Hyperbilirubinemia occurs in up to 40% of critically ill. In ICU, hyperbilirubinemia is an independent factor that influences patients’ morbidity and mortality. Jaundice can reflect the course of disease or be caused by treatment (e.g. extracorporeal membrane oxygenation (ECMO)), thus can be difficult to differentiate. Sepsis was also associated with development of jaundice secondary to intrahepatic cholestasis. Prolonged cholestasis should be addressed to avoid liver damage. The patient with diagnosis of septic shock and severe acute respiratory distress syndrome was retrieved to our hospital for ECMO. Three days after initiation of ECMO, the patient developed jaundice, with increase of bilirubin, Gamma-glutamyltransferase and Alkaline phosphatase, without elevation of alanine aminotransferase and INR. Although ECMO was stopped, bilirubin serum levels were increasing, reaching the peak of 18.41 mg/dL of total and 15.67 mg/dL of direct bilirubin. Abdominal computed tomography showed homogeneous liver and non-dilated bile ducts. Viral hepatitis was excluded. CIOMS/RUCAM score was 0. Sepsis-related cholestasis was diagnosed. Despite cessation of sedation, the patient remained unconscious. Hemoadsorption therapy was initiated due to prolonged high levels of conjugated bilirubin. After 48 h of CytoSorb treatment, total bilirubin level was decreased to 2.4 mg/dL, the patient regained spontaneous eyes opening and could be transferred to regional hospital. Hyperbilirubinemia did not return in 3 months. Sepsis-related cholestasis is a diagnosis of exclusion that should be considered in case of jaundice in critically ill patients. In our patient, CytoSorb was a useful therapeutic option in prolonged cholestasis. Adsorption therapy was able to facilitate long-term regain of balance between inflammatory process, cytokine production and bilirubin turnover in the liver.

Background. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread throughout Europe. However, there is a lack of data on the full clinical course of patients infected with SARS-CoV-2 in Europe, especially in the population that developed acute respiratory failure (ARF).Objectives. To identify risk factors associated with developing ARF during SARS-CoV-2 infection. Materials and methods.This was an observational study of 60 adult patients with laboratory-confirmed SARS-CoV-2 infection. Data were collected from March 26, 2020 to May 26, 2020 in a tertiary academic hospital in Poland. All patients reached final outcome (discharge from the hospital or death). We divided patients into 2 groups based on whether they developed ARF, compared their clinical data, and performed multivariate logistic regression.Results. Twenty-two patients (36%) from the observed cohort developed ARF. Logistic regression identified that a high sequential organ failure assessment score at admission (odds ratio (OR) = 6.97 (1.57-30.90, p = 0.011)), and a long time from admission until pneumonia (OR = 1.41 (1.06-1.87, p = 0.016)), correlated with ARF development. D-dimer, lactate dehydrogenase, neutrophil to lymphocyte ratio, C-reactive protein (CRP), and interleukin 6 (IL-6) differed both statistically and clinically between ARF and non-ARF groups. The mortality rate in the observed cohort of patients was 13.3%, and it was 32% in the group that developed ARF. Conclusions.Routine vigilant examination of the above markers may identify patients at the highest risk of ARF early on during COVID-19 infection.

Extracorporeal membrane oxygenation (ECMO) requires constant management of coagulation. Whereas unfractionated heparin remains the anticoagulant of choice, experienced centers report high bleeding rates. Biocompatibility of the extracorporeal circuit enables management of anticoagulation with subcutaneous low-molecular-weight heparins only. The aim of this study was to evaluate the safety and feasibility of anticoagulation with subcutaneous nadroparin compared with unfractionated heparin during respiratory ECMO in patients. We assessed for thrombotic complications and number of bleeding and life-threatening bleeding events. Additionally, we evaluated the change in resistance to flow in the oxygenator and the number of transfused blood products. Nadroparin and unfractionated heparin were comparable in terms of number of bleeding (34 vs. 53%; p = 0.12), life-threatening bleeding (2.8 vs. 9.3%; p = 0.26) events, and daily red blood cell transfusion rates (0.79 units/patient/day vs. 0.71 units/patient/day in nadroparin group; p = 0.87) during respiratory ECMO. The relative change in resistance to flow in the oxygenator was similar between groups (8.03 vs. 11.6%; p = 0.27). Nadroparin seemed equivalent to unfractionated heparin in the number of thrombotic and hemorrhagic events as well as in the daily red blood cell transfusion rates during venovenus-ECMO.

Introduction and objective. Cytososorb is haemadsorption device approved in the European Union in 2011 for cytokine adsorption. Recently, in 2018, new indications for the device use have been added, including bilirubin and myoglobin removal. This study aimed to present the results of studies pertaining to Cytosorb use in clinical practice. In subsequent sections of this review, indications for Cytosorb therapy and clinical relevance of presented evidence are listed. State of knowledge. In clinical practice, Cytosorb has been reported as one of potential supportive therapies in patients with septic shock. There is evidence of significant reduction of interleukin 6 and vasopressors when Cytosorb is implemented. However, the decreased mortality after Cytosorb has yet to be reported. Besides cytokine adsorption, Cytosorb also collects drugs, a property that can have a beneficial effect on acute drug poisoning (anticoagulants). However, Cytosorb lowers the plasma concentration of some antibiotics which might affect the outcome of patients in septic shock. The haemadsorption device has also been researched in cardiac patients, and some reports suggest a reduced need for vasopressors and blood transfusions when therapy is installed during surgery. Other indications for Cytosorb are also reported, especially the effectiveness in decreasing bilirubin serum concentrations as treatment or bridge therapy, without affecting the albumins. Cytosorb might also be the last resort treatment in acquired haemophagocytic lymphohistiocytosis. Conclusions. The evidence supporting the use of CytoSorb remains elusive. There is lack of large prospective studies which could provide definitive answers about the place of Cytosorb in clinical practice. There are no reports of safety and feasibility issues in all presented studies.

Anxiety and fear are determinants of acute and chronic pain. Effectively measuring fear associated with pain is critical for identifying individuals’ vulnerable to pain. This study aimed to assess fear of pain among students and evaluate factors associated with pain-related fear. We used the Fear of Pain Questionnaire-9 to measure this fear. We searched for factors associated with fear of pain: gender, size of the city where the subjects lived, subject of academic study, year of study, the greatest extent of experienced pain, frequency of painkiller use, presence of chronic or mental illness, and past hospitalization. We enrolled 717 participants. Median fear of minor pain was 5 (4–7) fear of medical pain 7 (5–9), fear of severe pain 10 (8–12), and overall fear of pain 22 (19–26). Fear of pain was associated with gender, frequency of painkiller use, and previously experienced pain intensity. We found a correlation between the greatest pain the participant can remember and fear of minor pain (r = 0.112), fear of medical pain (r = 0.116), and overall fear of pain (r = 0.133). Participants studying medicine had the lowest fear of minor pain while stomatology students had the lowest fear of medical pain. As students advanced in their studies, their fear of medical pain lowered. Addressing fear of pain according to sex of the patient, frequency of painkiller use, and greatest extent of experienced pain could ameliorate medical training and improve the quality of pain management in patients.