventilation in patients with moderate to severe ARDS. The fifth part deals with the relationship of selected pathophysiological aspects to clinical practice and results. It is an investigation of exhaled air analysis for determining the clinical outcome of patients with ventilator-associated pneumonia (VAP). Furthermore, there is also a description of the relationship between dead space ventilation and the prognosis of patients with ARDS. The sixth part deals with the optimization of artificial lung ventilation settings based on the use of transpulmonary pressure measurement. The next part of the article, the seventh, deals with a meta-analysis of the comparison of the effectiveness of non-invasive forms of mechanical ventilation and other methods, such as high-flow oxygen therapy and conventional oxygen therapy. The penultimate section relates to the effect of various forms of nebulization therapy, such as the use of heparin in patients with COVID-19 pneumonia, and in the general population of patients on mechanical ventilation, and the use of volatile anesthetics in patients with refractory bronchospasm. In the last section, the text deals with various aspects of interventions in patients with severe respiratory failure who remain conscious. This invloves the effect of the so-called awake prone position and awake extracorporeal oxygenation support.

Mechanical ventilation (MV) is one of the established methods of organ support in intensive care units. In patients with lung disease, especially in its more severe forms, MV can act with such forces that it can lead to further damage to the diseased lungs. Mechanical energy (ME) is a parameter representing the total energy that the MV exerts on the lungs (or lungs, airways, and chest). Higher ME values are associated with a higher risk of ventilator-induced lung injury (VILI). ME can be calculated from ventilation parameters using equations, some of which allow calculation directly at the patient's bedside on a regular calculator. By adjusting individual parameters, we can then reduce the ME to reduce the risk of VILI. From the formulas, it is also possible to derive how the individual parameters contribute to the overall ME, and we can thus decide which parameter should be adjusted. This review article provides a comprehensive view of the current knowledge of ME as a ventilatory parameter associated with the risk of VILI. Equations for calculating ME for individual ventilation modes are presented here, with a critical assessment of the accuracy of individual calculation options and the use of the ME concept in routine daily practice at the patient's bed on MV.

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is associated with specific coagulopathy that frequently occurs during the different phases of coronavirus disease 2019 (COVID-19) and can result in thrombotic complications and/or death. This COVID-19-associated coagulopathy (CAC) exhibits some of the features associated with thrombotic microangiopathy, particularly complement-mediated hemolytic-uremic syndrome. In some cases, due to the anti-phospholipid antibodies, CAC resembles catastrophic anti-phospholipid syndrome. In other patients, it exhibits features of hemophagocytic syndrome. CAC is mainly identified by: increases in fibrinogen, D-dimers, and von Willebrand factor (released from activated endothelial cells), consumption of a disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13 (ADAMTS13), over activated and dysregulated complement, and elevated plasma cytokine levels. CAC manifests as both major cardiovascular and/or cerebrovascular events and dysfunctional microcirculation, which leads to multiple organ damage. It is not clear whether the mainstay of COVID-19 is complement overactivation, cytokine/chemokine activation, or a combination of these activities. Available data have suggested that non-critically ill hospitalized patients should be administered full-dose heparin. In critically ill, full dose heparin treatment is discouraged due to higher mortality rate. In addition to anti-coagulation, four different host-directed therapeutic pathways have recently emerged that influence CAC: (1) Anti-von Willebrand factor monoclonal antibodies; (2) activated complement C5a inhibitors; (3) recombinant ADAMTS13; and (4) Interleukin (IL)-1 and IL-6 antibodies. Moreover, neutralizing monoclonal antibodies against the virus surface protein have been tested. However, the role of antiplatelet treatment remains unclear for patients with COVID-19.

Study objective: Administration of systemic corticosteroids in patients with severe COVID-19 (Coronavirus Disease 2019) has been recommended by World Health Organization (WHO) according to the RECOVERY trial results. However, there is still ongoing debate regarding the evidence supporting the dose, timing, route of administration and type of corticosteroid. This survey aimed to describe the current clinical practice of administration of systemic corticosteroids for patients with COVID-19 within Intensive Care Units (ICU) in Czech Republic. Study design: cross-sectional survey Material and methods: Electronic survey containing 15 questions was sent to the members of Czech Society of Anaesthesiol-ogy, Resuscitation and Intensive Care, Czech Society of Intensive care and Czech Pneumological and Phthisiological Society members. The results were analysed by descriptive statistic methods. Results: The survey fulfilled 233 respondents and 231 answers were eligible for analysis. The most prevalent group was attending physician with completed training in anaesthesiology and intensive care medicine (AIM) (32 %, n = 74). The most prevalent indication for initiation of corticosteroid treatment was oxygen therapy (face mask or nasal cannula) (59,3 %, n = 137) and high-flow nasal oxygen therapy (HFNC) (21,6 %, n = 50). The most preferred corticosteroid was dexamethasone (75,8 %, n = 175) at dose of 8 mg intravenously (i. v.) (48,6 %, n = 85), or dose of 6 mg i. v. (32,0 %, n = 56) followed by methylprednis-olone (25,5 %, n= 59) at dose of 80 mg i. v. (35,6 %, n = 21), and 40 mg i. v. (13,6 %, n = 8), respectively. The preferred duration of therapy was 10 days (dexamethasone 60,6 %, n = 106, methylprednisolone 20,3 %, n = 12). Conclusion: Administration of corticosteroid was dominantly initiated in patients with severe COVID-19 receiving supplemental oxygen. The corticosteroid of first choice was intravenous dexamethasone at dose of 8 mg and 6 mg for 10 days, respectively.

The use of ECMO methods has experienced a significant boom in recent years, mainly due to the SARS-CoV-2 pandemic. Many workplaces that had little or no experience with ECMO currently possess the relevant technology and can use this method in real clinical practice. The prone position (PP) has changed from the original position of rescue intervention to the leading position among the methods that should be considered standard in patients with a severe form of acute respiratory failure. Thus, the combination of pronation and ECMO support has received considerable attention in recent years. This text, although a year in the 2022 review, briefly discusses available evidence-based medicine publications over the past few years devoted to this topic. The use of PP in clinical conditions other than mechanical ventilation (MV), e.g. in conscious patients on non-invasive ventilatory support, is described in the next section of this text. Another topic is the correct setting of MV while using PP and the effect of PP in pregnant patients with COVID-19. Inhalational anesthetics and their use for sedation of patients on UPV are currently among the frequently discussed topics within the optimization of intensive care. Conversely, ventilator-induced dysfunction of the main respiratory muscles, especially the diaphragm, has been a serious topic in critical care for a long time. Next, critically ill patients are at risk of hyperoxemia both as part of MV and ECMO support. The negative impact of this condition is the final topic of the article.Copyright © 2022, Czech Medical Association J.E. Purkyne. All rights reserved.

The year 2021 took place in the shadow of the ongoing pandemic of the COVID-19. This affected not only the number of patients treated, but also the focus of the vast majority of important publications. Nevertheless, several important publications can be identified that relate to the current agenda of the field of Intensive Care Medicine. One of the leading ones is the publication of resuscitation guidelines and guidelines for the treatment of sepsis. In this review article, we bring the readers of the journal a selection of the most important things that have been published this year and should not run away.

BACKGROUND: The evaluation of the predictive value of the neutrophil gelatinase-associated lipocalin (NGAL) for an early acute kidney injury (AKI) development in severely injured patients.Determination of the time-dependent roles of trauma-related physiologic markers of tissue hypoxia, systemic infl ammation and rhabdomyolysis in AKI development.METHODS: 81 adult patients were screened for the presence of AKI for eight consecutive days following the injury.Arterial levels of plasma NGAL, lactate, interleukin-6, procalcitonin, and myoglobin were investigated at 24 hours (T1), 48 hours (T2), and 96 hours (T3) after the injury.RESULTS: The incidence of AKI was 32.1 %.Patients with AKI were older, but no signifi cant difference in injury severity was observed.NGAL levels were signifi cantly higher in the AKI group at T1, T2, and T3 when compared to the non-AKI group.Lactate levels were signifi cantly higher in the AKI group at T2 only, and IL-6 levels were signifi cantly higher in the AKI group at T2 and T3.Procalcitonin and myoglobin levels were signifi cantly higher in the AKI group at T1, T2, and T3, when compared to the non-AKI group.Positive correlations were found between plasma NGAL and all screened physiological factors at all defi ned time points.CONCLUSION: Development of AKI after blunt trauma is very complex and multifactorial.Activation of the systemic infl ammatory response and rhabdomyolysis (high concentration of myoglobin) were strongly involved in AKI development.Blood NGAL levels after injury were signifi cantly higher in patients, who developed posttraumatic AKI.Plasma NGAL, lactate, procalcitonin, interleukin-6, and myoglobin had potential to be useful parameters for risk stratifi cation and prediction of AKI after trauma (Tab.6, Ref. 40).

Objective: The aim of our study was to assess the management of hypotension after general anaesthesia induction (GAIH). Design: Multicenter questionnaire study. Setting: Eight different size anaesthesiology departments located in the Czech or Slovak Republics. Materials and methods: The respondents responded to three identification questions (workplace, length of practince) and ten GAIH management questions in our online questionnaire. Simple descriptive statistics describing the representation of the respondents' answers in absolute and relative terms were used. Normalized entropy (H) was used to assess the variability of responses. Results: A fully completed questionnaire was obtained from 172 respondents. The highest rate of variability was observed in question 1.: "As the baseline blood pressure value (BP), to which I compare other BP values, I consider..." H = 0.966. The lowest response variability rate was observed in question 4.: "As hypotension, I consider the Of BP..." H = 0.07). Conclusion: Our results indicate high variability of GAIH management among anaesthetists.

The obstructive sleep apnoea syndrome (OSA) is characterized by repeated episodes of partial or complete occlusion of the upper airways during sleep. Patients with OSA have an increased risk of hypertension, congestive heart failure, pulmonary hypertension, diabetes and stroke. OSA presents a significant risk for the general anaesthesia induction as well as the entire perioperative period. OSA is an independent risk factor for difficult bag ventilation and difficult intubation. The diagnostic problem for OSA patients is to determine the site of their airway obstruction. Local findings differ significantly in consciousness and sleep. The aim of this review article is to discuss the safest way of sedation, which at the same time imitates the natural sleep pattern and ensures maximum validity of drug-induced sleep endoscopy (DISE).

Objective: Colorectal surgery significantly affects homeostasis. The aim of the study was to identify patients with high inflammatory response to surgical injury, objectivized by the levels of C-reactive protein (CRP), interleukin-6 (IL-6) and white cell count (WCC) measured within 48 hours after the beginning of surgery by pre-operative measurement of heart rate variability (HRV). Design: Prospective, observational study. Setting: Department of Anesthesiology and Intensive Care Medicine, University Hospital Materials and methods: HRV was measured during orthostatic load one day before surgery. The patients were divided according to the HRV results into two groups: CAR (with cardiac autonomic reactivity, n=23), and NCAR (without cardiac autonomic reactivity, n=30). Serum levels of CRP, IL-6 and WCC were obtained at 0, 12 (only IL-6), 24 and 48 hours after the beginning of surgery. Results: The observed CAR and NCAR were significantly different at the levels of CRP at TO (6.5 +/- 5.1 mg/L vs. 16.4 +/- 23.2 mg/L, p<0.05), T24 (70.5 +/- 33.6 mg/L vs. 95.7 +/- 49.1 mg/L, p<0.05), T48 (103.1 +/- 42.4 mg/L vs. 159.0 +/- 63.4 mg/L, p<0.001), and IL-6 at T12 (79.3 +/- 42.2 pg/mL vs. 248.2 +/- 285.2 pg/mL, p<0.05), T24 (68.0 +/- 28.0 pg/mL vs. 239.6 +/- 245.8 pg/mL, p<0.001), and T48 (39.5 +/- 18.4 pg/mL vs. 195.5 +/- 162.9 pg/mL; p<0.0001). There was no significant difference in WCC between CAR and NCAR patients. Conclusion: HRV is a method for identifying patients with high perioperative pro-inflammatory response. Statistical differences in CRP and IL-6 levels between the studied groups increased over time. IL-6 was statistically significantly different already at T24, thus enabled earlier identification of patients with higher pro-inflammatory response when compared to CRP.

Sepsis is a life-threatening condition caused by a dysregulated host response to infection. Over the last decades, the approach to sepsis is evolving dramatically, mainly as a result of a rapid increase in the knowledge of its epidemiology, physiopathology, and management. In this context, the new international criteria and definition for sepsis, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), were introduced in 2016. The criteria were established consensually by the Task Force which consisted of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. The main goal is the expansion of awareness of the professional public about this medical condition with a high fatality rate, particularly when not diagnosed and treated early. Sepsis-3 should also serve as a benchmark for future preclinical and clinical research, development of new diagnostic methods, and the terapy of patients with sepsis and septic shock.

Ventilator-induced lung injury (VILI) is a serious medical condition related to the use of injurious mechanical ventilation (MV). Recent literature outlines a novel perspective on the development of VILI - the mechanical power concept, unifying the static and dynamic variables of MV in relation to the energy load of the respiratory system and VILI. The aim of the text is a brief characteristic of the concept in relation to the recent literature.

Pleural effusion (fluidothorax) is characterized by the presence of excessive amount of fluid in the pleural space caused by various pathological clinical conditions. Pleural effusion leads to increased morbidity and adversely affects the prognosis and clinical outcome of critically ill patients in the intensive care setting. Early recognition of pleural effusion and diagnosis of the causal factors belong to the standard components of its management in intensive care. Diagnosis is usually made by chest X-ray and computer tomography followed by pleural aspiration. Nowadays, chest ultrasonography has become an invaluable diagnostic tool. Moreover, it also plays an important role as a guide for invasive pleural procedures. Therapeutic management of pleural effusion is based on treatment of causal factors whenever possible, or on symptomatic approaches.

Sepsis represents a life-threatening condition characterized by dysregulated host response to infection. Various definitions and criteria for sepsis, severe sepsis, septic shock and organ dysfunction were used in the past, giving rise to contradictions in the results of the reported data regarding sepsis. Recently,, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)" created by the task force of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine was published in 2016.

Alarmins are mostly protein-based substances which, under normal conditions, are localized intracellularly, fulfilling their physiological functions. Currently, the most studied group of alarmins consists of the high-mobility group box 1, heat-shock proteins, proteins S100A, mitochondrial DNA and formylated methionine-leucyl-phenylalanine. In pathological condition, alarmins are released or actively secreted into the extracellular space where they presumably play an important role in activation of innate immunity. A wide spectrum of alarmins has been identified. Alarmins were studied in several chronic diseases during the last decades but there is also an increasing number of research papers concerning their relationship with acute inflammatory conditions, e.g. the systemic inflammatory response syndrome caused by infectious or non-infectious insults. Extensive surgery has some attributes which might lead to the release of alarmins from the injured/damaged tissues. In such cases, the measuring of blood levels of alarmins could bring better understanding of the pathophysiology of surgical trauma, refine its monitoring and improve our ability to predict the clinical outcome of the patients. This issue warrants further thorough studying.

BACKGROUND:The impact of different approaches to fluid management during intraoperative volume resuscitation in patients undergoing major elective surgery is poorly defined. We compared volume effectiveness of crystalloid and colloid substitution aimed to maintain the cardiac index (CI) between 2.6 and 3.8 l/min/m(2) as measured by transesophageal Doppler (TED).METHODS:A total of 115 urological patients were enrolled in the prospective randomized trial and then randomized into 2 groups, one with volume therapy based on crystalloids (n = 57) and the other with colloids (n = 58). A TED probe was inserted and then hemodynamic optimization (therapy with Ringer's solution or hydroxyethyl starch 6 % 130/0.4 and administration of vasoactive drugs) was started according to TED variables to maintain the CI between 2.6 and 3.8 l/min/m(2).RESULTS:We observed high incidence of CI < 2.6 l/min/m(2) after induction of anesthesia (75 %) in both groups. There were no significant differences in demographic characteristics, ASA classification, length of surgery, estimated blood loss and the CI during surgery. To maintain the CI within the requested interval, significantly different amounts of crystalloids were needed as compared to colloid (median: 5000 ml vs 1500 ml). In the CRY group, more patients were treated by vasodilatators (40.4 vs 20.7 %).CONCLUSIONS:The study confirmed that crystalloids and colloids are effective in correcting flow-related perfusion abnormalities. The significant difference between volumes of crystalloids and colloids proved their different characteristics such as unequal distribution between compartments. The expansion of therapeutic algorithm by using vasoactive drugs allows us to avoid adverse events resulting from fluid overload (Tab. 1, Fig. 5, Ref. 35).