Levels of small extracellular vesicles in patients treated with hyperbaric oxygenation.

Introduction: Hyperbaric oxygen (HBO2) therapy involves the inhalation of pure oxygen in a pressure chamber under increased ambient pressure. Recent research indicates that circulating small extracellular vesicles (sEVs) play important roles in human physiology and pathology. Therefore, the objective of this pilot study was to monitor the impact of HBO2 therapy on the levels of circulating sEVs in the serum of patients with necrotizing soft-tissue infections (NSTI), aseptic bone necrosis (ABN) or idiopathic sudden sensory neural hearing loss (ISSNHL). Material and methods: Serum-derived sEVs were isolated and quantified in 80 patients before and after HBO2 therapy applied for NSTI, ISSNHL and ABN patients as well as in normal controls who received neither HBO2 therapy nor steroids. Results: We observed a significant increase of circulating sEVs in patients with ISSNHL after HBO2 therapy (p < 0.05), as well as significantly elevated levels of sEVs after HBO2 therapy compared to patients with NSTI (p < 0.05) and ABN (p < 0.01). Conclusions: The increase in the levels of sEVs in ISSNHL may be evidence for both the intended reduction of inflammation as a result of steroid therapy and the inhibitory effect of oxidative stress induced by HBO2 therapy. Thus, sEVs released during HBO2 therapy might play an important biological role in mediating the response to therapy and might be a promising approach to gain further insights into the therapeutic efficacy of HBO2 therapy.

Assessing the Effectiveness of Different Hyperbaric Oxygen Treatment Methods in Patients with Sudden Sensorineural Hearing Loss.

INTRODUCTION: Hyperbaric oxygen therapy (HBOT) is one of the treatment methods in patients with sudden sensorineural hearing loss (SSNHL). It is recommended as an elective treatment in patients undergoing steroid therapy. According to current scientific reports, HBOT should be implemented within two weeks after the first symptoms. However, as far as the profile of HBOT is concerned, there are no straightforward recommendations. METHODS: The data obtained from the medical records of 218 patients undergoing HBOT for SSNHL at the Military Institute of Medicine-National Research Institute were analyzed statistically for the impact of the duration and the delay in implementing HBOT on the end results of pure-tone audiometry (PTA). RESULTS: A statistically significant hearing improvement in patients undergoing more than 15 cycles of HBOT was detected at all frequencies except for 1500 Hz; in the group reporting for treatment with a delay of more than 10 days, hearing improvement was statistically unsignificant at frequencies of 1500, 3000, and 4000 Hz. CONCLUSIONS: The statistical analysis showed that the urgent onset of HBOT could be a significant factor in the therapy of SSNHL.

HMGB1 Carried by Small Extracellular Vesicles Potentially Plays a Role in Promoting Acquired Middle Ear Cholesteatoma.

Cholesteatoma is a specific medical condition involving the abnormal, non-cancerous growth of skin-like tissue in the middle ear, potentially leading to a collection of debris and even infections. The receptor for advanced glycation (RAGE) and its ligand, high-mobility box 1 (HMGB1), are both known to be overexpressed in cholesteatoma and play a potential role in the pathogenesis of the disease. In this study, we investigated the role of small extracellular vesicles (sEVs) in carrying HMGB1 and inducing disease-promoting effects in cholesteatoma. No significant differences in the concentration of isolated sEVs in the plasma of cholesteatoma patients (n = 17) and controls (n = 22) were found (p > 0.05); however, cholesteatoma-derived sEVs carried significantly higher levels of HMGB1 (p < 0.05). In comparison to sEVs isolated from the plasma of controls, cholesteatoma-derived sEVs significantly enhanced keratinocyte proliferation and IL-6 production (p < 0.05), potentially by engaging multiple activation pathways including MAPKp44/p42, STAT3, and the NF-κB pathway. Thus, HMGB1(+) sEVs emerge as a novel factor potentially promoting cholesteatoma progression.

The management of sudden sensorineural hearing loss during COVID-19 pandemic.

<b>Introduction:</b> The COVID-19 pandemic constituted a significant challenge for healthcare systems. Epidemiological restrictions led to deferral of healthcare and influenced the variety of symptoms reported by patients suffering from Sudden Sensorineural Hearing Loss.</br></br> <b>Aim:</b> The aim of the study was to compare the duration of treatment implementation and symptoms reported by patients suffering from SSNHL before and during the COVID-19 pandemic.</br></br> <b>Material and methods:</b> Patients admitted to the Military Institute of Medicine - National Research Institute for SSNHL treatment were included in a survey conducted between 01.10.2021-31.12.2021. Questions on symptoms reported, chronic conditions, timeframe between first symptoms and implementation of pharmacotherapy, and hyperbaric oxygen therapy were included in the survey. The results were compared with data obtained by the Team between 01.2017-12.2019.</br></br> <b>Results:</b> 34 patients (19 females, 15 males) of the average age of 46.3 who participated in the survey indicated a significantly delayed implementation of pharmacotherapy and hyperbaric oxygen therapy in comparison to population from before the pandemic (12.08 vs. 5.41 [days]; 17.5 vs. 8.29 [days]). The survey also showed differences in the number of symptoms reported.</br></br> <b>Discussion:</b> The differences in time of implementation of SSNHL treatment could have been related to pandemic restrictions which contributed to longer queueing for health benefits and fear of contact with health service. Differences in symptomatology point towards SARS-CoV-2 as a pathogenetic factor of SSNHL.</br></br> <b>Conclusions:</b> The COVID-19 pandemic significantly influenced the treatment of Sudden Sensorineural Hearing Loss. The study demonstrated a diverse symptomatology of SSNHL before and during the pandemic.

Evaluation of the effects of hyperbaric on human attention functions based on eye movements recorded using an infrared camera.

BACKGROUND: This study aimed to assess the influence of elevated atmospheric pressure on the functions of attention of medical personnel working in hyperbaric chambers. We enrolled 15 participants who met the inclusion criteria. The test consisted of performing the same medical procedure under 2 conditions. For each of these test conditions, right eye movements were recorded using an oculograph. The obtained results revealed a relationship between elevated atmospheric pressure and the ability of medical personnel to focus. OBJECTIVES: To assess the influence of hyperbaric oxygen (HBO2) on visual attention in medical personnel during medical activities performed under normobaric (1 absolute atmosphere (1 ATA)) and hyperbaric (4 ATA) conditions inside a hyperbaric chamber. MATERIAL AND METHODS: Each participant had a valid license to act as a medical attendant during therapeutic hyperbaric sessions. Fifteen individuals, 10 men and 5 women aged between 28 and 65 years, participated in the study. The participants were asked to perform a medical procedure involving the preparation of a syringe with a drug administered by an infusion pump under 2 test conditions: 1 ATA corresponding to the atmospheric pressure on land, and 4 ATA corresponding to an underwater depth of 30 m. The order of test conditions was random. Both test conditions were performed inside a hyperbaric chamber. RESULTS: The number of fixations in the area of interest (AOI) varied between stages (1, 2 and 3) and task conditions (1 ATA and 4 ATA), with lower values for the 4 ATA condition. Under 1 ATA, 30% of eye fixations were in the AOI, as compared to only 6% under 4 ATA. CONCLUSIONS: The obtained results indicate that elevated atmospheric pressure has negative effects on the attention of medical personnel.

Hypoxia, but Not Normoxia, Reduces Effects of Resveratrol on Cisplatin Treatment in A2780 Ovarian Cancer Cells: A Challenge for Resveratrol Use in Anticancer Adjuvant Cisplatin Therapy.

Natural compounds, such as resveratrol (Res), are currently used as adjuvants for anticancer therapies. To evaluate the effectiveness of Res for the treatment of ovarian cancer (OC), we screened the response of various OC cell lines to the combined treatment with cisplatin (CisPt) and Res. We identified A2780 cells as the most synergistically responding, thus optimal for further analysis. Because hypoxia is the hallmark of the solid tumor microenvironment, we compared the effects of Res alone and in combination with CisPt in hypoxia (pO2 = 1%) vs. normoxia (pO2 = 19%). Hypoxia caused an increase (43.2 vs. 5.0%) in apoptosis and necrosis (14.2 vs. 2.5%), reactive oxygen species production, pro-angiogenic HIF-1α (hypoxia-inducible factor-1α) and VEGF (vascular endothelial growth factor), cell migration, and downregulated the expression of ZO1 (zonula occludens-1) protein in comparison to normoxia. Res was not cytotoxic under hypoxia in contrast to normoxia. In normoxia, Res alone or CisPt+Res caused apoptosis via caspase-3 cleavage and BAX, while in hypoxia, it reduced the accumulation of A2780 cells in the G2/M phase. CisPt+Res increased levels of vimentin under normoxia and upregulated SNAI1 expression under hypoxia. Thus, various effects of Res or CisPt+Res on A2780 cells observed in normoxia are eliminated or diminished in hypoxia. These findings indicate the limitations in using Res as an adjuvant with CisPt therapy in OC.

The Influence of Steroid Therapy on the Treatment Results in Patients with Sudden Sensorineural Hearing Loss.

Oral, intravenous, or intratympanic steroid therapy (ST) are commonly applied methods of pharmacotherapy in Sudden Sensorineural Hearing Loss (SSNHL). There are vast discrepancies on the recommended initial dose and the duration of ST in medical reports. The aim of the research is a retrospective comparison of patients' examination results with different therapeutical strategies. The medical records of 218 patients treated for SSNHL at the Military Institute of Medicine were subjected to retrospective analysis by comparison of the results of pure tone audiometry prior to and after treatment with steroid therapy (first-dose delay, mass of first dose, duration of treatment). Postponement of implementation of ST to 5 days resulted in a significant improvement of hearing across all frequencies. The implementation of ST sequentially in periods (5th−10th day; >10th day) resulted in a statistically insignificant improvement of hearing in the following frequencies: 250 Hz, 1000 Hz, 1500 Hz, 2000 Hz, 3000 Hz, 4000 Hz. There was a statistical improvement of hearing within all frequencies analyzed for the initial dose of prednisone above 50 mg. For an initial dose below 50 mg, in 4000 Hz, the improvement of hearing was statistically insignificant. The research demonstrated a significant influence of steroid therapy on treatment results in patients with Sudden Sensorineural Hearing Loss.

Effectiveness of Hyperbaric Oxygen Therapy in SARS-CoV-2 Pneumonia: The Primary Results of a Randomised Clinical Trial.

Mortality in COVID-19 is mainly associated with respiratory failure, cytokine storm, and macrophage activation. Oxygenation and anti-inflammatory effects of Hyperbaric Oxygen Therapy (HBOT) suggest that it is a promising adjunct treatment for COVID-19. Repeated sessions of HBO with standard COVID-19 therapy were used to reduce the inflammation and increase oxygenation. We evaluated the safety and efficacy of HBOT in avoiding the replacement ventilation and/or ECMO and its effect on the inflammatory process. Twenty-eight moderate-to-severe COVID-19 patients were randomized into control or HBOT group. HBOT patients participated in 5 hyperbaric sessions (60 min). Before and after each session blood gas levels and vital parameters were monitored. Blood samples were collected for extended biochemical tests, blood morphology and immunological assays. There were 3 deaths in the control, no deaths in the HBOT group. No adverse events leading to discontinuation of HBOT were observed and patients receiving HBOT required lower oxygen delivery. We observed decrease in CRP, ferritin and LDH and increase in CD3 in HBOT group compared to control. This study confirmed the feasibility and safety of HBOT in patients with COVID-19 and indicated HBOT can lead to alleviation of inflammation and partial restoration of T cell responses.

Effect of Hyperbaric Oxygenation on Blood Cytokines and Arginine Derivatives; No Evidence for Induction of Inflammation or Endothelial Injury.

(1) Background: Hyperbaric oxygen therapy (HBOT) uses 100% oxygen delivered at 1.5-3 times the atmospheric pressure in a specialised chamber to achieve supraphysiological oxygen tension in blood and tissues. Besides its target, HBOT may affect inflammation, endothelial function or angiogenesis. This study analysed the effect of HBOT on blood concentrations of factors that may affect these processes in patients with necrotizing soft-tissue infections (NSTI), aseptic bone necrosis (ABN) and idiopathic sudden sensory neural hearing loss (ISSNHL). (2) Methods: Concentrations asymmetric dimethylarginine (ADMA) and other arginine derivatives were measured with liquid chromatography/mass spectrometry, whereas ELISA was used to quantitate vascular endothelial growth factor (VEGF) and cytokines (IL-1, IL-4, IL-6, IL-10, TGF-ß) before and after HBOT in 80 patients (NSTI n = 21, ISSNHL n = 53, ABN n = 6). (3) Results: While some differences were noted between patient groups in ADMA and other arginine derivatives as well as in cytokine concentrations, HBOT did not affect any of these parameters. (4) Conclusions: While cytokines and arginine derivatives concentrations were modified by underlying pathology, hyperbaric oxygenation did not immediately modify it suggesting that it is neutral for inflammation and is not inducing endothelial injury.

Small Extracellular Vesicles from Head and Neck Squamous Cell Carcinoma Cells Carry a Proteomic Signature for Tumor Hypoxia.

Tissue hypoxia is commonly observed in head and neck squamous cell carcinomas (HNSCCs), resulting in molecular and functional alterations of the tumor cells. The aim of this study was to characterize tumor-derived small extracellular vesicles (sEVs) released under hypoxic vs. normoxic conditions and analyze their proteomic content. HNSCC cells (FaDu, PCI-30, SCC-25) and HaCaT keratinocytes were cultured in 21, 10, 5, and 1% O2. sEVs were isolated from supernatants using size exclusion chromatography (SEC) and characterized by nanoparticle tracking analysis, electron microscopy, immunoblotting, and high-resolution mass spectrometry. Isolated sEVs ranged in size from 125-135 nm and contained CD63 and CD9 but not Grp94. sEVs reflected the hypoxic profile of HNSCC parent cells: about 15% of the total detected proteins were unique for hypoxic cells. Hypoxic sEVs expressed a common signature of seven hypoxia-related proteins (KT33B, DYSF, STON2, MLX, LIPA3, NEK5, P12L1) and were enriched in pro-angiogenic proteins. Protein profiles of sEVs reflected the degree of tumor hypoxia and could serve as potential sEV-based biomarkers for hypoxic conditions. Adaptation of HNSCC cells to hypoxia is associated with increased release of sEVs, which are enriched in a unique protein profile. Thus, tumor-derived sEVs can potentially be useful for evaluating levels of hypoxia in HNSCC.

Effects of Hyperbaric Oxygen Therapy in Children with Severe Atopic Dermatitis.

In the course of atopic dermatitis (AD), the overactivity of the immune system, associated with predominant Th2 lymphocyte responses, is observed, which leads to an increased inflammatory reaction. Cases of a severe course of atopic dermatitis lead to the search for new therapeutic options. The aim of this study was to assess the effects of hyperbaric oxygen therapy (HBOT) treatment for severe cases of AD in children. A total of 15 children with severe AD underwent therapy. The influence of HBOT on the clinical course of AD and immunomodulatory effect of the therapy was analyzed by the SCORAD and objective SCORAD (oSCORAD) scales and by determining the serum concentration of immunological parameters (blood: nTreg lymphocytes, CD4+CD25highCD127-FOXP3+, NKT lymphocytes CD3+, CD16/56+, and serum: total IgE, cytokines IL-4, IL-6, and IL-10, before and after the 30-day treatment cycle). The study showed a significant effect of the therapy on the improvement of the skin condition. In all children, a reduction in the extent and intensity of skin lesions, reduction of redness, swelling, oozing/crusting, scratch marks and skin lichenification after HBOT was observed. Patients also reported a reduction in the intensity of pruritus and an improvement in sleep quality after therapy. In all children, a statistically significant decrease in the serum level of IgE was observed. However, no statistically significant changes in the blood levels of IL-4, IL-6 and IL-10, as well as the percentage of CD4+CD25highCD127-FOXP3+ Treg and NKT lymphocytes, were found. In conclusion, the use of hyperbaric therapy has a positive impact on treatment results in children with a severe course of atopic dermatitis.

Potential Roles of Tumor Cell- and Stroma Cell-Derived Small Extracellular Vesicles in Promoting a Pro-Angiogenic Tumor Microenvironment.

Extracellular vesicles (EVs) are produced and released by all cells and are present in all body fluids. They exist in a variety of sizes, however, small extracellular vesicles (sEVs), the EV subset with a size range from 30 to 150 nm, are of current interest. They are characterized by a distinct biogenesis and complex cargo composition, which reflects the cytosolic contents and cell-surface molecules of the parent cells. This cargo consists of proteins, nucleic acids, and lipids and is competent in inducing signaling cascades in recipient cells after surface interactions or in initiating the generation of a functional protein by delivering nucleic acids. Based on these characteristics, sEVs are now considered as important mediators of intercellular communication. One hallmark of sEVs is the promotion of angiogenesis. It was shown that sEVs interact with endothelial cells (ECs) and promote an angiogenic phenotype, ultimately leading to increased vascularization of solid tumors and disease progression. It was also shown that sEVs reprogram cells in the tumor microenvironment (TME) and act in a functionally cooperative fashion to promote angiogenesis by a paracrine mechanism involving the differential expression and secretion of angiogenic factors from other cell types. In this review, we will focus on the distinct functions of tumor-cell-derived sEVs (TEX) in promotion of angiogenesis and describe their potential as a therapeutic target for anti-angiogenic therapies. Also, we will focus on non-cancer stroma-cell-derived small extracellular vesicles and their potential role in stimulating a pro-angiogenic TME.

High-Altitude Decompression Sickness Treated with Hyperbaric Therapy and Extracorporeal Oxygenation.

BACKGROUND: High-altitude decompression sickness (HADCS) is a rare condition that has been associated with aircraft accidents. To the best of our knowledge, the present paper is the first case report of a patient treated for severe HADCS using recompression therapy and veno-venous extracorporeal oxygenation (VV-ECMO) with a complete recovery.CASE REPORT: After depressurization of a cabin, the 51-yr-old jet pilot was admitted to the Military Institute of Medicine with a life-threatening HADCS approximately 6 h after landing from a high-altitude flight, in a dynamically deteriorating condition, with progressing dyspnea and edema, reporting increasing limb paresthesia, fluctuating consciousness, and right-sided paresis. Hyperbaric oxygen therapy in the intensive care mode was initiated. A therapeutic recompression with U.S. Navy Treatment Table 6 was performed with neurological improvement. Due to cardiovascular collapse, sedation, mechanical ventilation, and significant doses of catecholamines were started, followed by continuous veno-venous hemodialysis. In the face of disturbances in oxygenation, during the second day of treatment the patient was commenced on veno-venous extracorporeal oxygenation. Over the next 6 d, the patient's condition slowly improved. On day 7, VV-ECMO was discontinued. On day 19, the patient was discharged with no neurological deficits.DISCUSSION: We observed two distinct stages during the acute phase of the disease. During the first stage, signs of hypoperfusion, neurological symptoms, and marbled skin were observed. During the second stage, multiple organ dysfunction dominated, including heart failure, pulmonary edema, acute kidney injury, and fluid overload, all of which can be attributed to extensive endothelial damage.Siewiera J, Szalanski P, Tomaszewski D, Kot J. High-altitude decompression sickness treated with hyperbaric therapy and extracorporeal oxygenation. Aerosp Med Hum Perform. 2020; 91(2):106-109.

Hyperbaric oxygenation in pediatrics: indications in the light of evidence - based medicine.

Hyperbaric oxygen therapy (HBOT), which is a centuries-old treatment, has now increasingly often been used in the pediatric population. The basic indications for HBOT are well-known disease entities, i.e. carbon monoxide poisoning or decompression sickness. Due to the immunomodulatory properties of hyperbaric oxygen, attempts are made to use HBOT in the treatment of atopic dermatitis or inflammatory bowel diseases. The close cooperation between pediatricians and hyperbaric medicine teams is very important to obtain optimal results. The aim of this article is to present the mechanism of hyperbaric oxygen activity, and its influence on selected disease entities. The paper outlines new perspectives for HBOT in the pediatric population.

Withholding and withdrawing life-sustaining treatment: Experiences in limiting futile therapy from three Polish intensive care departments.

BACKGROUND: In intensive care units (ICUs), a patient's vital functions may be maintained, regardless of the patient's chances of survival. A key issue is how to precisely determine the moment in which life-support treatment should be withheld. In many countries, the decision-making process is regulated by the guidelines of scientific societies. However, heuristic errors may influence this process. OBJECTIVES: The objective of this study was to assess factors involved in decisions to implement or withhold treatment in general ICUs in Poland. MATERIAL AND METHODS: The medical records of patients treated in 3 clinical ICUs of general, cardiosurgical and neurosurgical profile were retrospectively analyzed. Patients with a diagnosis of brain death were finally excluded from the study. RESULTS: The records of 1,449 patients hospitalized between January 1, 2014 and December 31, 2014 were analyzed. Of these, 226 patient cases were evaluated. There were no correlations between the placement of restrictions on resuscitation in specific cases, use of noradrenaline, frequency of blood gas testing, and patients' age. There was a relationship between these factors and the duration of hospitalization in the ICU. There was a direct relation between a "do not resuscitate" (DNR) order in a patient's record and the frequency of both resuscitation procedures and withholding catecholamine treatment in the hours preceding a patient's death. CONCLUSIONS: Treatment was withheld in about 20% of cases involving dying patients in analyzed ICUs, regardless of age. Placing a limit on treatment consisted of either withholding new procedures or withdrawing existing therapy. The length of stay in the ICU affected the decisions to limit treatment.

Ondine's Curse - Genetic and Iatrogenic Central Hypoventilation as Diagnostic Options in Forensic Medicine.

In the Nordic mythology a man lost his ability to breathe without remembering it after he was cursed by water nymph - referred to as 'Ondine's curse' - and then he died as soon as he fell asleep. Family medicine specialists are familiar with many sleeping disorders that their patients commonly call by the term Ondine's Curse. In medical sciences this term is historically related to the group of conditions that have as the common denominator seemingly spontaneous onset of life-threatening hypoventilation. The physiology and genetics specialists focus mainly on congenital central hypoventilation syndrome (CCHS), which was proven to be linked to several genetic mutations. Anesthesiologists tend to be more interested in similarly manifesting iatrogenic condition. Typically, patients that were previously subjected to general anesthesia, after temporarily waking up and regaining the spontaneous respiratory drive, later fall back into unconsciousness and develop hypoventilation. Anesthesiologists also call it Ondine's curse because of the sudden and unexpected sleep onset. The iatrogenic Ondine's curse is proven to be precipitated by delayed anesthetics release from patients' fat tissue - where it was deposited at the time general anesthesia was administered - back into bloodstream. Forensic medicine has to consider the latter form of Ondine's curse called scenario more often, as they investigate sudden deaths related to surgery and general anesthesia in the post-operational care period. These cases may also fall into the category of medical malpractice-related deaths.

[New definition of ventilator associated pneumonia might not necessarily have been a step in the right direction. Key takeaways from published studies after two years in clinical use]. / Czy nowa definicja zapalenia pluc zwiazanego z wentylacja mechaniczna spelnila swoje zadanie? Wnioski z pierwszych doniesien po dwóch latach zastosowania w klinice.

Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections. VAP is associated with prolonged hospitalization and visibly increased mortality, which in the group of patients with VAP ranges from 25% to 47%. In January 2013 Centers of Disease Control and Prevention introduced a new definition for VAP. Subjective criteria in the previous VAP definition were the reason for difficulties in VAP surveillance and assessment of efficacy of ventilator bundles and other quality improvement initiatives. The purpose of this article is to summarise the new definition of VAP and the first researches after two years of use of the new definition. The new definition of ventilator-associated events (VAE) identifies a broader group of patients than the previous VAP definition. Surveillance of all complications of mechanical ventilation aimed to create more efficient prophylaxis bundles and to decrease the mortality in critically ill patients. The latest published studies suggest that most of the complications defined as VAE are patient-related, not modifiable risk factors and these patients had no evidence of hospital-acquired complications. The new definition failed to detect many patients with VAP and it has not resolved the ambiguities related to the diagnosis of this complication. It seems that the new surveillance program will not lead to introducing new prevention strategies that could decrease the mortality in intensive care unit patients.

The issue of penal and legal protection of the intensive care unit physician within the context of patient's consent to treatment. Part II: unconscious patient.

Cultural changes in Western societies, as well as the rapid development of medical technology during the last quarter of a century, have led to many changes in the relationship between a physician and a patient. During this period, the patient's consent to treatment has proven to be an essential component of any decision relating to the patient's health. The patient's will component, as an essential element of the legality of the treatment process, is also reflected in the Polish legislation. The correct interpretation of the legal regulations and the role the patient's will plays in the therapeutic decision-making process within the Intensive Care Unit (ICU) requires the consideration of both the good of the patient and the physician's safety in terms of his criminal responsibility. Clinical experience indicates that the physicians' decisions result in the choice of the best treatment strategy for a patient only if they are based on current medical knowledge and an assessment of therapeutic opportunities. The good of the patient must be the sole objective of the physician's actions, and as a result of the current state of medical knowledge and the medical prognosis, all the conditions of the legal safety of a physician taking decisions must be met. In this paper, the authors have set out how to obtain consent (substantive consent) to treat an unconscious patient in the ICU in light of the current Polish law, as well as a physician's daily practice. The solutions proposed in the text of the publication are aimed at increasing the legal safety of the ICU physicians when making key decisions relating to the strategy of the treatment of ICU patients.