Assessing pain in non-communicative patients remains challenging in anaesthesia and intensive care. When self-report is unavailable, clinicians infer nociception from behaviour and physiology. Behavioural scales such as the Behavioral Pain Scale and the Critical-Care Pain Observation Tool are simple and reproducible, supporting consistent practice; however, performance declines with deep sedation, neuromuscular blockade, or severe neurological injury. Where behavioural cues are absent or unreliable, physiological and neurophysiological signals provide partial information. Autonomic indicators, including heart rate variability, the Surgical Pleth Index, pupillometry, and skin conductance, capture sympathetic responses to noxious stimuli rather than perceived pain and are sensitive to drugs, haemodynamic instability, shivering, and agitation. Electroencephalography and functional near-infrared spectroscopy identify cortical responses to nociceptive input, yet clinically useful thresholds remain context dependent, and most applications are research-based. Emerging machine-learning systems that integrate behaviour and physiology show promise, but models validated in the operating room are not automatically applicable in the intensive care unit and require new external validation with potential recalibration. Evidence is generally stronger intraoperatively than in intensive care, and paediatric data are limited. No instrument directly measures subjective pain when self-report is absent. Available tools index nociception through behavioural and physiological correlates and must be interpreted within the clinical context.

Introduction: Although nutritional treatment is an established pillar of multidisciplinary care provided in critical illness, there are many concerns regarding this issue in severe COVID-19. This observational, retrospective, multicentre study aimed to analyse the approach to nutritional treatment among selected intensive care units (ICUs) in Poland.Material and methods: The medical records of 129 patients hospitalized in five units due to respiratory failure following COVID-19 were analysed in terms of nutritional management on the eighth day of the ICU stay. The Harris-Benedict equation (HB), Mifflin St. Jeor equation (MsJ) and ESPEN formula (20 kcal kg–1 body weight) were used to estimate the energy target for each patient, and two ESPEN formulas determined the protein target (1 g kg–1 body weight and 1.3 g kg–1 body weight).Results: Evaluation of nutritional therapy was performed in 129 subjects. The fulfilment of caloric requirement considering the HB, MsJ and ESPEN formula was 66%, 66.7% and 62.5%, respectively. Two clinical centres managed to provide 70% or more of daily caloric requirements. According to the ESPEN formula, the implementation of the protein target was 70%; however, one of the investigated units provided a median of 157% of the protein demand. The nutritional management varied in the preferred route of nutrition administration. Neither method nor grade of nutrition supply influenced biochemical parameters on the 8th day of ICU stay.Conclusions: Significant differences in nutritional treatment of critically ill COVID-19 patients in Polish ICUs were noted, which underlines the importance of setting up clear guidelines regarding this issue.

Opioids have long been central to perioperative analgesia, but their well-recognised adverse effects, including postoperative nausea and vomiting, respiratory depression, ileus, and the risk of persistent postoperative use, have increased interest in strategies that reduce perioperative opioid exposure. This narrative review examines two such strategies, opioid-sparing anaesthesia and opioid-free anaesthesia (OFA), and presents them as related points along a continuum of opioid minimisation rather than as opposing approaches. We define each strategy, outline the rationale for opioid reduction, including opioid-induced hyperalgesia, and review the multimodal and regional anaesthesia techniques that support both. Current evidence from mixed surgical populations and procedure-specific analyses, including cardiac, thoracic, orthopaedic, bariatric, and breast surgery, suggests that the most consistent benefit of opioid minimisation is improved tolerability, particularly reduced postoperative nausea and vomiting, rather than a major reduction in postoperative pain intensity. OFA may also shift the adverse-effect profile towards haemodynamic events such as bradycardia and hypotension. We also discuss the practical challenges of implementation, including training requirements, monitoring issues, and the important but often overlooked distinction between opioid-free anaesthesia and opioid-free analgesia. Finally, we consider the main limitations of the current literature, especially inconsistent definitions, a focus on short-term outcomes and the near-exclusive enrolment of opioid-naive patients. We conclude that clinically meaningful outcomes depend more on the quality of the perioperative pathway than on whether intraoperative opioids are reduced or completely avoided.