HIGH-MOLECULAR-WEIGHT HYALURONAN-A POTENTIAL ADJUVANT TO FLUID RESUSCITATION IN ABDOMINAL SEPSIS?

ABSTRACT: While fluid resuscitation is fundamental in the treatment of sepsis-induced tissue hypoperfusion, a sustained positive fluid balance is associated with excess mortality. Hyaluronan, an endogenous glycosaminoglycan with high affinity to water, has not been tested previously as adjuvant to fluid resuscitation in sepsis. In a prospective, parallel-grouped, blinded model of porcine peritonitis sepsis, we randomized animals to intervention with adjuvant hyaluronan (add-on to standard therapy, n = 8) or 0.9% saline (n = 8). After the onset of hemodynamic instability, the animals received an initial bolus of 0.1% hyaluronan (1 mg/kg/10 min) or placebo (0.9% saline) followed by a continuous infusion of 0.1% hyaluronan (1 mg/kg/h) or saline during the experiment. We hypothesized that the administration of hyaluronan would reduce the volume of fluid administered (aiming at stroke volume variation <13%) and/or attenuate the inflammatory reaction. Total volumes of intravenous fluids infused were 17.5 ± 11 versus 19.0 ± 7 mL/kg/h in intervention and control groups, respectively ( P = 0.442). Plasma IL-6 increased to 2,450 (1,420-6,890) pg/mL and 3,690 (1,410-11,960) pg/mL (18 hours of resuscitation) in the intervention and control groups (nonsignificant). The intervention counteracted the increase in proportion of fragmented hyaluronan associated with peritonitis sepsis (mean peak elution fraction [18 hours of resuscitation] intervention group: 16.8 ± 0.9 versus control group: 17.9 ± 0.6 [ P = 0.031]). In conclusion, hyaluronan did not reduce the volume needed for fluid resuscitation or decrease the inflammatory reaction, even though it counterbalanced the peritonitis-induced shift toward increased proportion of fragmented hyaluronan.

Methods of assessing fluid responsiveness in septic shock patients: a narrative review.

A growing body of evidence shows that some septic patients experience fluid overload, which leads to an increased number of serious complications and death. This is because the majority of septic patients are fluid non-responders. Therefore, a reliable distinction of which patient would benefit from fluid boluses is crucial in current sepsis mana-gement. Several methods used to assess fluid responsiveness have been developed. The principle of "dynamic" measurements (in contrast to static indices such as central venous pressure) involves the induction of a change in cardiac preload and the measurement of its effect on stroke volume. Dynamic methods are based on either heart-lung interaction during mechanical ventilation or on an assessment of change in cardiac stroke volume in response to fluid provocative stimuli such as rapid fluid administration, passive leg raising, or the end-expiratory occlusion test. Most dynamic measurements are easy to perform and interpret as well as being available at the bedside. However, they vary in their invasiveness, difficulty in performance, reliability, and limitations. In this study, we provide an overview of various methods for assessing fluid responsiveness and indicate those that potentially lead to haemodynamically guided fluid restrictive treatment that would prevent fluid overload in septic patients.

Predictors of treatment limitations in Finnish intensive care units.

BACKGROUND: Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS). METHODS: This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression. RESULTS: The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90 years or older in reference to those younger than 40 years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke. CONCLUSION: Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

Bowel Perforation During Haemophagocytic Lymphohistiocytosis Treatment with Corticosteroids and Anakinra.

We report the use of anakinra to treat a case of a 64-year-old man diagnosed with haemophagocytic lymphohistiocytosis (HLH) with neurological involvement. After the administration of intravenous pulse corticosteroid therapy, immunoglobulin and anakinra the patient showed neurological recovery. However, the recovery was complicated by the perforation of a pre-existing bowel diverticulum. The effect of anakinra on bowel inflammation has not yet been clearly established. It can potentially augment bowel inflammation and contribute to the risk of bowel perforation associated with the concomitant use of corticosteroids. LEARNING POINTS: Anakinra can potentially augment bowel inflammation.The concomitant use of anakinra and corticosteroids may increase the risk of bowel perforation.Use of anakinra and corticosteroids in patients with pre-existing gastrointestinal diseases requires vigilant observation for abdominal symptoms.

Unchanged Cognitive Performance and Concurrent Prefrontal Blood Oxygenation After Accelerated Intermittent Theta-Burst Stimulation in Depression: A Sham-Controlled Study.

Aim: Intermittent theta-burst stimulation (iTBS) delivered over the dorsomedial prefrontal cortex (DMPFC) has shown promise as a treatment for anhedonia and amotivation in patients with depression. Here, we investigated whether this protocol modulates cognitive performance and concurrent prefrontal blood oxygenation. We also examined whether depressed patients exhibit cognitive dysfunction and prefrontal hypoactivity at baseline compared to healthy controls. Methods: This sham-controlled study comprises 52 patients randomized to either active or sham accelerated iTBS over the DMPFC (applied twice daily) for 10 consecutive treatment days, and 55 healthy controls. Cognitive performance was assessed at baseline and once again 4 weeks later using a cognitive test battery targeting attention, inhibitory control, and numerical, verbal, and visual working memory. Concurrent prefrontal oxygenated hemoglobin (oxy-Hb) was captured with functional near-infrared spectroscopy. Results: Active iTBS over DMPFC did not affect cognitive performance or concurrent oxy-Hb change compared to sham iTBS in patients with depression. Compared to controls, patients at baseline showed impaired performance in the Trail Making Test, the Rey Auditory Verbal Learning Test, the Animal Naming Test, and the Digit Symbol Substitution Test, however no difference in prefrontal oxy-Hb was observed. Conclusion: Patients with treatment-resistant depression displayed cognitive deficits, however without prefrontal hypoactivity, compared to healthy controls at baseline. iTBS treatment did not alter cognitive performance, nor concurrent prefrontal blood oxygenation, in patients. Taken together, iTBS can likely be considered a cognitively safe treatment option in this sample of patients.

Modulation of the prefrontal blood oxygenation response to intermittent theta-burst stimulation in depression: A sham-controlled study with functional near-infrared spectroscopy.

OBJECTIVE: To better understand the neural mechanisms behind the effect of intermittent theta-burst stimulation (iTBS), we investigated how the prefrontal blood oxygenation response measured by changes in oxygenated haemoglobin (oxy-Hb) was modulated during a sham-controlled iTBS treatment course, and whether this was related to depressive symptom change. METHODS: In this randomised, double-blind study, patients with ongoing treatment-resistant depression received either active (n = 18) or sham (n = 21) iTBS over the dorsomedial prefrontal cortex for ten to fifteen days with two sessions daily. Event-related functional near-infrared spectroscopy (fNIRS) was measured during each iTBS train, and resting-state oxy-Hb was compared before and after each iTBS session at the first, fifth, and last treatment day. RESULTS: Patients receiving active iTBS had an increase of the event-related oxy-Hb response compared to the sham group on the fifth (bilateral prefrontal cortices p < .001) and last (left prefrontal p = .007, right prefrontal p = .025) treatment day. Resting-state analysis showed suppressed oxy-Hb change in active iTBS compared to sham iTBS on the last treatment day (p = .024). Oxy-Hb change was unrelated to depressive symptom change (p = .474). CONCLUSIONS: This study describes a modulation of the blood oxygenation response over the prefrontal cortex that was built up during the course of active iTBS treatment in depression.

Intensive care patient survival after limiting life-sustaining treatment-The FINNEOL* national cohort study.

BACKGROUND: Few studies have examined survival in intensive care unit (ICU) patients after the restriction of life-sustaining treatment (LST). We aimed to analyse independent factors associated with hospital and 12-month survival rates in ICU patients after treatment restrictions. METHODS: This retrospective observational study examined all patients treated in adult ICUs from 1 January 2016 until 31 December 2016 included in the Finnish ICU Registry. Multivariable logistic regression analysis was performed to explain the effect on survival. RESULTS: Decisions to limit LST were made for 2444 patients (13.7%; 95% CI 13.2-14.2). ICU, hospital, and 12-month survival rates were 71% (95% CI 69-73), 49% (95% CI 47-51), and 24% (95% CI 22-26), respectively. In patients for whom life support was withheld, increased 12-month survival rates were associated with admission from the operating theatre (OR 1.9, 95% CI 1.1-3.4), good pre-hospital physical fitness (OR 4.7, 95% Cl 1.2-16.8) and being housed at home (OR 2.0, 95% Cl 1.4-2.8). Decreased survival rates were associated with admission from a hospital ward (OR 0.67, 95% Cl 0.5-0.9), higher comorbidity (OR 0.6, 95% Cl 0.4-0.9), cancer (OR 0.4, 95%CI 0.2-0.9), greater illness severity (SAPS II; OR 0.98, 95% Cl 0.98-0.99), and higher care intensity (TISS-76; OR 0.93, 95% Cl 0.92-0.95). CONCLUSION: Survival among ICU patients with limited treatment was higher than expected. Advanced age was not associated with higher mortality, potentially because treatment restrictions may be set more easily for older patients.

Frequency analysis of oscillations in cerebral hemodynamics measured by time domain near infrared spectroscopy.

In this paper, we propose the application of time-domain near-infrared spectroscopy to the assessment of oscillations in cerebral hemodynamics. These oscillations were observed in the statistical moments of the distributions of time of flight of photons (DTOFs) measured on the head. We analyzed the zeroth and second centralized moments of DTOFs (total number of photons and variance) to obtain their spectra to provide parameters for the frequency components of microcirculation, which differ between the extracerebral and intracerebral layers of the head. Analysis of these moments revealed statistically significant differences between a control group of healthy subjects and a group of patients with severe neurovascular disorders, which is a promising result for the assessment of cerebral microcirculation and cerebral autoregulation mechanisms.

ICU mortality and variables associated with ICU survival in Poland: A nationwide database study.

BACKGROUND: Recently published international comparison data across European countries revealed high mortality rates in Polish ICUs. OBJECTIVES: Estimation of the rate of ICU mortality and identification of variables associated with ICU survival in Poland. DESIGN: Retrospective analyses of a database reporting ICU stays in Poland. SETTINGS AND PATIENTS: The study included data from all adult patients admitted to an ICU in Poland from 1 January 2012 to 31 December 2012. MAIN OUTCOME MEASURES: ICU mortality and variables associated with ICU survival. RESULTS: A total of 48 282 patients were treated in 347 ICUs (mean age 63.1 ±â€Š16.8 years, 59% men) with 20 278 deaths (42.0%). Variables associated with ICU survival were: tertiary level of hospital care [relative risk (RR) 0.86, 95% confidence interval (CI) 0.80 to 0.92, P < 0.001]; high annual patient volume in the ICU (RR 0.9995 patient year, 95% CI 0.9994 to 0.9996, P < 0.001); younger patient age (RR 1.025 year, 95% CI 1.024 to 1.026, P < 0.001); female sex (RR 0.92, 95% CI 0.88 to 0.96; P < 0.001); and lower number of comorbidities (RR 1.33, 95% CI 1.31 to 1.35, P < 0.001). CONCLUSION: ICU mortality was high in Poland. Structural variables, such as the level of hospital care and annual patient volume, may be associated with ICU survival.

Multiwavelength time-resolved near-infrared spectroscopy of the adult head: assessment of intracerebral and extracerebral absorption changes.

An optical technique based on diffuse reflectance measurement combined with indocyanine green (ICG) bolus tracking is extensively tested as a method for the clinical assessment of brain perfusion at the bedside. We report on multiwavelength time-resolved diffuse reflectance spectroscopy measurements carried out on the head of a healthy adult during the intravenous administration of a bolus of ICG. Intracerebral and extracerebral changes in absorption were estimated from an analysis of changes in statistical moments (total number of photons, mean time of flight and variance) of the distributions of times of flight (DTOF) of photons recorded simultaneously at 16 wavelengths from the range of 650-850 nm using sensitivity factors estimated by diffusion approximation based on a layered model of the studied medium. We validated the proposed method in a series of phantom experiments and in-vivo measurements. The results obtained show that changes in the concentration of the ICG can be assessed as a function of time of the experiment and depth in the tissue. Thus, the separation of changes in ICG concentration appearing in intra- and extracerebral tissues can be estimated from optical data acquired at a single source-detector pair of fibers/fiber bundles positioned on the surface of the head.

Confirmation of brain death using optical methods based on tracking of an optical contrast agent: assessment of diagnostic feasibility.

We aimed to determine whether optical methods based on bolus tracking of an optical contrast agent are useful for the confirmation of cerebral circulation cessation in patients being evaluated for brain death. Different stages of cerebral perfusion disturbance were compared in three groups of subjects: controls, patients with posttraumatic cerebral edema, and patients with brain death. We used a time-resolved near-infrared spectroscopy setup and indocyanine green (ICG) as an intravascular flow tracer. Orthogonal partial least squares-discriminant analysis (OPLS-DA) was carried out to build statistical models allowing for group separation. Thirty of 37 subjects (81.1%) were classified correctly (8 of 9 control subjects, 88.9%; 13 of 15 patients with edema, 86.7%; and 9 of 13 patients with brain death, 69.2%; p < 0.0001). Depending on the combination of variables used in the OPLS-DA model, sensitivity, specificity, and accuracy were 66.7-92.9%, 81.8-92.9%, and 77.3-89.3%, respectively. The method was feasible and promising in the demanding intensive care unit environment. However, its accuracy did not reach the level required for brain death confirmation. The potential usefulness of the method may be improved by increasing the depth of light penetration, confirming its accuracy against other methods evaluating cerebral flow cessation, and developing absolute parameters for cerebral perfusion.

Perioperative analgesia after intrathecal fentanyl and morphine or morphine alone for cesarean section: A randomized controlled study.

OBJECTIVES: Intrathecal morphine is used in the postoperative management of pain after caesarean section (CS), but might not be optimal for intraoperative analgesia. We hypothesized that intrathecal fentanyl could supplement intraoperative analgesia when added to a local anesthetic and morphine without affecting management of postoperative pain. METHODS: This prospective, randomized, double-blind, parallel-group study included 60 parturients scheduled for elective CS. Spinal anesthesia consisted of bupivacaine with either morphine 100 µg (M group), or fentanyl 25 µg and morphine 100 µg (FM group). The frequency of intraoperative pain and pethidine consumption in the 24 hours postoperatively was recorded. RESULTS: Fewer patients in the FM group required additional intraoperative analgesia (P < .01, relative risk 0.06, 95% confidence interval [CI] 0.004-1.04). The FM group was noninferior to the M group for 24-hour opioid consumption (95% CI -10.0 mg to 45.7 mg, which was below the prespecified boundary of 50 mg). Pethidine consumption in postoperative hours 1 to 12 was significantly higher in the FM group (P = .02). Postoperative nausea and vomiting (PONV) were more common in the FM group (P = .01). Visual analog scale scores, effective analgesia, Apgar scores, and rates of pruritus and respiratory depression were similar between the groups. CONCLUSIONS: Intrathecal combination of fentanyl and morphine may provide better perioperative analgesia than morphine alone in CS and could be useful when the time from anesthesia to skin incision is short. However, an increase in PONV and possible acute spinal opioid tolerance after addition of intrathecal fentanyl warrants further investigation using lower doses of fentanyl.

Routine Treatment-Resistant Clostridium difficile Infection during Recovery from Myxedema.

Development of the extreme form of hypothyroidism defined as myxedema is very rare. Acute symptoms and their management have been described in detail previously. However, not much attention has been devoted to therapeutic challenges that are faced in the recovery phase of the treatment, especially pertaining to the gastrointestinal system. The link between myxedema and the appearance of severe Clostridium difficile infection (CDI) has not been established so far. A 61-year-old woman with no significant medical record was admitted to hospital because of infected heel pressure and thyroid dysfunction. A week later, due to hypothermia, hypotension, and unconsciousness, she was transferred to the intensive care unit. The clinical picture and the results of laboratory tests confirmed diagnosis of myxedema. After the introduction of resuscitative measures and hormonal substitution, patient's condition stabilized within 10 days. Due to concomitant sepsis, initially piperacillin/tazobactam and later cefuroxime were administered. After 20 days of antibiotic therapy, the patient developed CDI that was resistant to the routine mode of treatment. The clinical recovery was achieved only after a fecal microbiota transplantation procedure. The function of the digestive tract in myxedema is disturbed by gastric achlorydia and reduced peristalsis, which in turn can predispose the small intestine to overgrowth of bacteria. The use of antibiotics can additionally decrease the intestinal bacterial diversity, favoring the overgrowth of Clostridium difficile. The authors conclude that myxedema may increase the likelihood of a treatment-resistant form of CDI that requires the implementation of fecal microbiota transplantation.

Incidence of in-hospital cardiac arrest in Poland.

BACKGROUND: In-hospital cardiac arrest with its poor prognosis is a challenging problem in hospitals. The aim of this study was to evaluate in Polish hospitals the frequency of in-hospital cardiac arrests with the subsequent mortality, with special emphasis on the type of unit at which the event occurred, and the patient's demographic data, such as age and sex. METHODS: The study was a retrospective analysis of data for 2012 registered in the Polish General Hospital Morbidity Study. This research covered all Polish hospitals, excluding only government and psychiatric hospitals. The study inclusion criterion was the incidence of cardiac arrest in any hospital ward, recorded by the respective ICD-10 diagnosis code. RESULTS: Of the 7,775,553 patients hospitalized, the diagnosis of cardiac arrest was reported in a total of 22,602 patients, which included 22,317 adults (98.7% of all patients) and 285 children (1.3%). Overall mortality after cardiac arrest among adults was 74.2%, and in children 46.7%. In both absolute numbers and as percentages of all documented cases, cardiac arrests occurred most often at the departments of intensive care, internal medicine, cardiology and emergency medicine. The accompanying mortality was lower than average at the departments of intensive care, cardiology, cardiology high dependency unit and emergency medicine. The median age of patients with cardiac arrest who died in the hospital was higher than the median age of those who survived (72 vs. 64; P < 0.05). Although cardiac arrests were reported more often among men than women (58.2% vs. 41.8%; P < 0.001), the hospital mortality was higher among women (79.2% vs. 71.6%; P < 0.001). CONCLUSION: The frequency of in-hospital cardiac arrests in Polish hospitals and the subsequent mortality is not substantially different from that observed in other countries. However, our study, based on ICD-10 diagnosis codes, gives only limited information about the patients and circumstances of this event. An in-depth analysis of the causes, prognoses, and outcome of in-hospital cardiac arrests could be facilitated by the creation of a national registry.

Application of optical methods in the monitoring of traumatic brain injury: A review.

We present an overview of the wide range of potential applications of optical methods for monitoring traumatic brain injury. The MEDLINE database was electronically searched with the following search terms: "traumatic brain injury," "head injury," or "head trauma," and "optical methods," "NIRS," "near-infrared spectroscopy," "cerebral oxygenation," or "cerebral oximetry." Original reports concerning human subjects published from January 1980 to June 2015 in English were analyzed. Fifty-four studies met our inclusion criteria. Optical methods have been tested for detection of intracranial lesions, monitoring brain oxygenation, assessment of brain perfusion, and evaluation of cerebral autoregulation or intracellular metabolic processes in the brain. Some studies have also examined the applicability of optical methods during the recovery phase of traumatic brain injury . The limitations of currently available optical methods and promising directions of future development are described in this review. Considering the outstanding technical challenges, the limited number of patients studied, and the mixed results and opinions gathered from other reviews on this subject, we believe that optical methods must remain primarily research tools for the present. More studies are needed to gain confidence in the use of these techniques for neuromonitoring of traumatic brain injury patients.

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section: A randomized controlled study.

Cesarean section (CS) is one of the most common surgical procedures in female patients. We aimed to evaluate the postoperative analgesic efficacy of intrathecal fentanyl during the period of greatest postoperative analgesic demand after CS. This period was defined by detailed analysis of patient-controlled analgesia (PCA) usage.This double-blind, placebo-controlled, parallel-group randomized trial included 60 parturients who were scheduled for elective CS. Participants received spinal anesthesia with bupivacaine supplemented with normal saline (control group) or with fentanyl 25 µg (fentanyl group). To evaluate primary endpoints, we measured total pethidine consumption over the period of greatest PCA pethidine requirement. For verification of secondary endpoints, we recorded intravenous PCA requirement in other time windows, duration of effective analgesia, pain scores assessed by visual analog scale, opioid side effects, hemodynamic changes, neonatal Apgar scores, and intraoperative pain.Detailed analysis of hour-by-hour PCA opioid requirements showed that the greatest demand for analgesics among patients in the control group occurred during the first 12 hours after surgery. Patients in the fentanyl group had significantly reduced opioid consumption compared with the controls during this period and had a prolonged duration of effective analgesia. The groups were similar in visual analog scale, incidence of analgesia-related side effects (nausea/vomiting, pruritus, oversedation, and respiratory depression), and neonatal Apgar scores. Mild respiratory depression occurred in 1 patient in each group. Fewer patients experienced intraoperative pain in the fentanyl group (3% vs 23%; relative risk 6.8, 95% confidence interval 0.9-51.6).The requirement for postoperative analgesics is greatest during the first 12 hours after induction of anesthesia in patients undergoing CS. The addition of intrathecal fentanyl to spinal anesthesia is effective for intraoperative analgesia and decreases opioid consumption during the period of the highest analgesic demand after CS, without an increase in maternal or neonatal side effects. We recommend using intrathecal fentanyl for CS in medical centers not using morphine or other opioids intrathecally at present.

Optimization of the method for assessment of brain perfusion in humans using contrast-enhanced reflectometry: multidistance time-resolved measurements.

The aim of the study was to determine optimal measurement conditions for assessment of brain perfusion with the use of optical contrast agent and time-resolved diffuse reflectometry in the near-infrared wavelength range. The source-detector separation at which the distribution of time of flights (DTOF) of photons provided useful information on the inflow of the contrast agent to the intracerebral brain tissue compartments was determined. Series of Monte Carlo simulations was performed in which the inflow and washout of the dye in extra- and intracerebral tissue compartments was modeled and the DTOFs were obtained at different source-detector separations. Furthermore, tests on diffuse phantoms were carried out using a time-resolved setup allowing the measurement of DTOFs at 16 source-detector separations. Finally, the setup was applied in experiments carried out on the heads of adult volunteers during intravenous injection of indocyanine green. Analysis of statistical moments of the measured DTOFs showed that the source-detector separation of 6 cm is recommended for monitoring of inflow of optical contrast to the intracerebral brain tissue compartments with the use of continuous wave reflectometry, whereas the separation of 4 cm is enough when the higher-order moments of DTOFs are available.

Prospective assessment of standardized mortality ratio (SMR) as a measure of quality of care in intensive care unit--a single-centre study.

BACKGROUND: The standardized mortality ratio (SMR) is a recognized indicator of critical care quality. This ratio is used to compare actual hospital mortality of all patients treated in a Intensive Care Unit (ICU) with predicted mortality. The aim of the study was prospective analysis of SMR as a measure of quality of care in single ICU. METHOD: Prospective study was performed during the period of 12 months in ICU of Czerniakowski Hospital in Warsaw. Predicted hospital mortality was calculated using the SAPS 3 model. The value of SMR was evaluated in the three risk groups (low, moderate, high risk) and included patients surgical status (nonoperative, after elective and emergency surgery). RESULTS: A total of 341 patients were included. SMR in general population was 0,98 (95% CI 0,74-1,28). In the low and high-risk groups the value of SMR did not differ significantly from 1. In the average risk group as well as patients undergoing elective surgery, the value of SMR tended to exceed 1. CONCLUSIONS: In groups of patients with low and high risk the values of SMR indicated favourable quality of care. Study results should prompt to carry out detailed analysis of the course of treatment of patients at average risk of death. Analysis of the course of treatment and qualification criteria for surgery in patients undergoing elective surgery is also indicated.