Lately, in Russia, the number of patients with severe stage of acute renal failure requiring renal replacement therapy is increasing. Intermittent hemodialysis is the most common type of this therapy, however, the continuous methods of renal replacement therapy also started to be more often used in clinical practice despite of their high basic cost. The subject of this study is to investigate of pharmaco-economic results reflecting direct medical and indirect non-medical costs when using these technologies versus the maximum effective use of funds while treating patients with severe renal dysfunctions. Objective: to perform comparative clinical and economic analysis of intermittent and continuous renal replacement therapy in the intensive care wards of medical units in Russia. Methods. The study was conducted in compliance with acting Standards on Clinical Economic Studies used in Russian Federation. The study methods included evaluation of existing randomized clinical studies and trials which included data from network meta-analyses and systematic reviews of the investigated technologies. The direct medical and indirect non-medical costs were calculated and analyzed in respect of cost-effectiveness and costs-utility and budget impact analyses, utility, expressed in the number of saved quality-adjusted life years. Result: Simulation and comparative healtheconomic analysis of intermittent (IRRT) and continuous (CRRT) renal replacement therapy showed that the use continuous (CRRT) renal replacement therapy resulted in reduction of direct medical and indirect non-medical costs even within the first year. By the end of the third year savings can achieve 341,129.5 RUR per patient, and of this amount, savings in direct medical costs show 279,646.3 RUR and savings of indirect non-medical costs show 61,483.1 RUR. Budget impact analysis identified that using continuous renal replacement therapy (CRRT) allowed to save more than 230 million RUR for the whole country during 3 years per 1,740 patients with acute renal failure. Conclusion: Despite its high initial costs, the use of CRRT results in the reduction of costs and maximum efficient use of funds, and thus CRRT can be recommended for wider use in the Russian practice.

The objective of the study: to investigate the course of infection, caused by A. baumannii, in the patients in the intensive care units of a general hospital. Methods. The retrospective cohort study was conducted, which included 830 patients of the intensive care wards suffering from nosocomial infections caused by Acinetobacter baumanii. The bacterial diagnostics and drug susceptibility testing were performed using the analyzer of ADAGIO (Bio Rad, USA), Vitex 2 Compact 60 (bio Mariex, France) and the bacteriological analyzer for testing of sterile blood cultures of Bact Alar 3D60 (bio Mariex, France). As a result, certain specific features of this infection were identified: higher frequency of this disease in the patients with unfavorable co-morbid background (p = 0.042), prevailing lesions of abdomen (p = 0.04), skin and soft tissues (p = 0.02), frequent manifestations of septic shock (14%; p = 0.025) with a high mortality rate (16%; p = 0.025). Conclusions. 1. In 28% of cases, Acinetobacter baumannii accounts for the development of nosocomial infection in the patients staying in the intensive care ward. 2. Abdomen (18%), skin and soft tissues (8%) are most frequent sites where lesions caused by this infection are diagnosed. 3. The co-infection caused by A. baumannii most often develops in the patients with compromised co-morbid background (Charlson score makes 4.6 ± 0.3), which explains the severity of their state (APACHE II score makes 18.0 ± 1.6), development of organ failures (SOFA scores make 6.00 ± 0.05) and high frequency of septic shock (14%; p = 0.025). 4. The high mortality is typical of the course of the infection caused by A. baumannii, (16% versus 5.6%) in the patients with nosocomial infections caused by the other gram-negative bacteria.

Currently, the majority of colorectal surgeries is performed using laparoscopic and minimal invasive methods, providing the best outcomes in the soonest post-operative period and equal oncological safety when compared to traditional open surgeries. Data of the publications on the safety of laparoscopic surgeries in such patients are fairly contradictory. The objective of the study: to evaluate the impact of intra-operative intra-abdominal hypertension on the course of post-operative period in the patients undergoing surgery for colorectal cancer. Subjects and Methods. 48 patients who had surgeries for colorectal cancer were enrolled into the study. All patients were divided into 2 groups based on the course of post-operative period: with complications(no. 1, n = 36) and no complications during the post-operative period (no. 2, n = 12). The analysis included the data of invasive monitoring of arterial blood pressure, blood gases and acid-base balance of arterial and venous blood, blood lactate level, frequency of critical incidents. The patients who had laparoscopic surgeries had their level of intra-abdominal pressure recorded and intra-abdominal perfusion pressure calculated. The statistic analysis was performed using the software of SPSS 20.0 IBM. In order to define the significance of differences between the groups, paired non-parametric Mann-Whitney test was used. Differences were considered valid with p < 0.05. Chi-square method was used to evaluate the differences between categorical values. Results. It was found out that two and more episodes of systolic blood pressure drop during surgery significantly increased the risk of post-operative complications (χ2 test with Yates' correction of 4.636, p = 0.001; OR 24.0, RR 8.6, 95% CI 2.002–7.981). The patients with complicated post-operative period had a significantly higher level of lactate, venoarterial differences of pСО2, more severe base deficit versus the comparison group. When laparoscopic methods were used, these differences were even more significant. When performing correlation analysis the significant association was detected between the levels of intra-abdominal pressure and lactate, BE and ΔpCO2 in 60 minutes after pneumoperitoneum and desufflation, which indirectly confirmed the impact of the increased intra-abdominal pressure on development of intra-abdominal hypoperfusion. Conclusion. Ischemic and reperfusion damage, developed during the intra-operative period, is one of the pathogenetic stages of development of post-operative complications in the patients who had surgeries for colorectal cancer. One of the risk factors promoting its development is a decrease of arterial blood pressure during the intra-operative period for more than 20% out of the initial letter as well as intra-abdominal hypertension, caused by the increase in intra-abdominal pressure during laparoscopic pressures.

Search for most effective way of management of non-specific delirium is an important aspect of treatment of severe concomitant trauma. The objective of the study: to investigate the correlation and impact of sedation method on those injured with delirium during the intensive care of severe concomitant trauma. Subjects and Methods. The retrospective prospective analysis of two groups of patients with delirium was performed, 30 patients in each group, who received sedation with dexmedetomidine or propofol. Results. After stopping delirium, the intensity of multiple organ dysfunctions was lower in the group of patients who had sedation with dexmedetomidine. The complex of unfavorable events – death within 1 year and continuous cognitive deficiency was 4 times more frequent in the group of patients after sedation with propofol. Evaluation of the trauma severity was a significant predictor of unfavorable outcomes. Conclusions. The use of dexmedetomidine for management of delirium resulted in the reduction of multiple organ dysfunctions versus propofol. The severity of trauma was associated with chances to develop a continuous cognitive dysfunction and lethal outcome. Use of dexmedetomidine promoted early rehabilitation in case of cognitive dysfunction.

The objective: to compare the impact of two methods of general anesthesia during carotid endarterectomy on central hemodynamics and cerebral blood flow in order to choose the best anaesthesiologic tactics. Materials and subjects. The total intravenous anesthesia (sedation with propofol, n = 60) and general combined anesthesia (sedation with sevoflurane, n = 60) were compared in 130 patients undergoing carotid endarterectomy. Parameters of central hemodynamics and cerebral blood circulation were investigated. Results. It was found out that anesthesia with sevoflurane supported an effective level of central hemodynamics and provided a higher level of cerebral blood flow and was associated with statistically significant (11.9%) reduction in the number of neurological complications versus anesthesia with propofol. Conclusion: Inhalation anesthesia with sevoflurane can be considered the choice of anesthesia in carotid endarterectomy.

As a rule, methods evaluating the need and volume of fluid therapy are expensive, they require relevant equipment and it is not always available in hospitals; therefore it has been proposed to use mobile devices with Capstesia software to capture the image of the arterial pressure curve from the monitor screen and to analyze it in order to determine the variability of the pulse pressure (PPV). Materials and subjects. The efficiency of defining the need for fluid therapy using Capstesia was assessed in the clinical settings. 95 integrated measurements were performed in 19 patients with septic shock, who had the catheter installed to monitor the fluid therapy for trans-pulmonary thermodilution; and the PiCCO2 monitor was used. Simultaneously, the test with the volemic load (VLT) was conducted and PPV was tested with the aid of Capstesia. Results. The analysis revealed significantly higher mean differences and ranges of levels' consistency when testing PPV by Capstesia, in which the error rate was also higher than the acceptable level and it made 56%, whereas the method of VLT had only 20% of errors and significantly smaller mean difference and ranges of consistency levels.

The pain and pain syndrome remain to be serious problems of clinical medicine and surgery as one of its aspects. The positive correlation was found out between the type of surgery and post-operative pain in abdominal, thoracic and orthopedic surgeries. Materials and methods. Results of a questionnaire survey in 130 patients were analyzed; from 2015 to 2017 all those patients had lobectomies for lung cancer using video-assisted thoracoscopic or open accesses in the Thoracic Department of Petrov National Medical Research Center of Oncology. The intensity of pain and life quality in the post-operative period were assessed using visual analogue scales, the Wong-Baker FACES pain rating scale, verbal rating scales, and McGill pain questionnaire. In order to assess life quality, the non-specific questionnaire of SF-36 was used in the cancer patients and those enrolled in the clinical studies of EORTC QLQ-C30 including the special module of QLQ-LC13 for lung cancer patients. The obtained results were analyzed and it was found out that intensity of pain was statistically significantly lower in video-assisted thoracoscopic access versus thoracotomy (U = 678.00; p < 0.05). When using the questionnaires of SF-36 (U = 8,742.50; p < 0.05) and EORTC QLQ-C30 (U = 3,759.00; p < 0.05) and the special module of QLQ-LC13 for lung cancer (U = 4,243.00; p < 0.05), the obtained data also indicated the better life quality and functions, reduction of pathologic manifestations versus open surgical access. Conclusion: Reduction in the pain intensity and higher life quality were typical of surgeries with use of video-assisted thoracoscopic technologies versus classical open access.

Hippocampus plays an important role in the cognitive mnestic functions. It coordinates emotional process, defines the intensity and specificity of behavioral, neuron and hormone reactions. Structural changes in hippocampus neurons can result in learning and memory disorders. The objective: to investigate morphometric parameters of hippocampus fields in rats after abdomen surgery with exposure to sevoflurane. Subjects and methods. The experimental research was performed using Wistar rats (n = 15). Rats from the experimental group (n = 7) had abdomen surgery with anesthesia with sevoflurane with the consequent continuous exposure to it (6 hours, 2 vol. % of sevoflurane, air flow – 1 l/min.). During 21 days rats from both groups had a number of behavioral tests. In 12 hours after the last behavioral test (on the 22-th day after the start of the experiment) the rats were decapitated with consequent brain extraction. The obtained materials were fixed in 10% neutral formalin on phosphate buffer (pH 7.4) for 24 hours minimum. Preparations of CA1, Ca2, Ca3, and Ca4 fields were studied under light microscope DM-750 (Leica, Germany) using the computer image analysis software of ImageScope M with 400-fold magnification. Results. The tests showed that cytoarchitectonics of hippocampus field was intact, pyramidal neurons had a large rounded nucleus with one, two or more distinct nucleoli. No pericellular and perivascular edema was detected. In the experimental group, all fields of the hippocampus had structural and functional changes. It manifested through both quantitative and qualitative signs of neuronal damage, especially in the Ca1 field. Segments of pyramidal neurons were disorganized, morphologically modified neurons were found: hyperchromatic shriveled neurons with no nucleus or poorly visible nucleus of the irregular shape. The appearance of morphologically changed neurons and disorganization of hippocampal layers led to changes in the width of pyramidal neurons segments. Conclusion. Morphological changes of hippocampal structures of rats after surgery and anesthesia may be the cause of cognitive functions decline during the postoperative period.

According to calculation methods recommended by World Health Organisation, in Russia, approximately 600,000 people (from 378,46 to 561,52 per 100,000 population) are need of palliative care. Palliative care includes various medical interventions aimed at pain relief and management of other severe manifestations of the disease, life quality improvement of incurably ill citizens and this care can be provided on the out-patient and in-patient basis by medical workers who had training in the provision of such care (pp. 36 of FZ-323). Due to the above, it is necessary to work out standard approaches to assessment and management of main severe symptoms in the patients in need of palliative care. The article discusses the opportunities for management of severe gastrointestinal symptoms in the adults patients in need of palliative care with life expectancy from several weeks to several years. Pharmacological and non-pharmacological methods, individual approach attentive to details are to be combined for the effective management of severe events.

Heart wounds are fairly rare, out of all chest penetrating wounds they make 5-7%. The main causes of lethal outcomes in cardiac incision wounds are massive blood loss, a combination of acute massive blood loss and cardiac tamponade, and isolated cardiac tamponade. The juries of coronary arteries and intracardiac structures also provide an impact on the mortality level. The clinical observation described in the article demonstrates the opportunity to provide a favorable outcome of the trauma disease in the patients with severe concomitant incision wounds of head, neck, chest, abdomen, and acute massive blood loss when providing adequate intensive care and surgical treatment.