Goal: to review new definitions and criteria of sepsis and septic shock by Society Critical Care Medicine (SCCM) and European Society Intensive Care Medicine (ESICM) in the light of evolving understanding of interaction between the contagium and the host, appearance of potential problems and possible clinical benefits for the practice. Results. Upon results of the review the conclusion has been made that the sepsis is to be considered not only as progressing system inflammation but given the diversity of the response – as life threatening regulation disorder of the host reaction (disregulation) to the infection with acute multi-organ dysfunction reflecting the tissue damage of the host. SOFA score is to be used as a diagnostic tool. The introduction of the new concept into routine practice is limited since it can be difficult to define the contribution of the infection into already existing dysfunction due to the presence of some chronic disorder, since doctors do not adhere to using scales of multi-organic failure severity and it is impossible to test blood lactate in numerous medical units. Introduction of new criteria into practice can be beneficial for the justification of the care provision in hospital due to the risk of the unfavorable outcome and with the purpose of targeted monitoring. Quick SOFA is to be used to detect patients with the suspicion of sepsis and developing life threatening conditions beyond premises the intensive care departments.

 

Goal of the study: working out procedure aimed at the diagnostics of painless myocardial ischemia in the patients expecting surgery on aorta and main arteries of lower limbs. Materials and methods. 72 patients with disorders of aorta and main arteries of lower limbs were enrolled into the study. Depending on factors of risk to develop cardiac vascular disorders as per Lee score they were divided into two groups. Group 1 (n = 38) included patients who had 2 and more risk factors in the pre-operative period, Group 2 included patients (n = 34) who had less than 2 risk factors. All of the patients had holter monitoring, stress echocardiography and coronary arteriography during pre-operative period. Results. The study showed the high efficiency of Lee score of cardiac-vascular complication risks. The patients who had 2 risk factors and more had hemodynamically significant lesions of coronary bed in 97.4% which was detected by coronary arteriography. In Group 2 painless myocardial ischemia was detected almost in 1/3 of patients, which later provided certain impact in the choice of surgical treatment strategy. Conclusions. The results proved low efficiency of holter monitoring in the patients suffering from multi-focal atherosclerosis and high efficiency of stress echocardiography. The latter should be mandatory included into the examination procedure of such patients regardless of the results of Lee score; and coronary arteriography is to be performed in case of 2 risk scores and more. Detection of painless myocardial ischemia can change the plan of surgical treatment and requires amending anesthesia tactics.

 

Goal of the study: to detect the correlation between lactate and pyruvate levels and their ratio (LPR) during ischemia/reperfusion with the post-operative increase of troponin I as a marker of myocardial lesion. Materials and methods. The study was performed among the patients undergoing myocardial revasculization surgery with the use of cardiopulmonary bypass in order to evaluate the prognostic opportunities to predict development of post-perfusional cardiac failure. 56 patients with coronary disease who underwent surgery with cardiopulmonary bypass were examined. The samples of blood for lactate and pyruvate tests were collected from the catheter of heart coronary sinus before aortic compression, before release of the clamps and in 30 minutes after reperfusion. During the surgery the following rates of hemodynamic profile were registered (cardiac index, systolic output index, medium arterial tension, index of peripheral resistance and pulmonary vessels resistance, index of systolic output of the left and right ventricles, pulmonary capillary wedge pressure), oxygen transportation, consumption and extraction co-efficient, arteriovenous oxygen difference. In the early post-operative period the following rates were evaluated: need in inotropic support, duration of artificial pulmonary ventilation and stay in the intensive care department. The level of troponin I was tested in 12 and 24 hours. Correlations were evaluated for the whole group in general, and in certain subgroups the patients were divided into basing on LPR value before aortic compression. Group 1 (LLPR) included 24 patients with LPR lower than the medium level of the cohort (M 17.6), Group 2 (HLPR) included 29 patients with LPR above the medium level. No significant differences were found between the groups. Results. The obtained results confirmed the certain dependence between the lactate level and increase of plasmic troponin I. However it was shown that the strong correlation between them could manifest only if the initial levels per-perfusional lactate level and lactate-pyruvate ratio had been high. The pre-perfusional lactate level did not allow predicting the development of post-perfusional cardiac failure. High values of lactate-pyruvate ratio prior to the start of cardiopulmonary bypass reflected the probability of this complication. This fact allows treating patients with high LPR as a group undergoing the advanced risk of the unfavorable course of the post-operative period. The increase of lactate in blood collected from coronary sinus of such patients during anoxia is to be regarded as an argument for adequate increase of myocardium protection. Conclusion: In order to evaluate the risk of post-reperfusional cardiac failure the routine testing of the lactate level in coronary sinus is to be supplemented by testing of the pyruvate level.

 

The study was conducted with the purpose to optimize the management activities during first hours after burn injury. The prospective, open, randomized, comparative study included 50 children with severe burns demonstrated the safe reduction of fluid volume combined with the early enteral load. It was shown that early use of albumin in children with burns exceeding 20% of total body surface area allowed decreasing the need in crystalloid solutions when compiling infusion therapy regimen. That regimen allowed avoiding fluid overloading and development of the edema syndrome.

 

Goal of the study: to define the most optimal technique for blood loss reduction during reconstructive surgeries in maxillofacilal area. Materials and methods. The study included 100 patients, the patients were randomly divided into 5 groups, and after the randomization the cohort included 80 patients. Group 1 (control) (n = 12) – acute normal and hypervolemic hemodilution (ANH and AHH), infusion volume made 8-10 ml/kg x h^-1. Group 2 (n = 17) – reduction of infusion volume down to 4-6 ml/kg x h^-1 in combination with prescription of aprotinin. Group 3 (n = 17) – reduction of infusion volume down to 6-8 ml/kg x h^-1 in combination with prescription of tranexamic acid (TA). Group 4 (n = 19) – reduction of infusion volume down to 6-8 ml/kg x h-1, TA in combination with regional blocks in order to provide sympatholysis. Group 5 (n = 15) – reduction of infusion volume down to 6-8 ml/kg x h^-1, TA in combination with system sympatholysis. Colorimetry was used to evaluate blood loss. Results. All groups included into the study compared to the control group manifested reduction of blood loss and as a result reduction in the need for blood preparations transfusion. The most effective blood saving approach was the combination of the infusion volume reduction with the use of TA. The use of local and system sympatholysis did not result in the additional reduction of the blood volume. Use of ANH and AHH could result in the development of massive blood loss.

 

The acute severe blood loss is one of the leading causes of mortality of the wound disease in its first period, i.e. wound shock. The potential negative impact of blood transfusions on the course of wound disease in the wounded with acute severe blood loss is not significantly expressed. In the wounded with acute massive blood loss at the extremely severe degree the development of life threatening conditions related also to blood transfusion is mostly defined by the tactics of blood transfusion therapy in the post shock period of wound disease.

 

The article analyzes the specific features of the training specialists in the technique of percutaneous dilatation tracheostomy (PDT) in the intensive care department. This training is divided into three stages (theory, practical demonstration, direct performance of this manipulation by the staff personnel under supervision of experienced doctors). Total number of procedures required for staff doctors to master PDT made 20 and it was accompanied by certain features which however did not cause any significant intra-operative and early post-operative complications. This is the evidence of the successful three stage training at the place of work.

 

Ischemia, reperfusion, oxidative stress, system inflammatory response – all these events are the cause or important link in the pathogenesis of numerous serious complications of cardiac surgeries. The damaging action of each of the above has been numerously proved by experiments and clinical practice and it seems that these events can be considered to be only very negative ones. However controlled ischemia initiates development of the phenomenon so-called as ischemic pre-conditioning, when the targeted organ develops enhanced resistance to the consequent damaging ischemia. Reperfusion is an inevitable and necessary stage of rehabilitation after previous ischemia. What about oxidative stress? Damaging potential of the active forms of oxygen is a fact, however minimal concentrations of the active oxygen forms are intercellular regulators and it means they are absolutely necessary for normal cellular vital activity. Besides numerous studies have proved noticeable intensification of the oxidative stress during artificial circulation (AC), however stuides failed to demonstrate reduction in the number of complications and peri-operative mortality when performing coronary artery bypass on the beating heart compared to the surgeries performed under AC. What is the true contribution of the oxidative stress into the development of post-operative complications? There have been found no evidences of the clinical efficiency of any of existing antioxidants as per mortality reduction criteria or decrease of hospital stay duration. Unfortunately we do not have unambiguous answers to the set up questions. There is no doubt only about the fact that critical actuality dictates the urgent need for further studying of the oxidative stress role in the pathogenesis of ischemic and reprefusional lesions in cardiac surgery.

 

Nutritive support is the equally important component of the intensive care and it is impossible without the adequate evaluation of resting energy expenditures (REE) of a specific patient. This article describes the most common evaluation techniques of REE, among which the technique of the indirect calorimetry is the most informative. The review included calculation equations for REE evaluations studied the most. The most sensitive equation which informativeness is confirmed by prospective studies is Penn State formula, and the Harris-Benedict equation is not suitable for the use in the intensive care department. It is worth highlighting that the use of equations is acceptable only when the indirect calorimetry technique is not available.

 

The article describes the clinical case of reperfusional syndrome after caesarean section in the new mother with giant liver tumor which manifested through development of multi-organ dysfunction with hemodynamic disorders, acute respiratory distress syndrome, and acute liver lesion. This clinical case confirms the hypothesis that reperfusion syndrome can complicate the course of pregnancy and post-delivery period and shows that the issue of intra-abdominal hypertension in the pregnant requires further investigation.

 

Pulmonary embolism in pregnant women is fairly common complication, and it remains to be the one of major causes of maternal mortality in the number of countries. The need to compare risks of the mother and child makes the search for optimal treatment tactics very complicated in this specific case. The experience of the last decades provides evidences for choosing aggressive treatment tactics, accurate diagnostics and early surgical intervention. The authors of this article describe the clinical case of successful treatment of the young woman whose pregnancy course was complicated by pulmonary embolism at the 11th week of gestation. The article describes the results of laboratory and instrumental diagnostics and anasthesiological support technique within available scope of pharmacological and technical means. Also the article reviews the literature data on this problem. The conclusion contains recommendations for intra-operative management of such patients.