A new federal model of in-patient medical care funding provides payment for treatment basing on the average costs estimated when evaluating "completed cases" of certain diseases grouped together due to their similarity and types of the provided medical care (CSG system). The lack of differentiation does not allow full reimbursement of expenses of in-patient units occurring during treatment of the severely ill in the intensive care wards. Goal: to estimate risks of financial losses of units providing medical care to the patients with high chances of a complicated course of the disease when medical care is reimbursed within the system described above (CSG system) and to propose improvement of this system. Results. The article presents the results of joint work of the experts from Organizational Economic Committee of the Association of Anesthesiologists and Intensive Care Physicians and workers of St. Petersburg Regional Fund of Mandatory Medical Insurance aimed at the improvement of the medical care funding system based on the so-called clinical statistic groups (CSG). It was suggested splitting up certain clinical statistic groups into subgroups considering the need of patients in the intensive care and its content. The coefficients reflecting the content of costs were calculated for the identified subgroups. The offered approach was piloted during the project in St. Petersburg through estimating costs for a completed case in parallel with estimation as per the existing method of reimbursement related to medical economic standards. The obtained results proved that the offered approach allowed achieving better differentiation due to re-distribution of funds from less severely ill patients who required no treatment in the intensive care departments to the more severely ill. The data were submitted to Center of Expertise and Monitoring of Medical Care Quality in order to prepare suggestions to amend guidelines on medical care reimbursement by the Russian Ministry of Health. Conclusion. The article describes specific practical outcomes – the model was developed to be introduced for reimbursement of the in-patient care as per CSG system within mandatory medical insurance.

The tactics of blood transfusion therapy provides a significant impact on the course of wound disease but only in those with acute massive blood loss of the extremely severe degree. A proper use of blood transfusions in the post-shock period results in faster relief of the severity and reduces the risk to develop severe sepsis and acute respiratory distress syndrome. One of the most crucial organizational problems in blood transfusion is the issue of blood donation being especially critical in treatment of those with severe traumas since they often require blood transfusions including massive ones. The existing regulatory documents containing indicators and procedures for using blood transfusion media in those with severe traumas are often contradictory and require certain amendments.

Goal of the study: to study the level of markers of the system fetal inflammatory response and endothelial dysfunction in the umbilical blood of full-term newborns survived after intranatal asphyxia. Materials and methods. Group 1 included 12 full-term newborns who were born with 5 and less Apgar scores for the 1st minute, and Group 2 included 12 children with a normal course of the early neonatal period. The levels of interleukin-8 (IL-8), interleukin-10 (IL-10), C-reactive protein (CRP), soluble form of E-selectin (sE-selectin) and intercellular adhesion molecule-1 (sICAM-1) in umbilical blood were tested. Results. Mothers of newborns from Group 1 demonstrated inflammatory changes in placenta compared to Group 2 (60 and 8%, p = 0.018) as well as higher levels of CRP (961 [520; 1 096] and 43 [33; 71] ng/ml, p < 0.06), IL-8 (153 [53; 323] and 28 [22; 42] pg/ml, p = 0.001), IL-10 (12.3 [7.5; 43.5] and 2.5 [1.9; 5.0] pg/ml, p < 0.001), and sICAM-1 (40 [33; 45] and 18 [17; 21] ng/ml, p < 0.06), which correlated to the inflammatory changes in placenta (r = 0.812, p = 0.028; r = 0.534, p < 0.001; r = 0.492, p = 0.034; r = 0.688, p = 0.089 for CRP, IL-8, IL-10 and sICAM-1 respectively). It was also found that Apgar score had negative correlation with IL-8 level (r = -0.453, p = 0.04 and r = -0.565, p = 0.008 on the 1st and 5th minutes respectively); IL-10 (r = -0.711, p < 0.001 и r = -0.727, p < 0.001 on the 1st and 5th minutes respectively), and sICAM-1 (r = -0.796, p = 0.013 и r = -0.904, p = 0.002 on the 1st and 5th minutes respectively). Conclusions. The system fetal inflammatory response and endothelial dysfunction related to it may predetermine the development of hypoxic ischemic encephalopathy and reduce the efficiency of treatment interventions.

Goal of the study: to assess the feasibility of using inhalation anesthetics of desflurane and sevoflurane during cardiopulmonary bypass to reduce the chances of post-perfusion cardiac dysfunction during myocardial revasculization surgeries. Materials and methods: 75 patients suffering from coronary disease and undergoing myocardial revasculization with cardiopulmonary bypass were divided into three groups as per the type of used anesthetic: Group 1 receiving desflurane (n = 30), Group 2 receiving sevoflurane (n = 28) and Group 3 receiving propofol (n = 17). Anesthetics were used at all stages of anesthesia including cardiopulmonary bypass. The rates of the wider 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). During cardiopulmonary bypass the blood was collected from cardiac coronary sinus in order to assess changes in the levels of lactate and pyruvate before aortic compression, before the release of clamps and in 30 minutes of reperfusion. During the first 24 hours of the post-perfusion period, the following parameters were assessed: frequency of post-perfusion cardiac failure development, duration of artificial pulmonary ventilation and stay in the intensive care department. The level of troponin I was tested in 12 and 24 hours. Results. The hemodynamic profile, blood levels of lactate and pyruvate during cardiopulmonary bypass did not differ between the groups. The rate of increase of the levels of the above metabolites by the 30th minute of reperfusion was the same for all the groups; lactate-pyruvate ratio was stable during all time of anesthesia. There were no differences in the post-operative level of troponin I between the groups during the first 12 and 24 hours after the surgery. The frequency of post-perfusion cardiac failure and its course were similar for all group. Conclusion. Prolonged administration of inhalation anesthetics during cardiopulmonary bypass does not protect myocardium from ischemic and reperfusion lesions.

Xenon is an inert gas being very close to an ideal anesthetic. Goal of the study: to evaluate changes in gases and acid-base balance of arterial blood during general xenon anesthesia with the closed circuit and to compare it with general anesthesia with sevoflurane. Methods. The article describes a prospective assessment of anesthesia with expanded hemodynamic monitoring in 50 patients undergoing planned surgery. Based on the main inhalation anesthetic (xenon or sevoflurane) patients were divided into two groups. The monitoring included blood gases and O₂ delivery; cardiac output was evaluated through analysis of arterial pressure pulse wave after calibration by transpulmonary thermodilution (PiCCO). Results. Xenon anesthesia did not result in serious disorders of acid-base balance and O2 delivery and compared to sevoflurane the metabolic acidosis was less frequent as well as the need to manage it. Changes in the lactate level provided the evidence that both inhalation anesthetics did not result in serious disorders of tissue perfusion and gas exchange.

The endoscopic monitoring when performing percutaneous dilatation tracheostomy requires continuous (up to several dozens of minutes) presence of fiberotic bronchoscope in the endotracheal tube. Under a certain proportion of the outer diameter of fiberotic bronchoscope and the inner diameter of the endotracheal tube it is not always possible to provide proper volume of the artificial pulmonary ventilation and it can result in the hypoventilation. Goal: using the lung model of TestChest® Respiratory Flight Simulator to define the most important factors limiting the increase of minute pulmonary ventilation (MPV) on APV during bronchoscopy through the endotracheal tube. Materials and methods: fiberotic bronchoscope of 5.9 mm outer diameter was put through endotracheal tube no. 8 which was pressure-proof installed to the inspiratory limb of the TestChest lung model with setup parameters reflecting the respiratory system of a patient with no disorders of respiratory mechanics. APV was under volume control. The respiratory volume was increased from 350 ml up to maximum with 25 ml step under the respiratory rate of 12, 16 and 20 respiratory movements per minute. Peak pressure, plateau pressure, autoPEEP, pressure behind the tip of endotracheal tube were registered before and after insertion of fiberotic bronchoscope. Results: increase of MPV was limited by the preset maximum pressure in the respiratory tract. Under the respiration rate of 12 movements per minute, MPV was 9.6 l/min; under the respiration rate of 16 movements per minute it was 12 l/min; under the respiration rate of 20 movements per minute it was 13.5 l/min. However, under the respiration rate of 12 movements per minute autoPEEP made 5 cm. w. c. with maximum MPV, and under the respiration rate of 16 and 20 movements per minute autoPEEP made even 14 and 24 cm. w. c. respectively. On the compared level of PEEP of 5 cm. w. c. MPV made 7.6 l. under the respiration rate of 16 movements per minute; and under the respiration rate of 20 movements per minute with the volume of 350 ml. the autoPEEP made 7 cm. w. c. Conclusion. Factors limiting MPV during APV in bronchoscopy through the endotracheal tube are peak pressure in the endotracheal tube and development of autoPEEP.

The review presents the most recent data on the causes, frequency, risk factors, prevention methods, and principles of management of post-operative nausea and vomiting. The special attention is paid to specific aspects of this type of adverse reactions to anesthesia in the neurosurgical practice. The review concludes that it is still necessary to search for better methods of prevention and management of post-operative nausea and vomiting in the group of neurosurgical patients considering the specific risk factors.

The article gives the updated understanding of the physiology of cerebral fluid exchange and pathophysiology of cerebral edema. The first part of the article has been devoted to a description of the mechanisms of fluid and electrolyte exchange in health and the second part describes pathophysiological aspects of cerebral edema development, going through certain stages. A cytotoxic edema is the first stage when fluid is redistributed between spaces. It is followed by the sodium deficiency in the interstitium resulting in the development of the second stage - an ionic edema characterized only by functional disorders of hematoencephalic barrier. The consequent anatomic disorder of hematoencephalic barrier results in the development of a vasogenic edema and transfer to the stage of hemorrhagic transformation. Understanding the mechanism of the brain edema development provides new prospectives of the management of this state.

The review continues informing the readers about modern opioids, the first part of the review can be found in the preceding issue. In the light of increased interest towards pain management with opioids, the article will be useful for a broad audience of doctors treating acute and chronic pain.

The course of sepsis can be peracute in HIV patients, and its initial manifestations could be non-specific (a headache, inadequate behavior etc.) thus it can be difficult to be diagnosed. Sepsis is to be differentiated in intravenous drug users from narcotic intoxication and abstinence. The article presents a clinical case of angiogenic peracute sepsis in a female HIV infected patient, substance abuser, demonstrating that in such patients regardless of their social status the history is to be very carefully taken and thorough clinical examination is to be performed as well as follow-up due to various non-typical manifestations of sepsis.