BACKGROUND: After cardiac surgery, patients are liberated from mechanical ventilation despite diaphragm dysfunction and atelectasis; understanding their breathing pattern can help interpreting conditions with diaphragm d...BACKGROUND: After cardiac surgery, patients are liberated from mechanical ventilation despite diaphragm dysfunction and atelectasis; understanding their breathing pattern can help interpreting conditions with diaphragm dysfunction and defining a tolerable range of effort under mechanical ventilation. METHODS: Prospective physiological study describing the magnitude and pattern of breathing effort after cardiac surgery. Three spontaneous breathing trial modalities performed in random order, including two un-assisted (continuous positive airway pressure 0 cmH2O -CPAP0- and T-piece) and one assisted (pressure-support 5/PEEP 5 cmH2O- PS5PEEP5). Airway, esophageal, and gastric pressures were recorded and diaphragm ultrasound was performed. Airway occlusion pressure (P0.1) was also measured. Difference in magnitude of respiratory effort between conditions was explored through linear mixed-models with Tukey adjustment for pairwise comparisons. Association between pre-defined clinical variables (opioid dose, body mass index, and chest wall compliance) as well as measures of diaphragm function with expiratory muscle activity was explored through mixed-effects models. RESULTS: Thirty patients were included. Maximum inspiratory pressure during a Mueller maneuver was − 29.8 ± -12.6 cmH2O. Estimated mean (CI95%) global inspiratory effort (pressure-time product per minute) during un-assisted modalities for the population was 138.5 (120.6,156.3) cmH2O•sec/min. With increasing support, drive decreased as well as pressure-time product per minute (median PS5PEEP5: 101, CPAP0 129, T-piece 135 cmH2O•sec/min, p < 0.001 for PS5PEEP5 vs. other modalities), and transdiaphragmatic pressure (PS5PEEP5 median 4.1, CPAP0 median 6.6, T-piece median 6.0 cmH2O respectively, p < 0.001 for PS5PEEP5 vs. other modalities). During mechanical ventilation, expiratory muscle effort (i.e., gastric pressure rise) contributed on average to 31–37% of the drop in esophageal pressure during inspiration, being lower after extubation. Gastric pressure rise was directly associated with a higher intraoperative dose of opioids (p = 0.004) and inversely with measures of respiratory muscle function (p = 0.001). Tension-time indices lied within the higher end of a non-fatiguing range. All patients were successfully extubated. CONCLUSIONS: Stable patients after cardiac surgery show an increase in respiratory drive and inspiratory effort with increasing load despite signs consistent with diaphragm dysfunction. Expiratory muscle use is common, it is associated with decreased diaphragm activity, higher intraoperative dose of opioids and decreases after extubation.
In patients with auto- or intrinsic positive end-expiratory pressure (PEEPi), a portion of the inspiratory effort is spent to overcome PEEPi before lung inflation begins. End-expiratory whole-breath airway occlusion pres...In patients with auto- or intrinsic positive end-expiratory pressure (PEEPi), a portion of the inspiratory effort is spent to overcome PEEPi before lung inflation begins. End-expiratory whole-breath airway occlusion pressure (ΔPocc) is a useful tool to estimate inspiratory muscle pressure (ΔPmus) but it may not capture this component. We retrospectively analyzed data from patients with various degrees of PEEPi enrolled in a study who underwent PEEP titration during pressure support ventilation (PSV) with esophageal pressure (Pes). Inspiratory effort was partitioned into the effort generated before inflation and the effort required for ventilator triggering and inflation. ΔPmus, Pes swing (ΔPes) and dynamic transpulmonary pressure (ΔPL, dyn) were both measured and predicted from ΔPocc using established conversion factors. Linear mixed-effects models were used to evaluate the effect of PEEPi on estimation accuracy. The results showed that (1) PEEPi values ranged from mean (± SD) of 4.7 (± 5.0) to 1.2 (± 0.7) cmH2O from PEEP 2 to 14 cmH2O; (2) ΔPocc does not represent the total inspiratory effort when PEEPi or relaxation of active expiration is present, and is limited to the triggering and inflation components; (3) when the airway pressure following ΔPocc exhibits a visible stable plateau, PEEPi may be estimated under selected waveform conditions on the ventilator screen; (4) Baydur’s maneuver for esophageal balloon calibration might be biased in case of PEEPi or active expiration; (5) the predicted estimate of ΔPL, dyn appears acceptable at group level but can lack precision. Conclusion: this proof-of-concept study shows that ΔPocc may underestimate inspiratory effort in case of PEEPi. When a plateau airway pressure can be observed in the end of ΔPocc, it seems possible to estimate PEEPi noninvasively.
Observational studies link high net ultrafiltration (UF) rates during continuous kidney replacement therapy (CKRT) to increased mortality. The Restrictive versus Liberal Rate of Extracorporeal Volume Evaluation in Acute...Observational studies link high net ultrafiltration (UF) rates during continuous kidney replacement therapy (CKRT) to increased mortality. The Restrictive versus Liberal Rate of Extracorporeal Volume Evaluation in Acute Kidney Injury trial evaluated the feasibility of a restrictive versus liberal UF rate strategy. This stepped-wedge cluster-randomized trial enrolled patients in ten ICUs across two healthcare systems from July 2022 to June 2024. Each ICU was a cluster, with 1 randomly transitioning from liberal (2.0-5.0 mL/kg/h) to restrictive (0.5-1.5 mL/kg/h) group every two months after the first six months. The coprimary outcomes included between-group separation in UF rates, protocol adherence, and recruitment rate. Of 97 patients (55 liberal, 42 restrictive) enrolled, the mean (SD) delivered UF rate did not differ between the groups (2.05 [0.83] vs. 1.81 [0.86] mL/kg/h; adjusted P = 0.4). In per-protocol analysis, there was a significant between-group separation in mean UF rates (2.24 [0.72] vs. 1.22 [0.32] mL/kg/h; P = 0.002). Protocol deviations were similar (9.1% vs.7.1%, P = 0.7), and the recruitment rate was 0.99 (0.27) patients per ICU per two months. The use of rescue UF was higher in the restrictive group (14.5% vs. 66.7%; P < 0.001). In conclusion, despite high protocol adherence, there was minimal separation in delivered UF rates. While both strategies were feasible in select patients, the high rates of hemodynamic instability, the need for rescue UF and physician override orders suggest that UF is more often driven by dynamic patient physiology than fixed protocols. This makes it challenging to maintain distinct, alternative UF targets in clinical practice.Trial registration number: ClinicalTrials.gov Identifier: NCT05306964.
Mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO), left ventricular assist devices (LVADs), and intra-aortic balloon pumps (IABP), are increasingly used in patients with s...Mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO), left ventricular assist devices (LVADs), and intra-aortic balloon pumps (IABP), are increasingly used in patients with severe cardiac or cardiorespiratory failure. Despite major technical advances, vascular complications related to cannulation, device support, and decannulation remain frequent. Duplex ultrasound (DUS) is the primary vascular imaging modality because it is fast, can be performed at the patient’s bedside, is repeatable, and provides functional data via Doppler imaging. However, this is a specialized examination requiring expertise, as the flows are significantly altered by MCS, and the ultrasound findings are specific. This review summarizes current applications of DUS in patients supported with extracardiac MCS devices, organized into three key phases: pre-implant assessment, monitoring during mechanical support, and post-decannulation surveillance. Pre-implant DUS allows detailed evaluation of arterial and venous anatomy, vessel diameter, patency, and wall morphology, guiding cannulation strategy and cannula selection while facilitating ultrasound-guided percutaneous access. During MCS support, DUS plays a critical role in assessing limb perfusion, cannula positioning, and diagnosing vascular complications, particularly in patients unable to report ischemic symptoms. After decannulation, systematic ultrasound surveillance enables early detection of access-related complications, including thrombosis, pseudoaneurysm, arteriovenous fistula, arterial dissection, and acute limb ischemia. The objective is to guide the ultrasound practitioner in performing and interpreting DUS at each stage of the assessment of critically ill patients with an MCS device.
Theobald V, Gregorius J, Berger MM
… +12 more, Decker SO, Feißt M, Herbstreit F, Nusshag C, Skarabis A, Schmidt KD, Schmitt FCF, Schmoch T, Dietrich M, Brenner T, Weigand MA, German Society of Anaesthesiology and Intensive Care (GSAIC) Trials Group
BACKGROUND: Triggering receptor expressed on myeloid cells-1 (TREM-1) is one of the more recently described biomarkers for sepsis and currently of great interest, as an inhibitor called nangibotide (Inotrem, Paris, Franc...BACKGROUND: Triggering receptor expressed on myeloid cells-1 (TREM-1) is one of the more recently described biomarkers for sepsis and currently of great interest, as an inhibitor called nangibotide (Inotrem, Paris, France) for TREM-1 has made it into a phase 3 study for the treatment of sepsis. TREM-1, as a pattern recognition receptor (PRRs), plays a crucial role in the immune defense of the host. Several studies revealed promising results for soluble TREM-1 (sTREM-1) as a biomarker for outcome prediction. However, its usefulness in different subgroups of sepsis and the cut-off threshold at which patients are exposed to a higher risk of mortality have not yet been sufficiently investigated. METHODS: This study is a secondary analysis of data and sTREM-1 measurements from plasma samples obtained in the prospective, observational, non-interventional, multicentric Next GeneSiS-Trial (DRKS00011911). We aimed to characterize the role of sTREM-1 in septic and septic shock patients in a large cohort with regard to different pre-existing factors, infectious aspects and outcome parameters. Furthermore, we investigated the influence of sTREM-1 cut-offs previously described from Francois et al. on different outcome parameters. Therefore, data from 500 patients were analyzed. RESULTS: Median sTREM-1 values were statistically significant higher in patients with septic shock than in septic patients (406 (IQR;270–650) pg/mL vs. 293 (IQR;189–489) pg/mL; p < 0.001). Non-survivors, patients with the need of renal replacement therapy, mechanical ventilation or a positive Sepsis-Induced-Coagulopathy (SIC) score presented with statistically significant higher sTREM-1 values (p < 0.001). sTREM-1 levels were significantly higher in patients in the highest quartile for fluid balance and Sequential Organ Failure Assessment score, and significantly lower in those in the highest quartile for Horowitz Index and platelet count (PSSC). sTREM-1 levels showed slight but statistically significant differences based on the site of infection or blood culture results on day one; however, these differences were no longer detectable by day three. The best cut-off of sTREM-1 values to differentiate between survival and non-survival on day 28 was 408 (CI;297–505) pg/ml in our study. CONCLUSION: Elevated sTREM-1 concentrations particularly occur in patients with a high degree of organ damage, who are at high risk for adverse outcomes. In addition, the primary site of infection may be of relevance for the sTREM-1 increase. These characteristics support its suitability as a biomarker across different causes of sepsis and highlights its potential as a therapeutic target. A cut-off value exceeding 400 pg/mL has shown robust diagnostic performance across multiple studies. Our results support this observation, indicating that this threshold may be useful for future clinical and research applications.
BACKGROUND: Considering the significant heterogeneity of traumatic brain injury (TBI), uniform treatment thresholds applied to all patients may be overly simplistic. Cerebral autoregulation (CA) capacity may vary signifi...BACKGROUND: Considering the significant heterogeneity of traumatic brain injury (TBI), uniform treatment thresholds applied to all patients may be overly simplistic. Cerebral autoregulation (CA) capacity may vary significantly between TBI patients and may change dynamically over time. Within a precision neurointensive care framework, this study aimed to evaluated the associations between cerebral perfusion pressure (CPP) or intracranial pressure (ICP) and the pressure reactivity index (PRx) in patients with different types of TBI, and to investigated whether PRx modified the associations between ICP and CPP and functional outcome. METHODS: A prospective observational study was performed. Eligible patients had acute TBI with ICP, and arterial blood pressure monitoring and available 6-month outcome data assessed using the Glasgow Outcome Scale–Extended (GOSE). During the first 7 days postinjury, we calculated the proportion of good monitoring time (%GMT) spent predefined thresholds. The %GMT within predefined cerebral physiological intervals of PRx in combination with ICP or CPP, in relation to outcome, was analyzed using two-variable heatmaps. The associations between PRx and ICP or CPP were further evaluated using generalized additive models (GAMs) with cubic splines. RESULTS: In total, 187 patients requiring invasive neuromonitoring after TBI were included. PRx exhibited a U-shaped relationship with CPP, with the optimal PRx observed at a CPP of 70–80 mmHg. In the PRx–ICP heatmap, the combination of elevated PRx and high ICP was significantly associated with worse outcomes. In the PRx–CPP heatmap, outcomes worsened when CPP decreased and PRx deviated from 0. Lower CPP appeared better tolerated in patients with preserved autoregulation, as indicated by lower PRx values. Patients without decompressive craniectomy (DC), with diffuse injury or younger age demonstrated better tolerance to lower CPP when autoregulatory function was preserved compared to patients with DC, focal injury or older age. When all physiological variables were incorporated into a single multivariable model, only composite variable 2 remained independently associated with favorable outcome (odds ratio [OR] 1.026, 95% confidence interval [CI] 1.006–1.046, P = 0.012). CONCLUSIONS: This study provides novel insights into cerebral physiology across various TBI subtypes by delineating safe and hazardous thresholds for ICP, PRx, and CPP. The acceptable lower limit of CPP appears to be directly proportional to the PRx. Consequently, patients with severe impairment of CA may require higher CPP targets to achieve favorable outcomes. These findings emphasize the importance of individualizing target CPP based on PRx dynamics rather than relying on universally applied empirical thresholds.
BACKGROUND: Sepsis remains a major global health burden, yet the economic value of reducing avoidable sepsis-related mortality is not well established. This study aimed to evaluate global trends in adult sepsis-related m...BACKGROUND: Sepsis remains a major global health burden, yet the economic value of reducing avoidable sepsis-related mortality is not well established. This study aimed to evaluate global trends in adult sepsis-related mortality and estimate the economic values of reducing avoidable deaths from sepsis between 2000 and 2023, with projections to 2050. METHODS: Sepsis-related mortality data for adults aged ≥ 20 years were obtained from 79 countries included in the World Health Organization (WHO) Mortality Database for the period 2000–2023. Bayesian neural network age–period–cohort projections of mortality through 2050, with locally weighted scatterplot smoothing incorporated to stabilize temporal continuity. Avoidable mortality was defined as mortality rates exceeding the 20th percentile derived from a frontier model. The economic value of reducing avoidable mortality to frontier levels was estimated using the value of a statistical life, expressed as a proportion of annual income in 2021 international dollars (Int$). All analyses were stratified by age, sex, and five World Bank–based region, and results are presented with 95% confidence intervals (CIs). RESULTS: Global age-standardized mortality rate from sepsis increased from 9.15 deaths per 100,000 population in 2000 to 12.77 (95% CI, 8.67–17.72) in 2023 and is projected to reach 20.32 (14.61–27.55) in 2050. In 2023, approximately 61.34% of all sepsis-related mortality were considered avoidable, with adults aged ≥ 70 years contributing disproportionately to mortality and, consequently, to the overall economic estimates, reflecting the distribution of mortality rather than any differential valuation of life by age. The global economic value of reducing avoidable deaths was estimated at Int$ 62.6 billion in 2023 (1.41% of annual income). Males had a slightly higher proportion of annual income represented by the estimated economic value (1.48%) than females (1.35%), reflecting differences in income levels and mortality patterns rather than sex-specific preferences. Regional disparities were substantial, highest in North America (1.80%) and lowest in Europe and Central Asia (1.00%). CONCLUSIONS: Although sepsis-related mortality has increased, most deaths remain avoidable, suggesting substantial scope for improvement. Further reductions in mortality could yield considerable and growing economic benefits, particularly through interventions targeting older adults and high-burden regions.
Although diaphragm dysfunction is increasingly recognized as a major contributor to morbidity and mortality in the intensive care unit, the physiological mechanisms leading to its development in mechanically ventilated p...Although diaphragm dysfunction is increasingly recognized as a major contributor to morbidity and mortality in the intensive care unit, the physiological mechanisms leading to its development in mechanically ventilated patients are incompletely understood. Mechanical ventilation is often recognized as the main cause of the problem, delineating a paradigm known as ventilator-induced diaphragm dysfunction (VIDD). Yet, evidence on this causal relationship in ventilated critically ill patients is scarce, with direct experimental data mostly coming from animal models or brain-dead organ donors. In this narrative review, we provide a critical appraisal on the contribution of mechanical ventilation to diaphragm dysfunction and an integration with other major mechanisms involved in its development and trajectory over time. Examining this complex interplay is important, as it may support clinicians in adhering to expert consensus on diaphragm protective mechanical ventilation. First, the evidence for mechanisms potentially caused by mechanical ventilation, such as disuse atrophy, under- and over-assistance, PEEP and asynchronies is analyzed. Secondly, important contributors not directly explained by ventilator support, such as inflammation and sepsis, muscle hibernation and impaired calcium sensitivity of force are addressed. Finally, a summary of this complex scenario is provided together with clinical and research-oriented key messages, highlighting the reasons for which the term critical illness-associated diaphragm dysfunction may be more appropriate.
BACKGROUND: An increasing proportion of critically ill patients receive prolonged, high-acuity care in the emergency department (ED) before admission to the intensive care unit. Despite its clinical relevance, this early...BACKGROUND: An increasing proportion of critically ill patients receive prolonged, high-acuity care in the emergency department (ED) before admission to the intensive care unit. Despite its clinical relevance, this early phase of care remains poorly characterized and difficult to capture using existing metrics. MAIN BODY: This Perspective argues that this early phase of critical illness represents a distinct but underrecognized component of the critical care continuum, commonly referred to as emergency critical care (ECC). Rather than being defined by location or specialty, ECC is characterized by time-critical decision-making, dynamic trajectory, and evolving care demands. A major challenge in studying this phase is its limited measurability within current frameworks. We therefore propose a pragmatic conceptualization of ECC based on three complementary dimensions: disease severity, clinical care intensity, and therapeutic organ support. Together, these dimensions describe key aspects of early critical illness and provide a pragmatic basis for translating ECC dimensions into observable clinical and administrative variables suitable for research, governance, and system evaluation without imposing rigid definitions or thresholds. CONCLUSION: Conceptualizing ECC along clinically meaningful and observable dimensions offers a practical way to improve its visibility in research and system evaluation. Recognizing ECC as a spectrum of critical care delivery rather than a binary state may provide a pragmatic basis for describing and studying early critical illness.
Stephens AF, Šeman M, Hackwill R
… +9 more, Diehl A, Pilcher D, Barbaro RP, Brodie D, Pellegrino V, Kaye DM, Gregory SD, Hodgson CL, Extracorporeal Life Support Organization Member Centres
BACKGROUND: Prognostication for venovenous extracorporeal membrane oxygenation (ECMO) outcomes is crucial for risk-adjusting centre performance. This study aimed to leverage a large, multicentre, international database t...BACKGROUND: Prognostication for venovenous extracorporeal membrane oxygenation (ECMO) outcomes is crucial for risk-adjusting centre performance. This study aimed to leverage a large, multicentre, international database to develop and evaluate AI-driven models for predicting survival to hospital discharge of adult patients receiving venovenous ECMO. The model was called ECMO PAL VV (ECMO – Predictive Algorithm for VV). METHODS: Training and temporal validation data were sourced from the Extracorporeal Life Support Organization Registry (ELSO), 39,501 patients across 660 hospitals. Deep neural networks were trained on all adult patients receiving VV ECMO between 2017 and 2023 (N = 35,182) to predict survival to hospital discharge. Temporal validation was performed on registry data cases from 2024 (N = 4,318). Model predictions were compared against published venovenous ECMO outcomes scores using the validation cohort. RESULTS: Internal training yielded an accuracy of 79% and an area under the receiver operating characteristic curve (AUC) of 0.87. Temporal validation revealed a drop in accuracy to 73% with an AUC of 0.78, primarily due to a reduction in sensitivity to mortality prediction (71% to 57%). ECMO PAL VV outperformed published venovenous ECMO scores, which had accuracies of 65% (RESP) and 60% (Lazzeri score) for predictions on the validation data. CONCLUSIONS: ECMO PAL VV demonstrated strong accuracy on contemporary international registry data (73%) with strong sensitivity (81%) and precision (77%) to predict survival to hospital discharge, outperforming existing published scores. ECMO PAL VV has the potential to improve risk adjustment and enable data-driven healthcare.
This narrative review serves as an update to previous reviews on the topic after the results of recent randomized controlled trials and meta-analyses. It describes some of the latest evidence around the use of volatile s...This narrative review serves as an update to previous reviews on the topic after the results of recent randomized controlled trials and meta-analyses. It describes some of the latest evidence around the use of volatile sedation as an alternative to intravenous sedation in mechanically ventilated patients in the intensive care unit (ICU) and their possible lung-protective properties. Preclinical evidence supporting an anti-inflammatory protective effect of volatile anesthetics suggests that volatile sedation could be employed in patients with inflammatory lung injury, including acute respiratory distress syndrome (ARDS). Large randomized controlled non-inferiority trials of isoflurane for general ICU sedation have suggested that it is effective, with no differences between groups in safety outcomes; however, the results of a recent RCT in patients with ARDS have demonstrated significant harm with the use of sevoflurane sedation. Therefore, the utility and safety of volatile sedation in patients with inflammatory lung injury, including ARDS, is now in question.
Electroencephalography (EEG) is a powerful tool that can provide unique and real time insight into cerebral functioning in the context of acute brain injury in the intensive care unit (ICU), ranging from focal deficits t...Electroencephalography (EEG) is a powerful tool that can provide unique and real time insight into cerebral functioning in the context of acute brain injury in the intensive care unit (ICU), ranging from focal deficits to seizures and coma. Despite being a safe, relatively inexpensive, non-invasive and meaningful tool, EEG has not yet transitioned into a true bedside monitoring system in the ICU, as continuous EEG monitoring cannot realistically be provided to all ICU patients, and EEG implementation and interpretation remains heavily dependent on specialized personnel. In order to integrate EEG into routine ICU monitoring, two conditions must be fulfilled: first, the EEG montage should be adjusted to answer the specific clinical question; second, the presentation of EEG-derived information must be stratified and adapted to the healthcare professional interpreting it, from the inexperienced nurses and junior physicians to the experienced neurophysiologist. Integrating the EEG into the multimodal monitoring of critically ill patients would allow earlier detection of reversible brain insults, it would promote brain monitoring across different levels of expertise, and it could potentially expand EEG use with rapid data acquisition that could facilitate early identification and treatment of acute brain events, even outside the ICU.
BACKGROUND: The prompt identification of clinical deterioration in emergency department (ED) patients presenting with infection is crucial yet challenging. Microvascular dysfunction has been linked to poor clinical outco...BACKGROUND: The prompt identification of clinical deterioration in emergency department (ED) patients presenting with infection is crucial yet challenging. Microvascular dysfunction has been linked to poor clinical outcome in critically ill patients, but it remains unclear whether its detection can predict clinical deterioration in early sepsis. This study aims to evaluate the utility of quantitative microvascular videomicroscopy for predicting clinical deterioration in patients with suspected sepsis. METHODS: In this prospective observational study, 299 ED patients with suspected infection or sepsis were enrolled, with the addition of 50 healthy volunteers, 14 non-infected ED patients and 34 intensive care unit (ICU) patients with sepsis as controls. All participants underwent sublingual sidestream darkfield videomicroscopy. The GlycoCheck™ software quantified vascular density, perfused boundary region (PBR; inverse marker of endothelial glycocalyx (eGC) thickness), and the Microvascular Health Score (MVHS™), which integrated capillary density and eGC dimensions. The primary outcome was disease progression within the first week, defined as progression from infection to sepsis or increase in SOFA score in septic patients. Secondary outcomes included in-hospital and 90-day mortality, ICU admission, or a composite outcome of progression or in-hospital death. RESULTS: Sublingual videomicroscopy revealed significant differences in all microvascular variables between ED patients, healthy volunteers and control groups, correlating with disease severity. ED patients with disease progression showed lower capillary density, higher PBR, and lower MVHS at baseline than non-progressors. In patients presenting with infection without sepsis, MVHS demonstrated strong predictive discrimination for progression (AUC 0.79, p < 0.0001), outperforming procalcitonin and interleukin-6. An intact microvascular phenotype (high capillary density and low PBR) markedly reduced the risk of disease progression or in-hospital mortality (OR 0.17, p < 0.001), whereas combined glycocalyx damage and reduced capillary density significantly increased risk (OR 2.39, p = 0.01). CONCLUSION: Quantitative sublingual videomicroscopy predicts early disease progression within the first week and stratifies patients with suspected sepsis into high and low-risk groups at ED presentation. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT03126032, Registration Date 20.02.2017.