Poland's first vascular access team 3-year analysis: Insights and learnings

BACKGROUND

During the COVID-19 pandemic, Poland saw a surge in interest in midline catheters (MCs) and Long Peripheral Catheters (LPCs) for intravenous therapy. Before this, MCs were not extensively utilised in the country, and there was no formally established Polish vascular access team. MCs, which have been used for years in many countries, are now becoming increasingly common in Poland. This study aimed to analyse the use of MCs in a 3-year perspective of their introduction in daily clinical practice based on a nurse-led Vascular Access Team (VAT).

METHODS

The records of adult patients who received intravenous therapy with 727 MCs and 293 LPCs from January 2021 to December 2023 at the University Clinical Centre of the Medical University of Warsaw were analysed.

RESULTS

The main indication for cannulation was expected intravenous therapy over 5 days (81.66%, n = 833), of which 71.37% (n = 728) of patients in this group had concomitant difficult intravenous access (DIVA). Over 6 years, centrally inserted central catheters (CICCs) inserted due to DIVA were reduced from n = 108 in 2017 to n = 18 in 2023. The end of intravenous therapy was the reason for the removal of 64.6% of catheters (n = 659), including death and switch to CICCs as well. Complications leading to premature removal accounted for 31.2%, such as: occlusion (14.6%), patient self-removal (7.1%) and thrombosis (3.43%).

CONCLUSIONS

The introduction of MCs as a possible option for peripheral venous access reduces the use of CVCs. Developing MCs programmes should be based on investing in staff competencies, which increases success rates. The nurses and physicians should be trained in infusion care to achieve better results in the use of MCs and LPCs. Increasing the competence of nurses in Poland is necessary for the implementation of full-service and top-level functioning of VAT.

Pyruvate dehydrogenase-E1α deficiency presenting as generalized dystonia: A genetic diagnosis with important clinical implications

Pyruvate dehydrogenase complex (PDC) deficiency is a genetic mitochondrial disease mostly associated with severe lactic acidosis, rapid progression of neurological symptoms and death during childhood. We present a 33-year-old male with PDC deficiency caused by a Val262Leu mutation in PDHA1gene. He demonstrated generalized dystonia affecting trunk and upper extremities and paraparesis as the most significant features, with onset of symptoms at age 8. Brain MRI showed bilaterally increased signal within the globus pallidus, typical of Leigh syndrome. A periodic lactate increase in serum and cerebrospinal fluid was detected. We describe a case of pyruvate dehydrogenase deficiency being diagnosed only 25 years after the onset of symptoms and highlight PDHC deficiency as a possible cause of treatable dystonia in childhood, which may respond well to thiamine and levodopa treatment.

Mortality in patients with septic cardiomyopathy identified by longitudinal strain by speckle tracking echocardiography: An updated systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Septic cardiomyopathy is associated with poor outcomes but its definition remains unclear. In a previous meta-analysis, left ventricular (LV) longitudinal strain (LS) showed significant prognostic value in septic patients, but findings were not robust due to a limited number of studies, differences in effect size and no adjustment for confounders.

METHODS

We conducted an updated systematic review (PubMed and Scopus up to 14.02.2023) and meta-analysis to investigate the association between LS and survival in septic patients. We included studies reporting global (from three apical views) or regional LS (one or two apical windows). A secondary analysis evaluated the association between LV ejection fraction (EF) and survival using data from the selected studies.

RESULTS

We included fourteen studies (1678 patients, survival 69.6%) and demonstrated an association between better performance (more negative LS) and survival with a mean difference (MD) of -1.45%[-2.10, -0.80] (p < 0.0001;I2 = 42%). No subgroup differences were found stratifying studies according to number of views used to calculate LS (p = 0.31;I2 = 16%), severity of sepsis (p = 0.42;I2 = 0%), and sepsis criteria (p = 0.59;I2 = 0%). Trial sequential analysis and sensitivity analyses confirmed the primary findings. Grade of evidence was low. In the included studies, thirteen reported LVEF and we found an association between higher LVEF and survival (MD = 2.44% [0.44,4.45]; p = 0.02;I2 = 42%).

CONCLUSIONS

We confirmed that more negative LS values are associated with higher survival in septic patients. The clinical relevance of this difference and whether the use of LS may improve understanding of septic cardiomyopathy and prognostication deserve further investigation. The association found between LVEF and survival is of unlikely clinical meaning.

REGISTRATION

PROSPERO number CRD42023432354.

Fatigue amongst anaesthesiology and intensive care trainees in Europe: A matter of concern

BACKGROUND

There is a growing awareness of the effects of fatigue on trainee wellbeing and health. Trainees in anaesthesiology and intensive care work long hours, switching work schedules frequently with insufficient rest. This may have unwanted long-term effects on mental and physical health and emotional well being, resulting in burnout and affecting patient safety.

OBJECTIVE

The study aimed to evaluate the prevalence, severity, causes and effects of work-related fatigue in trainees in anaesthesiology and intensive care.

DESIGN

Online survey of trainees in anaesthesiology and intensive care.

SETTINGS

A total of 31 countries within Europe were included in the survey.

PARTICIPANTS

European anaesthesiology and intensive care trainees who responded to an invitation to take part by electronic mail or through social media.

MAIN OUTCOME MEASURES

Responses from a 29-item online survey to assess the realities within European countries with regards to work-related fatigue.

RESULTS

One thousand and two hundred trainees from 31 European countries answered the survey demonstrating that an alarming number of trainees were fatigued by their working patterns and night shifts. Trainees reported effects on personal well being, safe commuting and potential for clinical errors. Respondents described a lack of support from hospitals and management for recovery during and after night shifts.

CONCLUSION

Fatigue among trainees in anaesthesiology and intensive care has a significant impact on their well being and potentially, on the incidence of clinical errors. Current measures from authorities and hospital management are not sufficient to prevent serious fatigue, and therefore a fatigue risk management system should be considered. Failure to address this issue might lead to a further decline in trainees' wellbeing, their capacity to work in the speciality in the future, and potentially increase patient care errors.

Real-Time Ultrasound Guidance as Compared With Landmark Technique for Subclavian Central Venous Cannulation: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

OBJECTIVES

We conducted a systematic review and meta-analysis to assess the effectiveness of real-time dynamic ultrasound-guided subclavian vein cannulation as compared to landmark technique in adult patients.

DATA SOURCES

PubMed and EMBASE until June 1, 2022, with the EMBASE search restricted to the last 5 years.

STUDY SELECTION

We included randomized controlled trials (RCTs) comparing the two techniques (real-time ultrasound-guided vs landmark) for subclavian vein cannulation. The primary outcomes were overall success rate and complication rate, whereas secondary outcomes included success at first attempt, number of attempts, and access time.

DATA EXTRACTION

Independent extraction by two authors according to prespecified criteria.

DATA SYNTHESIS

After screening, six RCTs were included. Two further RCTs using a static ultrasound-guided approach and one prospective study were included in the sensitivity analyses. The results are presented in the form of risk ratio (RR) or mean difference (MD) with 95% CI. Real-time ultrasound guidance increased the overall success rate for subclavian vein cannulation as compared to landmark technique (RR = 1.14; [95% CI 1.06-1.23]; p = 0.0007; I2 = 55%; low certainty) and complication rates (RR = 0.32; [95% CI 0.22-0.47]; p < 0.00001; I2 = 0%; low certainty). Furthermore, ultrasound guidance increased the success rate at first attempt (RR = 1.32; [95% CI 1.14-1.54]; p = 0.0003; I2 = 0%; low certainty), reduced the total number of attempts (MD = -0.45 [95% CI -0.57 to -0.34]; p < 0.00001; I2 = 0%; low certainty), and access time (MD = -10.14 s; [95% CI -17.34 to -2.94]; p = 0.006; I2 = 77%; low certainty). The Trial Sequential Analyses on the investigated outcomes showed that the results were robust. The evidence for all outcomes was considered to be of low certainty.

CONCLUSIONS

Real-time ultrasound-guided subclavian vein cannulation is safer and more efficient than a landmark approach. The findings seem robust although the evidence of low certainty.

Critical care echocardiography: barriers, competencies and solutions. A survey of over 600 participants

INTRODUCTION

Critical care echocardiography (CCE) is at the core of point-of-care ultrasound (POCUS), and although a list of the necessary competencies has been created, most European countries do not have established training programmes to allow intensivists to gain such competencies. To address barriers to the implementation of CCE, we conducted an online European survey, and analysed the current barriers to this with the aim of providing novel, modern solutions to them including environmental considerations.

MATERIAL AND METHODS

A 23-item survey was distributed via email with support from the European Society of Intensive Care Medicine, national societies, and social media. Questions focused on bedside CCE prevalence, competencies, and barriers to its implementation. An additional questionnaire was sent to recognised experts in the field of CCE.

RESULTS

A total of 644 responses were recorded. Most respondents were anaesthesia and intensive care physicians [79% ( n = 468)], and younger, with 56% in their first five years after specialization ( n = 358). Most respondents [92% ( n = 594)] had access to an ultrasound machine with a cardiac probe, and 97% ( n = 623) reported being able to acquire basic CCE windows. The most common barriers identified by respondents to the implementation of CCE in practice were a lack of sufficient experience/skill [64% ( n = 343)], absence of formal qualifications [46% ( n = 246)] and lack of a mentor [45% ( n = 243)]. Twenty-eight experts responded and identified a lack of allocated time for teaching as a main barrier [60% ( n = 17)].

CONCLUSIONS

We found that bedside CCE is perceived as a crucial skill for intensive care medicine, especially by younger physicians; however, there remain several obstacles to training and implementation. The most important impediments reported by respondents were inadequate training, absence of formal qualifications and difficulties in finding a suitable mentor.

Echocardiography and Ultrasound Committee statement for the accreditation programme in point-of-care ultrasonography in Poland

Ultrasonography is becoming an essential part of the management of critically ill patients. There has been a sufficient body of evidence to support the incorporation of point-of-care ultrasound (POCUS) in anaesthesia and intensive care medicine training programme. Recently the European Society of Intensive Care Medicine reco-gnized POCUS as an essential skill for European Intensive Care Medicine specialists and updated Competency Based Training in Intensive Care (CoBaTrICe). Following European training standards, the Ultrasound and Echocardiography Committee of the Polish Society of Anaesthesiology and Intensive Therapy issued this Position Statement for recommendations for the accreditation process in POCUS in Poland.

How to Maintain Safety and Maximize the Efficacy of Cardiopulmonary Resuscitation in COVID-19 Patients: Insights from the Recent Guidelines

Since December 2019, the novel coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has remained a challenge for governments and healthcare systems all around the globe. SARS-CoV-2 infection is associated with increased rates of hospital admissions and significant mortality. The pandemic increased the rate of cardiac arrest and the need for cardiopulmonary resuscitation (CPR). COVID-19, with its pathophysiology and detrimental effects on healthcare, influenced the profile of patients suffering from cardiac arrest, as well as the conditions of performing CPR. To ensure both the safety of medical personnel and the CPR efficacy for patients, resuscitation societies have published modified guidelines addressing the specific reality of the COVID-19 pandemic. In this review, we briefly describe the transmission and pathophysiology of COVID-19, present the challenges of CPR in SARS-CoV-2-infected patients, summarize the current recommendations regarding the algorithms of basic life support (BLS), advanced life support (ALS) and pediatric life support, and discuss other aspects of CPR in COVID-19 patients, which potentially affect the risk-to-benefit ratio of medical procedures and therefore should be considered while formulating further recommendations.

Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study

Diastolic dysfunction is associated with major adverse outcomes following cardiac surgery. We hypothesized that multisystem endpoints of morbidity would be higher in patients with diastolic dysfunction. A total of 142 patients undergoing cardiac surgical procedures with cardiopulmonary bypass were included in the study. Intraoperative assessments of diastolic function according to the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines using transesophageal echocardiography were performed. Cardiac Postoperative Morbidity Score (CPOMS) on days 3, 5, 8, and 15; length of stay in ICU and hospital; duration of intubation; incidence of new atrial fibrillation; 30-day major adverse cardiac and cerebrovascular events were recorded. Diastolic function was determinable in 96.7% of the dataset pre and poststernotomy assessment (n = 240). Diastolic dysfunction was present in 70.9% (n = 88) of measurements before sternotomy and 75% (n = 93) after sternal closure. Diastolic dysfunction at either stage was associated with greater CPOMS on D5 (p = 0.009) and D8 (p = 0.009), with CPOMS scores 1.24 (p = 0.01) higher than in patients with normal function. Diastolic dysfunction was also associated with longer durations of intubation (p = 0.001), ICU length of stay (p = 0.019), and new postoperative atrial fibrillation (p = 0.016, OR (95% CI) = 4.50 (1.22–25.17)). We were able to apply the updated ASE/EACVI guidelines and grade diastolic dysfunction in the majority of patients. Any grade of diastolic dysfunction was associated with greater all-cause morbidity, compared with patients with normal diastolic function.

Postoperative Analgesia after Open Liver Surgery: Systematic Review of Clinical Evidence

Background: The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery. Methods: The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors’ agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design. Results: The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review. Conclusions: The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a “blended approach” which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative “stress hormones”, and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.

Pre-operative platelet reactivity is a strong, independent predictor of bleeding complications after branched endovascular thoracoabdominal aortic aneurysm repair

Endovascular aortic repair (EVAR) an alternative to open surgical repair of thoracoabdominal aortic aneurysm (TAAA). The effect of EVAR on platelet reactivity is unknown. We prospectively determined the effect of branched EVAR (bEVAR) on platelet reactivity in patients with TAAA, and evaluated the predictive value of preoperative platelet reactivity for post-operative bleeding in 50 consecutive patients undergoing elective bEVAR (mean age 70.9 ± 5.7 years, 66% male). Blood samples were collected within 24 hours before bEVAR, after bEVAR and at hospital discharge. Platelet reactivity was assessed with impedance aggregometry using ASPI, ADP and TRAP tests. Platelet reactivity decreased within 24 hours after bEVAR compared to the measurement before bEVAR in all tests (p ≤ 0.04), with a further decrease in hospital discharge in the ADP test (p = .004). Twenty-three patients experienced post-operative bleeding complications (transfusion ≥2 red blood cell [RBC] units). Preoperative platelet reactivity below the cutoff value of 30 AUC units predicted post-operative bleeding with 78% sensitivity and 59% specificity (p = .045). In the multivariable analysis, platelet reactivity was the only independent predictor of postoperative bleeding (OR 6.507, 95% CI 1.227-34.506, p = .028). We conclude that platelet reactivity decreases following bEVAR of TAAA and is a strong and independent predictor for postoperative bleeding complications.

Seven-year follow-up of persistent postsurgical pain in cardiac surgery patients: A prospective observational study of prevalence and risk factors

BACKGROUND

Our aim was to describe the long-term prevalence, risk factors and impact on quality of life of persistent postsurgical pain (PPP) following cardiac surgery.

METHODS

All patients undergoing sternotomy in a single centre over 6 months were prospectively interviewed by telephone at six months and seven years following surgery.

RESULTS

We analysed data from 174 patients at six months and 146 patients at seven years following surgery, revealing a PPP prevalence of 39.7% (n = 69) and 9.6% (n = 14) respectively. At six post-operative months, younger age, higher acute pain score, intraoperative remifentanil infusion and more prolonged surgery were associated with sternotomy-site PPP. These variables, in combination, predict PPP in this study group with area under the receiver operating curve of 0.91 (95% CI 0.86-0.94) at 6 months and 0.74 (95% CI 0.57-0.86) at 7 years. Quality of life scores were significantly lower with PPP (median change in EQ-5D score = -0.23 [-0.57, -0.09] compared to 0.00 [0-0.24] without PPP at 7 years, p < 0.001). At7 years, younger age, prolonged surgery and intraoperative remifentanil infusion were associated with sternotomy-site PPP.

CONCLUSIONS

To the best of our knowledge, this is the longest follow-up of PPP across all surgical specialities and certainly within cardiac surgery. Prevalence of PPP and impact on QOL after cardiac surgery are high and associated with young age, high acute pain score, use of remifentanil and long operative time. We present a predictive score to highlight patients at risk of developing PPP.

SIGNIFICANCE

Seven years after cardiac surgery, almost 10% of patients in this cohort described persistent pain in and around the incision. While higher than previous reports in the literature (limited to up to five post-operative years), this assessment was made following three maximal coughs and therefore is movement or function evoked. High incident of persistent postsurgical pain may adversely affect long-term quality of life which is measured using a validated tool.

Infections as Novel Risk Factors of Atherosclerotic Cardiovascular Diseases: Pathophysiological Links and Therapeutic Implications

Atherosclerotic cardiovascular diseases (ASCVD) are the major cause of mortality worldwide. Despite the continuous progress in ASCVD therapy, the residual risk persists beyond the management of traditional risk factors. Several infections including Helicobacter pylori infection, periodontal disease, and viral infections are associated with the increased risk of ASCVD, both directly by damage to the heart muscle and vasculature, and indirectly by triggering a systemic proinflammatory state. Hence, beyond the optimal management of the traditional ASCVD risk factors, infections should be considered as an important non-classical risk factor to enable early diagnosis and appropriate treatment. Here, we summarized the currently available evidence regarding the role of inflammation in ASCVD and the association between the particular infections and pathogens (Helicobacter pylori, periodontal disease, pneumonia, Cytomegalovirus, Human immunodeficiency virus, Herpes simplex virus, and severe acute respiratory syndrome coronavirus 2) on the development and progression of ASCVD. We also speculated about the potential therapeutic implications of the anti-inflammatory and anti-infective drugs on ASCVD outcomes, including drugs routinely administered in patients with ASCVD (statins, P2Y12 receptor inhibitors, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers) and novel strategies aiming at residual risk reduction (colchicine, anti-cytokine drugs, and methotrexate). Considering the emerging association between infections and ASCVD, it is crucial to determine the possible advantages of infection prevention and treatment in patients with ASCVD.

Cardiac Stress in High-Risk Patients Undergoing Major Endovascular Surgery-Focus on Diastolic Function

OBJECTIVES

The purpose of this study was to determine the relationship between the changes in diastolic function and their association with cardiac biomarkers in the perioperative period in patients undergoing complex endovascular aortic repair.

DESIGN

Prospective observational study.

SETTING

Single-center academic hospital, central teaching hospital in Warsaw, Poland.

PARTICIPANTS

The study comprised 27 high-risk patients scheduled for elective endovascular repair of aortic aneurysm.

INTERVENTIONS

Complex endovascular procedure using branched endograft of the thoracoabdominal aorta. Branches of the stent grafts included renal arteries, the superior mesenteric artery, and the celiac trunk.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was to evaluate changes in diastolic function parameters assessed with transthoracic echocardiography at two and 24 hours postoperatively. The major secondary outcomes were changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) and troponin I concentrations, systolic function parameters, hemodynamic parameters at two and 24 hours, length of hospital stay, and 30-day mortality. There was a reduction in e' wave velocity on both the septal and lateral sides at two hours compared with the baseline (p = 0.041 and p = 0.05, respectively). There was an increase in both NT-proBNP and troponin I concentrations after surgery (p = 0.002 and p = 0.034, respectively), with troponin I peaking two hours after surgery and NT-proBNP peaking 24 hours after surgery.

CONCLUSIONS

Patients undergoing a branched endovascular aortic repair of a thoracoabdominal aortic aneurysm experience a cardiac insult that manifests with deterioration in diastolic parameters and concomitant increases of troponin and NT-proBNP concentrations. Additional large-scale prospective studies are required to confirm this phenomenon.

Diastolic dysfunction of the left ventricle - a practical approach for an anaesthetist

Bedside point-of-care echocardiography is being increasingly incorporated in peri-operative assessment and in intensive care units. Because of availability of tissue Doppler imaging in the modern ultrasound machines there has been an increased interest in research of diastolic function of left ventricle. The diastolic function is crucial for the hemodynamically effective function of the heart. Diastolic dysfunction is a well-established risk factor of the major adverse cardiac events during perioperative period, complications during weaning from ventilator and prognostic factor of mortality in septic shock.

Lessons Learned from a Study of the Integration of a Point-of-Care Ultrasound Course into the Undergraduate Medical School Curriculum

Background

Point-of-care ultrasound (POCUS) diagnosis, performed by a physician at the patient bedside, is routinely used in emergency medicine and critical care. Although training in ultrasonography has become part of the medical school curriculum, POCUS can be challenging for medical students. This study aimed to assess the effectiveness of a one-day POCUS course in a group of final-year medical students by pre-course and post-course assessment of both diagnostic ability and changes in student confidence levels in making a diagnosis.

Material/Methods

A prospective study recruited 57 final-year medical students who participated in a one-day POCUS course. Improvement in making decisions and levels of confidence were evaluated before and two weeks after the course, using image-based testing and a self- evaluation questionnaire.

Results

All 57 final-year medical students attended the course and completed the tests and surveys. The pre-training and post-training test scores of medical students improved from 41.78±12% to 58±13%. Student confidence scores in the post-training assessment significantly increased. The post-training confidence scores were significantly increased compared with the pre-training scores regardless of whether or not the questions were answered correctly (p<0.001). The Dunning-Kruger effect, or cognitive bias, might partially explain this phenomenon.

Conclusions

One day of POCUS training integrated into anesthesia curriculum for final-year medical students improved performance in the post-training test scores and improved their confidence scores. Further studies are needed to evaluate this effect and to develop adequate tools to assess medical students.

Acquired immunological imbalance after surgery with cardiopulmonary bypass due to epigenetic over-activation of PU.1/M-CSF

Background

It has been shown that severe insult to the immune system may trigger prolonged macrophage characteristics associated with excessive release of monocyte colony stimulating factor (M-CSF). However, it is unclear how persistent is the macrophage-like characteristics in circulating monocytes (MO). In this study, 20 patients who underwent non-emergent cardiopulmonary bypass had their monocytes characterized before surgery and 3 months after surgery.

Methods

We assessed the macrophage characteristics of MO using cytokine production, surface marker expression, an ability to stimulate T cells, and methylation of the promoter region of the gene encoding PU.1, a critical component to M-CSF production. MO function as well as activation and differentiation potential were longitudinally assessed.

Results

At 3 months after cardiopulmonary bypass, monocytes exhibited increased expression of MRP8, transforming growth factor-β/latency-associated peptide, suppressor of cytokine signaling 3 while phagocytic properties were increased. Concomitantly, we observed a decreased expression of CD86, a decreased ability to form regulatory dendritic cells, and a diminished ability to stimulate T cells. These characteristics were accompanied by a persistent increase in the secretion of M-CSF, over-activation of PU.1, and decreased methylation of the PU.1 promoter region. Serum levels of C-reactive protein and anti-cytomegalovirus IgG antibody titers were also elevated in some patients at 3 months after surgery.

Conclusions

We concluded that at 3 months after cardiopulmonary bypass, monocytes continued to express a new macrophage-like milieu that was associated with the persistent activation of the PU.1/M-CSF pathway.

Measurement of cricoid pressure force during simulated Sellick's manoeuvre

BACKGROUND

Cricoid pressure is a standard anaesthetic procedure used to reduce the risk of aspiration of gastric contents during the induction of general anaesthesia. However, for several years its validity has been questioned. There still remains the question of whether we perform it correctly. The aim of the study was an evaluation of the theoretical knowledge of Sellick's manoeuvre, as well an assessment of practical skill related with it when simulated on a model of the upper airway.

METHODS

The study was performed on a cohort of anaesthetists and anaesthetic nurses working in various hospitals in the Warsaw area. Measurements were taken on an upper airway model placed on an electronic kitchen scale. Participants were asked to perform Sellick's manoeuvre in the way they do it in their clinical practice. The test was done twice. Both the position and pressures applied on the model were documented. Knowledge concerning current recommendations of cricoid force was noted.

RESULTS

206 subjects participated in the study. Only 49% (n = 101) properly identified cricoid cartilage during their application of Sellick's manoeuvre. Application of the correct pressure on the model of the airway was noted in 16.5% (n = 34) during the first attempt and in 20.4% (n = 42) during the second attempt. The median force applied during simulated Sellick's manoeuvrewas 36 N (IQR: 26-55) in the first attempt, and 38 (IQR 25-55) in the second attempt.

CONCLUSIONS

Sellick's manoeuvre was performed incorrectly in many cases. Half of the participants of our study applied the pressure in the wrong place while the majority of them used an inappropriate amount of force. Thus, the application of cricoid pressure in patients should be preceded with simulation training.

The clinical and immunological performance of 28 days survival model of cecal ligation and puncture in humanized mice

Sepsis triggers a coordinated and thorough immune system response with long-term unfavorable sequelae after the initial insult. Long-term recovery from sepsis has garnered increasing attention recently, but a lack of suitable animal models impairs progress in this area. Our study, therefore, aimed to address the performance of the immune system in a survivable model of sepsis (cecal ligation and sepsis; CLP) for up to 28 d after the initial injury in humanized mice. Our model mimics human sepsis with weight loss and post-sepsis hypothermia. Within the first 7 d of sepsis, the M1 inflammatory cell subtype predominated, as evidenced by increased CD16 expression, but at 28 d, a mixed population of M1 and M2 inflammatory cells emerged, as evidenced by increased secretion of transforming growth factor TGFβ and CD206 expression. This change was accompanied by normalized production of interleukin (IL)-6, tumor necrosis factor TNFα and IL-10 at 28 d. Furthermore, the ability of MO to become regulatory DC or the frequency of endogenous DC were severely affected at 28 days. Thus, sepsis results in profound and persistent changes in the function of myeloid cells up to 28 days after CLP demonstrating the persistence of the new acquired immunological features long after resolution of the sepsis.

Long-term Monocyte Dysfunction after Sepsis in Humanized Mice Is Related to Persisted Activation of Macrophage-Colony Stimulation Factor (M-CSF) and Demethylation of PU.1, and It Can Be Reversed by Blocking M-CSF In Vitro or by Transplanting Naïve Autologous Stem Cells In Vivo

The duration of post-sepsis long-term immune suppression is poorly understood. Here, we focused on the role of monocytes (MO) as the pivotal cells for long-term regulation of post-sepsis milieu. Lost ability of MO to adapt is seen in several acute conditions, but it is unclear for how long MO aberrancy post-sepsis can persist. Interestingly, the positive feedback loop sustaining secretion of macrophage-colony stimulation factor (M-CSF) can persist even after resolution of sepsis and significantly alters performance of MO. Here, we investigated the activation of M-CSF, and it as critical regulator of PU.1 in mice surviving 28 days after sepsis. Our primary readout was the ability of MO to differentiate into dendritic cells (DCs; MO→iDC) in vitro since this is one of the critical processes regulating a successful transition from innate to acquired immunity. We utilized a survival modification of the cecal ligation and puncture (CLP) model of sepsis in humanized mice. Animals were sacrificed 28 days after CLP (t_CLP+28d). Untouched (CONTR) or sham-operated (SHAM) animals served as controls. Some animals received rescue from stem cells originally used for grafting 2 weeks after CLP. We found profound decrease of MO→iDC in the humanized mice 28 days after sepsis, demonstrated by depressed expression of CD1a, CD83, and CD209, diminished production of IL-12p70, and depressed ability to stimulate T cells in mice after CLP as compared to SHAM or CONTR. In vitro defect in MO→iDC was accompanied by in vivo decrease of BDCA-3⁺ endogenous circulating DC. Interestingly, post-CLP MO had persistent activation of M-CSF pathway, shown by exaggerated secretion of M-CSF, activation of PU.1, and demethylation of SPII. Neutralization of the M-CSF in vitro reversed the post-CLP MO→iDC aberration. Furthermore, transplantation of naïve, autologous stem cell-derived MO restored CLP-deteriorated ability of MO to become DC, measured as recovery of CD1a expression, enhanced production of IL-12p70, and ability of IL-4 and GM-CSF MO to stimulate allogeneic T cells. Our results suggest the role of epigenetic mediated M-CSF aberration in mediating post-sepsis immune system recovery.

Long-term alterations in monocyte function after elective cardiac surgery

Optimal immunological homoeostasis determines the long-term recovery of patients in the postoperative period. The functional adaptability of monocytes plays a pivotal role in adjusting the host's response to an insult, immunostasis and long-term health, and may help to determine successful recovery. We undertook a longitudinal analysis of the functional adaptability of monocytes in 20 patients undergoing heart surgery with cardiopulmonary bypass, as a model of severe stress. Using each patient's pre-cardiopulmonary bypass data as a baseline, we investigated the characteristics of peripheral blood monocytes' functional plasticity in-vitro before elective bypass, and three months afterwards. Approximately 30% of subjects showed diminished monocyte plasticity, as demonstrated by decreased monocyte differentiation into dendritic cells three months after bypass. Diminished monocyte functional plasticity was related to over-production of macrophage colony-stimulating factor. Adding a neutralising antibody to macrophage colony-stimulating factor corrected the monocytes' differentiation defect. Finally, patients with reduced monocyte plasticity had significantly elevated serum C-reactive protein, with a concomitant increase in cytomegalovirus IgG antibody titres, suggestive of the acquisition of immuno-suppressive traits. Our study shows that severe surgical stress resulted in a lasting immunological defect in individuals who had seemingly recovered.

The Ability of Precursory Monocytes (MO) to Differentiate Varies Among Individuals But Is Stable Over Time

Background

The ability to generate dendritic cells (DCs) from precursory monocytes (MOs) was a breakthrough in the field of immunology. However, it is unknown whether the ability of MOs to differentiate into immature DCs (iDCs) differs across subjects or is time dependent. Given that the study of immune system function is gaining recognition in the field of clinical medicine, it is important to know how certain immunologic features vary over time.

Material/Methods

This study investigates how much individuals’ MO-to-iDC differentiation potential changes over time. We estimated this potential by measuring the expression of an iDC marker (CD1a), cytokine secretion (interleukin [IL]-12p70), and the ability of IL-4 and granulocyte macrophage colony-stimulating factor (GM-CSF) differentiation MOs to stimulate T cells. We collected MOs obtained from different subjects (n=17) at least 1 month apart. Furthermore, we investigated several variables (expression for cytokine receptors, timing, and emergence of DC-related transcriptional factor PU.1).

Results

The ability of MOs to become DCs under the influence of IL-4 and GM-CSF varied greatly between individuals (range of CD1a expression, 20–80%) but was stable over time (change of CD1a expression between sampling, ~5%). A similar pattern emerged when production of IL-12p70 was analyzed. The ability to stimulate T cells was variable and depended on the T-cell source. The ability of MOs to become iDCs was not linked to the surface expression of receptors for IL-4 and GM-CSF but rather to the activation of PU.1 in the precursory MO. It took 5 days for all committed MOs to become iDCs under in vitro influence of IL-4 and GM-CSF.

Conclusions

We concluded that the potential of MO to become iDC is an individual feature and depends on activation of PU.1.