Goal of the study: to evaluate the accuracy of invasive measurement of cardiac output (CO) by pulse wave transit time (PWTT) (esCCO, Japan) compared to transpulmonary thermodilution (TPTD) (PiCCO₂ , Germany) after aortocoronary bypass (ACB) without cardiopulmonary bypass (ACB without CPB). Methods. 21 patients with ACB without CPB were enrolled into the study. During early post-operative period CO was simultaneously registered at eight stages basing on PWTT (CO_PWTT) and TPTD (CO_TPTD). Statistic analysis included evaluation of congruence of CO absolute values and capability to follow-up changes in CO. Results. In accordance with Bland-Altman analysis the average difference between two methods made 0.3 l/min. with consistency limits of ± 2.1 l/min. and percent error of 40%. Polar chart analysis showed the angular difference of 2.6°, radial consistency limits ± 53.3° and polar concordance of 69%. Conclusion: Lower repeatability of CO measurement by PWTT and insufficient capability to follow the changes in CO after ACB without CPB don not allow recommending this method in its invasive variant for routine practice as an alternative to thermodilution methods.

 

Goal of the study: to compare the impact pf sevoflurane and desflurane on metabolism in myocardium when performing aortocoronary bypass with cardiopulmonary bypass. Materials and methods: 56 patients suffering from coronary disease and undergoing myocardial revasculization with cardiopulmonary bypass were divided into two groups as per the type of used anesthetic: the group where desflurane was used (DG, n=28) and the group where sevoflurane was used (SG, n=28). Groups were divided into subgroups basing on lactate/pyruvate ratio (LPR) before aortic compression. The following rates of hemodynamic profile were registered (cardiac index, systolic output index, 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. During the first 24 hours of post-perfusion period the following rates were evaluated: frequency of post-perfusion cardiac failure development, 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. During cardiopulmonary bypass the blood samples were collected from coronary sinus before aortic compression, before release of clamps and in 30 minutes of reperfusion in order to evaluate the expression of anaerobic metabolism in myocardium as per the levels of lactate, pyruvate and LPR. Results: Analysis of hemodynamic profile and gas exchange rates showed no significant difference in the impact of these anesthetics on the investigated parameters in the pre- and post-perfusion periods. The frequency of development of post-perfusion cardiac failure, prompt management of its manifestations and changes in the markers of myocardial injury with the use of sevoflurane and desflurane were no significantly different. When sevoflurane was used during anoxia the patients with initially low LPR demonstrated the increase of LPR in coronary sinus due to the increase of lactate (р < 0.05). When desflurane was used, both lactate and pyruvate went up thus LPR remained on the initial level. After release of clamps from aorta LPR levels were compared when both anesthetics were used as well as the relevant levels of lactate and pyruvate. Conclusion: The investigated anesthetics have similar impact on hemodynamics and possess similar cardio-protective action. However they might have different ways of its implementation.

 

Goal of the study: to evaluate efficiency and safety of INTELLiVENT-ASV ventilation after aortocoronary bypass (ACB) on the beating heart. Methods: 40 patients after ACB on the beating heart were randomly divided into the groups of automated weaning (n = 20, INTELLiVENT®-ASV) and protocolized weaning from artificial pulmonary ventilation (APV) (n = 20, SIMV + PS). 102 additional patients were selected retrospectively and formed the group of the standard non-protocolized weaning (SIMV + PS). Duration of post-surgery ventilation, its safety and personnel workload were evaluated. Results. Cessation of respiratory support in the protocolized weaning group required correction of ventilation parameters 7 (5-9) times on the average in each patient, while in case of automated weaning manual correction of parameters was required only in 2 patients out of 20. Episodes of deviation from safe ventilation were more often observed in the protocolized weaning group, and the total duration of such episodes was also higher in this group. Groups of automated and protocolized weaning did not differ regarding the duration of APV and ventilation duration was confidently longer in the group of non-protocolized weaning. Conclusion: Use of automated weaning from APV in the post-operative period of ACB is safe, it reduces workload on personnel and does not increase the duration of APV.

 

Goal: to develop and evaluate the efficiency of the tactics for peri-operative nutritional-metabolic therapy as a component of Fast Track programme (FTP) in elderly patients suffering from colon cancer and having planned surgery. Methods. Treatment outcomes were analyzed for 400 elderly patients with colon cancer divided into two groups: main group (prospective n = 170), who were treated complying with optimized FTP and nutritional-metabolic therapy and control group (retrospective, n = 230), who were managed in the traditional way. Peri-operative nutritional-metabolic therapy in the main group included detection of those initially suffering from protein-calorie deficiency basing on changes in body mass loss and body weight index, and provision of integral nutritional support for them. During pre-operative preparation period lasting from 10 to 14 days they were prescribed with residue-free diet additionally to which, depending on the volume of food consumed by sipping, they received liquid nutritional mixture (Impact® Oral, Nestle) with high protein (7.6 g per 100 ml) and calories (1.4 kcal in ml) content. Post-operative nutritional support included early (from the 1st day after the surgery) enteral feeding with use of standard multisubstrate nutritional mixtures with protein content of 40g/l (Isosource® Standard, Nestle) in order to prevent paresis of gastro-intestinal tract combined with early activation of patients. Results. Patients in the main group confidently earlier restored the protein pool and immune status, nasogastric tube was removed faster, the duration of stay in the intensive care department and hospital after the surgery was less, the severity of complications as per Clavien – Dindo classification was lower, and life quality and late treatment outcomes were better. Conclusions. Use of the offered tactics of peri-operative nutritional-metabolic therapy as a component of FTP allowed speeding up rehabilitation and enhancing surgical and oncological outcomes in the burdened elderly patients having planned surgery due to colon cancer.

 

Goal: to develop the design of the experiment for evaluation of cognitive functions and behavior of rats after some aggressive impact imitating anesthesia and surgery in the clinical practice. Methods: Male rats of Wistar stock (n = 40) were used to evaluate long-term behavioral effects of the abdomen surgery and short-term (15-20 min.) and long-term (6 hours) actions of halothane. Simple (2x2) factorial plan was used for the experiment (4 blocks, balanced as per the number of animals from 4 experimental groups, n=2 for each group in the block). For anesthesia induction 4 volumes of % halothane in the air flow (2 l/min) were used, for anesthetic support it was 1.5 volume of % halothane. During surgery the rat was placed on the heated operating table and the mask was used for anesthesia. Laparotomy was performed; empty intestine was identified and irritated for 10 seconds by massage movement of the forefinger and thumb. After that the loop was placed into the abdomen and the wound was sutured layer by layer. Then for three weeks the following behavioral tests were performed in compliance with the protocol: motor activity (Actometer) and exploratory activity in new environment (Open field), social behavior (pair interaction test), novel object recognition, extrapolational deliverance rate, forced swimming, sexual behavior. Ovariectomized female (n = 16) were used as standard opponents for social behavior tests, and hormone-stimulated female rats (n = 26) were used for sexual behavior tests. The results showed that long-term action of halothane vapor caused behavioral changes in rats: it reduces exploratory activity, decreases the novel object recognition index, increases immobility during forced swimming and reduces latent period of extrapolational deliverance. Halothane made no significant impact on motor activity (open field) and sexual behavior of male rats. In general the results of performed tests provide evidence of emotional flattening development in rats. Conclusion: It is feasible to use the experiment design and pool of behavioral tests used in this study for experimental evaluation of inhalation anesthetics effects, their late consequences, and also for searching the ways of management of the developing behavioral disorders.

 

Goal: to demonstrate the rare case of transfusion-associated graft-versus-host disease (TA-GvHD) after transfusion of blood components. The cause of TA-GvHD is implantation of donor lymphocytes, contained in blood components, which is related to immunological HLA-homology between the donor and recipient, that does not eliminate the donor cells. Mortality makes 90-100%. 68 year old patient had planned surgery - aortocoronary bypass. In the post-operative period under pressure anemia three doses of unirradiated packed red blood cells were transfused. On the 17th day after transfusion the patient developed febrile fever and manifested erythematous cutaneous rush. On the 24th day after transfusion neutropenia developed. Evaluation results of allele discrimination of high-polymorphic markers confirmed the diagnosis of TA-GvHD. HLA-typing of the donor's and recipient's blood was done retrospectively. The donor was homozygous in five loci in low resolution and in loci of HLA-А*, HLA-В*, HLA-DRB1* he had the gene common with the patient. On the 34th day after the transfusion the patient died of infectious complications. X-ray or gamma-irradiation of blood components in order to inactivate the donor's viable T-lymphocytes is considered to be the only way to guarantee the prevention of TA-GvHD. Since there is no effective therapy for TA-GvHD, prevention of risk to develop the disease, strict indications to blood transfusions and capacity for early diagnosis become crucial.

 

Transfusion-associated graft-versus-host disease (TA-GvHD) is a very rare but potentially lethal complication occurring after blood components transfusion. Goal of the article: to analyze the literature describing this complication. TA-GvHD can develop due to several factors: quantity and viability of lymphocytes, contained in the transfused blood component, responsiveness of the patient's immune system to replantation of donor lymphocytes and degree of immunological HLA-homology between the donor and the recipient. History and epidemiology of this fatal syndrome, its pathogenesis, clinical manifestations, diagnostics and therapy have been reviewed. It has been shown that the main prevention techniques include abstaining from blood components transfusion collected from close relatives and using special irradiation modes, suppressing proliferation of the donor's lymphocytes. Conclusion: Doctors performing blood components transfusion should note that post-transfusion reaction development in the variant of graft-versus-host might develop in order to provide timely diagnostics and to start the specific treatment of this complication.

 

Goal: to familiarize Russian anesthesiologists with the most recent data of the evidence-based medicine about peri-operative infusion therapy. The right choice of the infusion therapy strategy and tactics is a mandatory component of the successful management of the peri-operative period. The most significant changes have recently occurred specifically in this field. First the concept of restrictive tactics of infusion therapy emerged and won its popularity very fast. Then some reasonable doubts appeared about feasibility and safety of using HES solutions. Both affect basic principles of infusion therapy and the recent changes are to be considered from the position of the evidence-based medicine. British and German experts attended these issues and published the relevant guidelines in 2011 and 2016. Comparison and analysis of the implementation opportunities in Russia and recommendations make the subject of this publication. Conclusion: It is necessary to implement the international recommendations for peri-operative infusion therapy with adjustment to relevant Russian regulations in the anesthesiology and intensive care departments.

 

Goal of the review: to review theoretical and practical aspects of using exogenous phosphocreatine in the patients with cardio-vascular disorders in various clinical situations, given that phospho-transporting system disorders are the one of pathogenic elements responsible for reduction of cardiac pumping ability.

 

The goal of this review based on the analysis and systematization of the results of numerous studies is to present the current view on preoxygenation method from the position of negative consequences development and opportunities for their prevention. Preoxygenation side effects and existing approaches to their prevention were analyzed. The role of high concentration of inhaled oxygen is highlighted as a potentially dangerous factor due to the development of post-surgical respiratory complications resulting from formation of resorption atelectasis. It has been proved that preoxygenation improvement is still the crucial issue for anesthesiology, and the search for ways of further safety enhancement for this technique has been discussed.

 

The letter contains comments on the draft clinical recommendations for diagnostics and treatment of severe sepsis and septic shock in medical units of St. Petersburg, prepared by St. Petersburg Society of Sepsis Specialists (www.spbsepsis.ru). The number of principal comments has been stated and the opinion is expressed that the use of publication of these recommendations in the present form is doubtful.