Objective: Difficult peripheral intravenous access (DIVA) affects a substantial proportion of the adult population and presents challenges for both patients and healthcare staff. In the Czech Republic, no validated predictive tools for identifying DIVA are currently available. The aim of this study was to identify available prediction scales, compare their characteristics, and assess the feasibility of their implementation in clinical practice. Methods: This study is a combined methodological analysis conducted in two phases: (1) systematic identification and selection of DIVA prediction scales (Web of Science and Scopus databases) and (2) expert evaluation of the selected tools by a clinical expert panel. The panel assessed the content and clinical relevance of the scales, their feasibility, degree of subjectivity, and potential contribution to practice. Results: The analysis included the following predictive tools: A-DIVA, SAFE Rule, A-DICAVE, EA-DIVA, and DIVA-CP. According to current evidence, the first three scales appear most suitable for a broad adult population. A-DIVA demonstrates good predictive value and external validity, but focuses primarily on firstattempt cannulation failure. The SAFE Rule is a simple screening rule based on the most common DIVA predictors, but lacks formal scoring and risk stratification. A-DICAVE is a fast threeitem tool suitable particuarly for emergency departments, although it has only been internally validated. Conclusion: Although no universal predictive instrument exists, the available tools provide an effective framework for identifying highrisk patients and optimizing cannulation techniques. For Czech healthcare, translation and validation studies of the most promising tools for the general adult population (A-DIVA, SAFE Rule, A-DICAVE) and for the oncology population (DIVA-CP) are essential, along with the development of standardized care algorithms that prioritize ultrasound guidance and limit “blind” attempts.

Inhalation injury is a common and potentially life-threatening complication in burn patients, significantly increasing the mortality of these patients. It is a result of smoke inhalation, toxic combustion products, hot gases or chemicals. It can affect multiple anatomical levels of the respiratory tract, while toxic substances may also cause systemic effects. Diagnosis is challen­ging due to nonspecific symptoms and a lack of diagnostic criteria, with bronchoscopy remaining the gold standard. This article reviews current knowledge on the epidemiology, pathophysiology, diagnostic strategies, and treatment options for inhalation injury in both adult and pediatric patients.

Malignant hyperthermia (MH) is a rare, hereditary, life-threatening pharmacogenetic disease induced by some commonly used anaesthetics. This review article aims to summarise, from a practical point of view, the news and current recommendations in the field of MH so that the anaesthesiologist-intensivist can easily use them in daily practice. The theoretical introduction is only brief, as it serves to gain an essential awareness of the issue of MH. As a matter of priority, we will look at the most common situations where a doctor may encounter MH. We will focus on the anaesthesiology clinic and the recognition of risk factors. In the operating room, preparation of the anaesthesia workplace for MH-risk patients and the management of the acute MH crisis are crucial. As part of intensive care, we will discuss the continuation of MH crisis therapy, and we will also mention situations when, in the case of unexplained rhabdomyolysis, it is worth considering MH. We will refer to the latest recommendations of the European Malignant Hyperthermia Group (EMHG) and briefly comment on their implementation in our conditions, e.g., recommendations regarding dantrolene availability. We will also not forget the approach to pregnant women at risk of MH. In conclusion, we will outline an outlook that reflects the current developments and future changes in the perspective on the issue of MH and explain why the centralisation of care for patients at risk of MH is so necessary.

Sepsis as a life-threatening organ dysfunction caused by a deregulated immune response to infection remains one of the greatest human health-related concerns globally and even though huge advances in diagnostics and treatment of sepsis have been made, around 11 million sepsis-related deaths are reported every year worldwide. Only half of the sepsis survivors can achieve complete recovery 2 years after discharge, one-third die, and the remaining one-sixth suffer from long-term complications known as post-sepsis syndrome. It involves physical symptoms - fatigue, muscle weakness, dysphagia, and chronic pain; neuropsychiatric consequences - anxiety, depression, post-traumatic stress disorder, and cognitive decline with impaired memory and attention. Even though many long-term changes have been described in post-septic patients, complex pathophysiological mechanisms responsible for the development of PSS are still not known. Syndrome of persistent inflammation, immunosuppression, and catabolism (PICS) is involved. Even less we know about possible treatment options for PSS. The goal of this review is to summarize current knowledge and raise awareness in the professional medical community with this syndrome.

Therapeutic drug monitoring (TDM) is a key tool in optimizing antibiotic therapy in critically ill patients. The variability of pharmacokinetics and pharmacodynamics (PK/PD) in this population often requires an individualized approach that goes beyond standard dosing schedules. Early implementation of TDM, especially during the first 48 hours of treatment, is essential to achieve target therapeutic antibiotic concentrations. The correct administration strategy, using prolonged or continuous infusions of the administered antibiotics, plays a significant role in achieving optimal PK/PD parameters. At our institution, we have observed a high variability in the concentrations achieved for β-lactam antibiotics over the years, which supports the wider implementation of TDM in routine clinical practice.

Study goal: Pain in patients in the intensive care unit (ICU) represents a significant clinical problem requiring a systematic approach to treatment, as well as to monitoring and evaluation of the presence or intensity of pain. Patients are often immobilized, exposed to invasive procedures, and other stressors affecting pain intensity. Patients' ability to verbally express pain levels is often limited. Effective assessment of pain intensity, as well as other pain indicators, is crucial to ensure patient comfort and to prevent complications associated with untreated pain. Study type: cross-sectional questionnaire study. Type of workplace: Intensive care units (ICU) of the Czech Republic. Material and methods: A quantitative cross-sectional study using a standardised KASRP questionnaire (divided into three main areas: demographic data, level of knowledge and attitudes towards pain management, and practical experience in clinical practice in a specific department). Results: 207 (100 %) respondents were analyzed in the study, of which 88 % (n=182) were female. The Visual Analog Scale (VAS) was the most frequently mentioned pain assessment tool for patients capable of verbal communication (62.6 %; n=129). Different levels of knowledge and attitudes among healthcare professionals were demonstrated. Higher levels of knowledge were demonstrated by respondents with higher education (p=0.001) and completed specialty training (p=0.00298). The level of knowledge varied by type of unit, with respondents from the post-acute care unit demonstrating the best knowledge (p=0.000549). Conclusion: A cross-sectional study of intensive care units in the Czech Republic revealed differences in the knowledge of healthcare workers, mainly influenced by education, type of unit and specialisation in the field. Differences in declared pain assessment tools were verified. The differences found highlight the need for systematic education of non-medical health care personnel and open up space for further research in pain assessment.

Introduction: Sleep is a fundamental component of human health, and its quality can be affected by various psychological and environmental factors. Objective: This study aimed to determine the level of anxiety in patients hospitalized in the intensive care unit (ICU), analyze its relationship with sleep quality, and identify environmental factors that disrupt this quality. Methods: A multicenter cross-sectional study was conducted in ICUs of six selected hospitals in the Czech Republic. The ICU Sleep Questionnaire (SICQ) and the Beck Anxiety Inventory assessed subjective sleep quality and anxiety levels. Results: A total of 267 ICU patients were included. Higher levels of anxiety were significantly associated with poorer sleep quality (R = -0.41; p < 0.001), with anxiety accounting for 19.6% of the variance in sleep quality. Subjective sleep quality (on a 0-10 scale) was lowest after the first night (4.5 ± 2.5), improved mid-stay (5.3 ± 2.1), and further enhanced by the end of the ICU stay (5.8 ± 2.2); however, it remained lower than at home (7.0 ± 2.3). A positive correlation was observed between sleep quality at home and in the ICU (r = 0.342; p < 0.001). Daytime sleepiness correlated with poor sleep (r = 0.206; p < 0.001). ICU environmental factors negatively affected sleep quality (Ra = -0.804 to -0.114), accounting for 13.7% of the variance in sleep quality. Conclusion: Elevated anxiety levels, pre-hospitalization sleep problems, increased daytime sleepiness, and unfavorable ICU environmental conditions negatively influence patients' subjective sleep quality during ICU hospitalization.

Despite progress in diagnosis and treatment, sepsis remains a significant challenge to the health care system globally. In recent decades, the level of knowledge in the field of sepsis has undergone a significant shift towards targeted therapy influencing the immune response in an attempt to dampen the early hyperinflammatory state but also to influence later immunoparalysis. Although this sepsis-induced immunosuppression has not been fully understood yet, it is evident that reduced functions of innate and adaptive immunity are associated with a worsened patient outcome. Based on this finding, several pharmacological approaches to immunostimulation are emerging to restore the immune balance of patients and to improve their prognosis. In the following text, we aim to provide a brief overview of current treatment options while highlighting the most significant challenges that may arise during the implementation of this therapy.

End-of-life (EOL) care in intensive care units (ICUs) is a complex clinical, legal and ethical challenge where language and terminology play a critical role in supporting decision-making and interdisciplinary collaboration. This article presents a proposal for a document that responds to the need to update and unify the terminology used in EOL care in the Czech Republic. Its aim is not to redefine terms from scratch but to reflect current developments in international discourse and to align terminology with the Czech clinical, legal and ethical context. The document is the result of a consensus process using a modified Delphi method. It was developed by a multidisciplinary expert panel including intensivists, anesthesiologists, palliative care specialists, legal experts, and bioethicists, and further reviewed by an external advisory group. The outcome is a structured set of updated terms grouped into thematic areas (e.g., appropriateness of care, shared decision-making, treatment limitations) and accompanied by practical definitions. The document also provides an ethical and legal framework for EOL decision-making in ICUs an overview of appropriate terminology. It emphasizes clarity, ethical consistency, and respect for patient autonomy. Its broader goal is to support clinical and academic dialogue and to offer a foundation for future development of educational materials, practice guidelines, and legislative documents related to palliative and intensive care.

Aim: Excessive fluid accumulation during fluid resuscitation is associated with increased mortality and organ dysfunction. The promise of personalized fluid therapy lies in maximizing its benefits while minimizing the harmful effects of fluid resuscitation. This includes prediction of the hemodynamic response to infusion and careful consideration of its volume and composition in the context of the clinical situation. In light of recent paradigm shifts in lactate metabolism, we therefore discuss current evidence on the concept of low-volume intravenous resuscitation with hypertonic sodium lactate (HSL). Design: A narrative review of the current literature on basic, applied and clinical research relevant to the issue of fluid resuscitation with hypertonic solution. Method: Keyword search of PubMed and Google Scholar databases, along with citation search. The limitations of the search are explained in the discussion. Results: A total of 569 results were found in PubMed and 721 results in Google Scholar. Due to the narrative nature of this review, no formal evaluation of the quality of evidence using standardised methods has been carried out. The non-protocolized selection of literature was made according to the consensus of the authors and based on professional relevance, type of study and availability of full text. Conclusion: Hypertonic sodium lactate may represent a promising alternative within the portfolio of resuscitation fluids, with the potential to optimize circulating volume and improve the bioenergetics of cardiac performance while avoiding excessive fluid and chloride load. However, current evidence regarding its efficacy in patients with septic shock remains very limited and does not yet allow implementation of HSL into clinical practice. Despite the exponential increase in the number of HSL studies in recent years, robust randomized trials designed in accordance with the latest findings from basic research on lactate metabolism are still required to definitively assess its efficacy and safety.

Cardiac output monitoring and other parameters as part of extended hemodynamic monitoring represent an advanced tool for the early detection of circulatory disturbances that cannot be identified through standard vital sign monitoring. Such disturbances may lead to inadequate tissue oxygen delivery and subsequent clinical deterioration. Extended hemodynamic monitoring is indicated in patients who do not respond to initial therapy, and in the perioperative setting, it is recommended for high-risk patients undergoing high-risk surgical procedures. The choice of cardiac output monitoring modality may be challenging due to the wide range of available technologies, which differ in their invasiveness and the spectrum of parameters provided. The aim of this article is to provide an overview of available continuous methods of advanced hemodynamic monitoring, assess their benefits and limitations, and support appropriate indication based on the patient's clinical condition.

The prevalence of psychiatric disorders is rising globally, with one in five individuals now affected. As a result, patients taking psychotropic medications are encountered frequently in clinical practice. This article explores the specific considerations in providing anaesthetic care to psychiatric patients, with a focus on pharmacological interactions between psychotropic and anaesthetic drugs, as well as on the risks associated with their combined use. Additionally, the article discusses strategies to minimize potential complications during the perioperative period.

Surgical treatment is the primary therapeutic option for patients with early-stage lung cancer. The most common causes of perioperative morbidity and mortality in these patients are postoperative pulmonary complications. Peak oxygen consumption (VO2) has long been considered the gold standard for predicting these complications. In recent years, several new parameters for risk assessment have been described in peer-reviewed journals, notably ventilatory efficiency (VE/VCO2 slope) and end-tidal CO2. Both parameters have demonstrated excellent predictive ability for postoperative pulmonary complications, even in patients in whom peak VO2 failed. This article provides an overview of current recommendations, with a focus on the latest findings in risk assessment for lung surgery.

Year 2025 brought significant advances in the field of cardiovascular issues in intensive and perioperative medicine. Research has focused primarily on the individualization of circulatory support, optimization of perfusion targets, and more accurate risk assessment. In the treatment of circulatory shock, there is a prevailing trend toward physiologically oriented, personalized strategies emphasizing hemodynamic phenotypes and a balance between fluid therapy, vasopressors, and mechanical circulatory support. Evidence continues to grow for the selective use of advanced methods, including mechanical cardiac support and extracorporeal cardiopulmonary resuscitation. In perioperative medicine, the focus is shifting toward systematic assessment of functional capacity and biomarkers, which allow for more accurate prediction of cardiovascular risk without the need for routine testing. Pharmacologic research confirms the safety of targeted heart rate control in septic patients and explores new approaches to anticoagulation during mechanical circulatory support. Overall, current developments are moving toward more precise phenotyping, integration of modern monitoring techniques, and rational use of advanced therapies. Individualization of treatment and cost-effectiveness are becoming the core principles of modern cardiovascular care in intensive medicine.

The article highlights and discusses several current topics that have been published in the field of anaesthesiology in obstetrics in the Czech Republic and abroad last year. It summarizes new challenges in the field of obstetric anesthesia, including the use of AI and simulations in this area. It also presents new developments in systemic and neuroaxial obstetric analgesia, caesarean section anaesthesia, and emergencies in the peripartum period.

Several original papers on the topic of acute respiratory failure (ARF) were published in 2025, including studies that support respiratory functions through mechanical ventilation (MV) or the veno-venous form of extracorporeal membrane oxygenation (VV ECMO). The aim of this text is to introduce readers to selected works that, according to the authors, may be of interest not only to researchers in the field but also to physicians in clinical practice. The review article is divided into several sections; the first includes randomized papers and post-hoc analysis of papers already published. The second part is devoted to large prospective observational studies and works based on registries. The final section addresses diagnostic and prognostic studies. The article search was carried out using an AI client (SciSpace). A prompt requesting the presence of human medicine articles dealing with ARF in critical care, published in high-impact journals in 2025 to date, was used. Review articles were excluded. AI ranked the searched database according to relevance from the perspective of the main topic. The next step involved standardizing the selection and finally describing the selected literature. Fifteen full-text articles were selected as sources for the paper from the original 100 results obtained.

This article presents a selected review of articles and topics published in the field of acute pain management over the past approximately 14 months. It focuses on new developments in systemic analgesia, pain management procedures, and selected international guidelines.

Objective: Covid-19 is associated with a significantly increased risk of macrovascular and microvascular thrombotic complications, especially in critically ill patients with a severe form of the disease. Antithrombotic prophylaxis is an important part of treatment and was being applied using different drugs and dosing schemes during the pandemic. Data comparing various possibilities of antithrombotic therapy in these patients is lacking. The primary endpoint of this study was a retrospective assessment of ICU-free days, hospital-free days, and bleeding or thrombotic complications in critically ill patients with covid-19 pneumonia, who initially received higher doses of anticoagulation therapy either using subcutaneous (s. c.) application of low molecular weight heparin (LMWH) or continuous intravenous (i. v.) infusion of unfractionated heparin (UFH). The secondary endpoint was to compare 30-day mortality. Design: Retrospective cohort study. Setting: Intensive Care Unit (ICU) of a university hospital. Material and methods: A retrospective analysis of medical records of critically ill patients with covid-19 associated pneumonia and acute respiratory failure was performed. Patients were admitted to the ICU from 1. 3. 2020 to 31. 3. 2022 and received higher doses of anticoagulation using s. c. nadroparine or i. v. infusion of UFH at least from the second to eighth day of admission. Results: A total of 153 patients were included in the analysis. Median of ICU-free days at 30 days was 15 days for LMWH group and 12 days for UFH group (p = 0.1932). Median of hospital-free days at 60 days and 90 days was 5,5 days for LMWH group and 0 days pro UFH group (p = 0.5511), 26 days and 23 days (p = 0.6590) respectively. The difference in incidence of thromboembolic complications was not significant (1.96% in LMWH group and 7.84% in UFH group (p = 0.2732)). Minor bleeding complications were more frequent in LMWH group (11.76% vs. 0.98%, p = 0.0058). Logistic regression model found no significant effect of anticoagulation therapy on 30-day mortality. Conclusion: No statistically significant difference was found between both groups in the incidence of thromboembolic complications, the number of ICU-free days, the number of hospital-free days. Logistic regression model proved no effect of anticoagulation type on 30day mortality. In the LMWH group, a higher frequency of minor bleeding complications was observed, while the frequency of major bleeding complications did not increase.

Objective: This paper evaluates adherence to traction splint use for suspected femoral midshaft fractures in prehospital care, focusing on patients transported to Level I Trauma Center. Design: Retrospective observational study. Setting: Emergency department, emergency medical service. Material and Methods: A retrospective analysis utilized datasets from the Level I Trauma Center and the Emergency Medical Service in the period of January to December 2023. Initially, 391 patients were searched in both databases. The study included 46 patients with prehospital traction splint application due to suspected femoral fracture and 8 patients with a femoral shaft fracture without traction splint application. Patients without a confirmed femoral shaft fracture and without applied traction splint and those who died during transport to the emergency department were excluded. The following variables were recorded: age and gender, mechanism of injury, Injury Severity Score (ISS), duration of the prehospital setting, administration of analgesics in the prehospital care, operation treatment within the first 24 hours after the injury, presence of other severe injuries, need for blood transfusion in early management, length of stay in the hospital and mortality. Subsequently, the sensitivity and specificity of a traction splint application in patients with femoral shaft fractures were evaluated. Results: A total of 54 patients were evaluated, 34 male (63%), median age was 39 years (IQR 26;73), high-energy mechanism of injury prevailed. Injury severity score was 11 (IQR 9;25), 40% of patients were polytraumatized. The duration of prehospital care was 59 min (IQR 47;72 min). Prehospital analgesics were administered to all patients, all polytraumatized patients received early blood transfusion. Length of stay in the hospital was 15 days (IQR 9;26 days). Mortality was 3.7%. Sensitivity of the correct indication of traction splint application in prehospital care in patients with femoral shaft fracture was 92% in our study, specificity 97%. Conclusion: Currently, a traction splint is a common device used for stabilization of the potential femoral shaft fractures in prehospital settings and in the emergency department. It is important to carefully consider contraindications and femoral fracture level for effective use according to the manufacturer's recommendations for the specific traction splint. The challenge remains the assessment of the fracture level on the prehospital scene. Systematic education significantly influences the recognition and appropriate indication for traction splint application and reflects the high specificity and sensitivity of traction splint application in patients with femoral midshaft fractures in our study.

New­‑onset atrial fibrillation is common in critically ill patients with septic shock and worsens haemodynamics through loss of atrial contraction, shortening of diastolic filling time, decrease in cardiac output, and elevation of filling pressures. In this context, atrial fibrillation is associated with prolonged hospitalisation, a higher risk of ischaemic stroke, and increased mortality. The pathogenesis is multifactorial, combining patient­‑specific predispositions and triggers associated with critical illness. These include excessive catecholamine release, electrolyte imbalances, autonomic nervous system dysregulation, systemic inflammation, and changes in preload and afterload. Together, these factors enhance atrial arrhythmogenicity and predispose to the development of new­‑onset atrial fibrillation. Bedside echocardiography enables personalised diagnosis, treatment, and prevention. Parameters focused on the left atrium aid in the risk stratification of atrial fibrillation, prediction of sinus rhythm maintenance, and selection of an appropriate management strategy (rhythm control vs. rate control). Therefore, a comprehensive and individualised assessment of the left atrium, along with evaluation of diastolic and systolic function of both ventricles, should be an integral part of arrhythmia management in patients with septic shock. This review also provides a practical bedside algorithm to guide phenotype­‑based management.

Lumbar spinal stenosis (LSS, M48.06) is a common degenerative disease of the spine, the incidence of which increases significantly with age. It can be a serious risk factor when performing central nerve blocks. Central blocks, especially spinal anaesthesia, are considered the method of choice for many orthopaedic procedures, including total knee replacement. However, their use in patients with lumbar spinal stenosis requires increased caution. It is documented by a case study described in the judgment of the Supreme Court of the Czech Republic. The patient developed a severe and permanent neurological deficit due to decompensated multi-level lumbar spinal stenosis after total knee replacement performed under general anaesthesia following a failed epidural anaesthesia. The case is presented from both a clinical and legal perspective. Possible pathophysiological mechanisms of neurological damage, in particular the role of volume effect in the narrowed spinal canal, perfusion deficits of nerve structures, and the importance of early diagnosis are discussed. The case emphasizes the need for careful preoperative assessment, thorough postoperative monitoring of neurological functions, and immediate treatment of newly emerging neurological symptoms. For patient safety, lumbar spinal stenosis should prompt at least increased vigilance. Therefore, in some patients, modern general anaesthesia with multimodal analgesia and peripheral nerve blocks may also be a suitable option.

A Nature Medicine publication redefines the biology of critically ill patients and opens the way to precisely targeted immunotherapy for sepsis and selected critical illnesses.