Dr. Konstanty Szułdrzyński: the effectiveness of all methods depends on the quality of intensive care

• The international conference Intensive Spring took place in Warsaw (30-31 May this year), which brings together leading specialists in the field of intensive care from around the world.
• This is a unique and valued event in Europe in the field of intensive care - this year's conference is held under the scientific patronage of the International Fluid Academy
• Dr. Konstanty Szułdrzyński, Medical Director of the State Medical Institute of the Ministry of Interior and Administration, in an interview with Rynek Zdrowia, talks about the challenges facing intensive care, including the growing number of patients admitted to intensive care, the treatment of sepsis, new methods of saving patients, and quality in IT.

What interesting topics were discussed this year during the recent Intensive Spring conference?

Dr. Konstanty Szułdrzyński : This is the only conference in Poland and one of the few in this part of Europe that is completely international in nature, i.e. almost all the lecturers are foreign. This year's edition brought many interesting topics, including one that appeared for the first time in Poland and one of the first times in Europe. It is about how to prepare intensive care, which is a field of medicine that is very demanding in terms of security, e.g. in medical gases, energy, etc., in the event of war and other crises. An anesthesiologist from Kiev spoke, talking about the problems they encountered. We also had an expert on this topic from the Ministry of Health in Norway, which is preparing quite extensively in this area. It is known that such crises can occur even without war, as the recent blackout in Spain showed. Medicine needs to be prepared for this, and intensive care is one of the most "resource-intensive" fields.

The second topic is the technique of extracorporeal support of gas exchange and circulation, or ECMO in its various forms. We talked about its usefulness, indications and contraindications, the use of ECMO also in the case of cardiac arrest. There is a method called ECPR, which is the use of ECMO in the resuscitation of patients if the cardiac arrest lasts longer. And this is a method that allows to improve survival with a good neurological result. Such a patient has a chance to come out of it with an undamaged brain. Instead of a few, 4-5 percent ECPR gives a 30 percent chance, so it is a big qualitative leap. However, the use of this method requires an impeccably functioning rescue system, so the question arises whether it can be fitted into the Polish system, what are the advantages and disadvantages of various solutions of this type in the world.

We also discussed the role of ECMO after cardiac arrest in people with irreversible brain damage or cardiac death, because this method helps to use organs for transplantation after death has been confirmed. Thanks to this, we are potentially able to greatly increase the availability of organs for transplantation. In this area, Spain has the greatest experience in Europe. This is something that Poland does not have at all. But it would certainly require a large public debate first.

In addition, a number of interesting topics were discussed, such as advanced neurological monitoring, i.e. brain function in intensive care, or news about mechanical ventilation, the role of fluid therapy. Fluids were treated for a very long time as an unclassified addition to therapy, and intravenous fluids are in fact drugs.

Awareness of how they work, dosing, assessing the effectiveness of fluid therapy - this was the topic of one of the sessions organized with the international organization International Fluid Academy from Belgium, with which we signed a partnership agreement this year. This is one of the largest organizations dealing with improving quality in hospitals when it comes to fluid therapy and shock treatment.

And how can we assess the condition of intensive care in Poland? What do we learn from experts from other countries, and what can they learn from Polish doctors?

In Poland we have no problem with equipment, individual competences or availability of medicines. However, what we still lag behind in is the culture of quality and safety, which results from certain system solutions. And in these system solutions we still clearly lag behind. So this is what is the system's problem in Poland in general - the lack of a culture of safety and quality. Currently, new accreditation standards are being introduced. Accreditation is finally starting to enforce quality control, but in this area we are still behind.

So what challenges are facing intensive care in Poland today, given the growing number of patients and hospital infections? Or are there any technological challenges?

There are many problems and challenges. I think that medicine is becoming more technical, more invasive, and society is getting older. There are more and more people who are subjected to immunosuppression for various reasons, in the course of cancer, autoimmune diseases, or after transplants. As a result, there is an increasing number of people in society with impaired immunity. In addition, there is an increasingly frequent appearance of multidrug-resistant microorganisms. This is a big problem.

In turn, in terms of society, the biggest problem of intensive care is its recognition. If we ask the average person what a cardiologist or allergist does, they will know. But if we ask what intensive care does, no one will be able to say exactly. And the problems that escape society also escape decision-makers.

At the moment we have many advanced methods of treatment, both pharmacological and technical. We have robotic surgery, drug programs, incredibly modern methods of treating cancer or hematological diseases, huge progress. But the effectiveness of all these methods is determined by the quality of intensive care, because if the patient's condition becomes complicated, he will end up in intensive care regardless of his initial diagnosis. So quality is extremely important here, because it is a factor that determines the results of treatment in sometimes very expensive programs in other areas of medicine.

Another challenge is improving the local conditions. In Poland, there are still few very modern intensive care units with good local conditions. I mean those that allow for patient isolation, but also have a large area, because intensive care has a huge amount of equipment, and you also need to have good access to the patient. In addition, you need to create decent conditions for people visiting our patients. Awareness of the architectural requirements for intensive care, their impact on treatment results, has advanced significantly in the world. However, in our country, most intensive care units are architecturally from the 1980s, and few new hospitals are being built.

You mentioned that one of the challenges is sepsis. How serious is that challenge, sepsis and septic shock?

I think that sepsis is and will always be a challenge, and there are more and more cases of sepsis. Statistics from the early 2000s said that every third patient who ended up in intensive care was there because of sepsis. Therefore, it is a huge burden. And many patients develop further infections while in the intensive care unit. So ultimately, most patients develop sepsis during their stay in intensive care. So this is a huge problem. Medicines, equipment and competences in the field of treating sepsis in intensive care are available. The problem, however, is that patients are not detected in the system early enough and therefore often end up in IT very late, when despite all our potential, it is already too late for certain things, for professional help. This is again a problem of awareness. And in the case of sepsis, the results of treatment depend to a large extent on the correct diagnosis and application of appropriate procedures.

What is the standard of care and what new options does modern medicine give us in the treatment of sepsis?

There is no miracle cure for sepsis. However, in the intensive care environment, there is full awareness that the effect of sepsis treatment is the result of early diagnosis and the application of the entire package of interventions. This package should be applied quickly and in the right order. We are constantly observing progress in our understanding of the mechanisms of sepsis and its proper treatment. For example, once the standard in septic shock was to administer a huge amount of fluids and only after a few hours, when there was no improvement, vasoconstrictor drugs were started. Now the strategy is different, you do not give such a huge amount of fluids, you administer as much as is necessary, and vasoconstrictor drugs are started much earlier and this brings good results. So there are changes in strategy, but the real revolution has taken place in diagnostic methods, because microbiological diagnostics has moved forward incredibly in recent years. Rapid microbiological tests, PCR tests have changed a lot. We are increasingly able to treat patients in a targeted manner. We know what we are dealing with, and then it is easier to treat the patient causally. This is a huge progress. These are expensive methods, but they pay off because you can treat the patient quickly, in a targeted manner. Previously, you had to treat the patient somewhat blindly, we gave empirical treatment, which is one that should work on all probable microorganisms, these were always the strongest antibiotics. Now, however, we have a proper diagnosis much faster.

It is precisely this personalization that I wanted to ask about in a broader context, of the entire intensive care, and not just the treatment of sepsis. Can we talk about a more personalized approach to treatment in anesthesiology thanks to various modern technological, pharmacological and therapeutic solutions?

Absolutely yes. As I said with the example of microbiological diagnostics. But also, for example, monitoring in intensive care has made a lot of progress. We have advanced hemodynamic monitoring, which shows the state of the circulatory system very precisely and if a patient's blood pressure drops, we are able to say with great accuracy why. So we can intervene much more accurately, treat the patient, which is more effective, brings results faster and is associated with a lower risk of adverse effects. We have advanced monitoring of brain function, so we catch worrying signals earlier.

Similarly, we have systems for monitoring the lungs, so mechanical ventilation of the lungs becomes safer.

Modern intensive therapy offers ever greater possibilities of individualization, i.e., adjusting treatment to the needs of each patient. Thanks to this, it is increasingly effective, and at the same time burdened with a lower risk of complications.

Copyrighted material - reprint rules are specified in the regulations .