The article presents the results of enhanced recovery after surgery (ERAS) or fast track surgery during abdominal aortic surgery from the position of an anesthesiologist and emergency physician.

The objective of the study: to improve outcomes of surgical treatment in patients with infrarenal aortic abnormality through development, introduction and optimization of enhanced recovery after surgery.

Subjects and methods. 67 patients who had infrarenal aortic surgeries were enrolled in the study. Depending on the use of ERAS, patients were divided into two groups. The protocol developed by ourselves was applied in Group 1 (Protocol, n = 27), which included auxiliary pulmonary ventilation, intra- (after the main stage of surgery) and post-operative epidural analgesia (for at least 48 hours), limited infusions with volume control through assessment of pulse wave variations, extubation of patients early or immediately under the surgery. In Group 2, (VIS, n = 40), the anesthesia was done as per the methods traditionally accepted in Vishnevsky Institute of Surgery, which included forced pulmonary ventilation at all stages of surgery, intra-operative epidural anesthesia and liberal infusion therapy.

Results. In Group 1, the volume of infusion therapy (inclusive compensation of visible losses) made 7.7 ml · kg^-1 · h^-1 [6.3; 9.2], while in Group 2, it made ‒ 9.8 ml · kg^-1 · h^-1 [7.6; 11.5] (p < 0.05). 100% of patients from Group 1 was extubated in the operating room versus 62% in Group 2. No difference in oxygenation indices was registered between the groups during surgery, extubation and stay in the intensive care wards. However, in the morning when patients were transferred out from intensive care wards after surgery, oxygenation index made 357 [297; 445] in Group 1, while in Group 2 it made 295 [280; 380] (p < 0.07). It means that in the patients with auxiliary pulmonary ventilation, oxygenation index reduced by 17% versus the initial value, while in the patients with forced pulmonary ventilation it went down by 44% (p = 0.003). Analysis of peri-operative complications discovered a bigger number of pronounced complications as per Clavien ‒ Dindo classification in Group 2 (p < 0.05). The applied protocol allowed reducing the time of hospital stay by 3.5 days ‒ 8.0 [6.0; 8.0] versus 11.5 [9.5; 18.5] in Groups 1 and 2 respectively (p < 0.05).

Conclusion. The application of enhanced recovery protocol in infrarenal aortic surgery results in a lower number of post-operative complications and reduction of hospital stay.

The objective of the study: to perform clinical efficiency assessment of epidural anesthesia combined with an epiglottic airway and auxiliary pulmonary ventilation in video-assisted thoracoscopic thymectomies.

Subjects and methods. 9 patients with generalized myasthenia who had video-assisted thoracoscopic thymectomy were examined.

Results. The efficient level of analgesia during surgery was confirmed clinically: patients were dry, pink, warm, the diuresis rate made 60 ml/h. Upon the completion of surgery, the patients were recovered in 1-2 minutes on the average. At the same time, the epiglottic airway was removed. The patients were able to walk in the ward without any assistance in 1 hour after surgery. In the post-operative period, on the average, the pain intensity made 1.50 ± 0.87 scores as per VAS. None of the patients needed therapeutic fibrobronchoscopy. No intra-operative or post-operative complications were registered. All 9 patients were transferred to the relevant specialized ward on the day of surgery; 6 (66.7%) went home on the 5th day after surgery, and 3 (33.3%) – on the 6th day.

Conclusion. Epidural block combined with an epiglottic airway and auxiliary pulmonary ventilation without tracheal intubation and muscle relaxants in video-assisted thoracoscopic thymectomies is an effective and safe method.

Currently, peroral endoscopic myotomy (POEM) gains increasingly frequent use for management of esophageal achalasia. Despite POEM being minimally invasive, the problem of the post-operative pain syndrome is still crucial for this type of surgery.

The objective of the study: to compare the degree of pain syndrome in the early post-operative period in different POEM methods.

Methods: 79 patients were divided into 2 groups depending on the solution injected into submucosal tissue in order to provide the safe performance of myotomy. 0.15% solution of ropivacaine was used in Group 1, and 0.9% solution of NaCl in Group 2. The severity of the pain syndrome was compared in all patients using a visual analog scale, as well as consumption of analgesics during first three days after surgery.

Results. On the first post-operative day, the clinically significant pain syndrome was more frequent in Group 2 (p < 0.05). The need in non-steroidal anti-inflammatory drugs did not differ between the groups. On the 2nd day it was observed that the need in NSIAD went down in Group 1 (p < 0.01).

The article presents the comparative assessment of efficiency and safety of neuraxial pain relief in labor.

Subjects and methods. Four groups of 40 women in each group participated in the study: In Group 1, epidural analgesia was used for pain relief in labor, in Group 2, ultra-low-dose spinal analgesia was used, and paravertebral analgesia was used for pain relief in Group 3. And Control Group included 40 women with no pain relief in labor. The efficiency of analgesia in labor was monitored (scores by N.N. Rasstrigin and B.V. Shneider), as hemodynamic rates: heart rate, arterial tension, and median arterial tension (ATmed). Bromage scores were used for assessment of motor block. The changes in cervical dilatation and duration of the first and second period of the labor were assessed. All complications and negative effects of pain relief and impact of analgesia on the fetus were registered.

Results. All methods of pain relief demonstrated statistically significant reduction of sensitivity to pain. Dilating pains were evaluated as 7.15 scores in Group 1; 6.88 scores in Group 2, and 7.43 in Group 3. In Control Group it made 3.87 scores (p < 0.001). During the second period of labor epidural and paravertebral analgesia was the most effective: 6.78 scores in Group 1 and 6.20 scores in Group 3 (p < 0.05). After pain relief in Groups 1, 2 and 3 there was a statistically significant reduction of specific peripheral vascular resistance, ATmed, reduction of cardiac index due to normalization of heart rate. In the groups with pain relief, the time from the development of analgesic effect until full dilation was statistically significantly shorter. The best result was achieved through paravertebral analgesia (27.5 minutes faster versus Control Group, p < 0.001). The statistically significant increase of active pushing phase was observed in Group 2, on the average for 6.1 minutes longer versus Control Group (p < 0.005).

The objective: to detect specific features of traumatic disease in those with severe concurrent trauma with a major injury of abdomen organs.

Subjects. 326 patients with severe concurrent traumas; the median severity of injury made 4.6 ± 0.1 scores according to Military Field Surgery Score (20.4 ± 0.2 scores as per ISS). 111 patients had severe concurrent abdomen injury (in 52 patients, the severity of abdomen injury prevail over injuries in the other anatomical regions).

Results. When analyzing the distribution of variants of the traumatic disease course in 111 patients with a severe concurrent abdomen injury, variant I was observed in 22.5% of patients, variant II – in 47.7%. and variant III – in 29.8%. Among 215 patients with no abdomen injury, variant I was observed in 25.1%, variant II – 46.0%, and variant III – in 28.9%. Thus the distribution of variants of the traumatic disease course among those included into the study was approximately the same. The difference in mortality rates during the first period of the traumatic disease in those injured was not associated with specific features of traumatic disease with abdomen injuries, but for presence or absence of severe brain injury. There were no differences in frequency or duration of the second period of the traumatic disease. In those with severe concurrent trauma and prevailing abdomen injuries, on the average, the time of maximum chances to develop complications is longer with a higher mortality level.

Antithrombin is one of the key regulating factors of homeostasis, which activity significantly reduces in SIRS.

The objective of the study: to investigate possibility and feasibility to test antithrombin level in blood plasma in order to predict treatment outcomes in patients with sepsis.

Subjects. The level of antithrombin was tested in 83 patients by the start and at the peak of the disease. Predictive value was compared for antithrombin tests, some other parameters of coagulogram, and clinical severity scales in sepsis.

Results. On the 5th day of the disease, the most significant predictors of the unfavorable outcome of sepsis were identified: fibrinogen level (Odds ratio – 2.42 [0.92–6.33]; p = 0.0722); and antithrombin level (Odds ratio – 26.4 [8.02 86.86]; p < 0.0001).

Pair-wise comparison of ROC-curves of fibrinogen and antithrombin at the final point of the study demonstrated differences between areas under curve (AUC), which made 0.337 [95% CI 0.154–0.520] with p = 0.0003, which confirmed the assumption of the high predictive value of antithrombin level. With the cut-off point at ≤ 61% this test demonstrated the sensitivity and specificity of 79% and 88% respectively.

Conclusion: In order to predict severity and potential outcome of sepsis, it is recommended to test antithrombin level at the peak of the disease.

Despite the availability of modern drugs, examination and treatment methods, the issue of cognitive dysfunction is still fairly important for intensive care and anaesthesiologic practice. The review presents statistic data on the frequency of cognitive dysfunction, discusses main tests used for detection of cognitive dysfunction, describes their specific features, advantages and deficiencies. It gives general recommendations on the performance of such tests, interpretation of their results and describes instrumental methods and biochemical markers in blood, spinal fluid and urine which can be used to detect deviations in cognitive functions in patients and objectify examinations in the intensive care practice.

Despite significant achievements in the management of patients with cardiac vascular pathology, this type of disorders remains to be the major cause of death all over the world. Patients undergoing surgery and suffering from cardiac vascular diseases face a high risk to develop post-operative complications and lethal outcome and about half of the post-operative lethal cases after non-cardiac surgery are caused by cardiac vascular complications. Inhibitors of angiotensin-converting enzyme as well as angiotensin II receptor blockers are the ones of the most frequently used drugs in cardiology; they have been proved to slow down the progress of the disease, improve life quality and reduce mortality. However, the use of these drugs in pre-operative period can be associated with such adverse events as hypotension and post-operative renal dysfunction. Thus, it is necessary to justify therapy with blockers of renin-angiotensin-aldosterone system in the peri-operative period in the patients undergoing cardiac and non-cardiac surgery.

The article describes sedation in dentistry and out-patient maxillofacial surgery. The definitions of sedation, psychoemotional comfort and discomfort are thoroughly described and introduced. A special emphasis is put on pathophysiology of psychoemotional discomfort and peri-operative stress. According to modern data, the objectives to be achieved by an anesthesiologist have been reviewed: provision of psychoemotional inhibition (as a basis of comfort staying in a dental chair), but not depression of consciousness as it used to be before.

With much detail it analyzes complication occurring during anesthesia; their correlations with age, concurrent conditions, anesthetic agent and doctor's professional level are highlighted.

The article presents a clinical picture of sedation depending on the depression of consciousness, respiration, and hemodynamics (ADA and ASA, 2016). It depicts thoroughly the state of minimal sedation (anxiolysis), moderate sedation (awake sedation), deep sedation and general anesthesia. Special attention is paid to the provision of patient's safety related to supporting airway patency and hemodynamics.

The article presents methods of sedation from the position of modern global data and personal experience of authors. Methods of medication administration are mentioned: enteral, parenteral, including intra-nasal which is fairly popular of late.

Special attention is paid to specific problems of sedation, presence of motion activity, psychoemotional agitation, compulsive coughing. Potential causes of these events are described, in particular, correlation between psychoemotional agitation with dysregulation of GABA-ergic and dopaminergic systems.

Current data on the intra-operative monitoring are presented, as an important component of the patient's safety during sedation. Additionally to Harvard Standard, it is recommended to use capnography and monitoring of sedation depth through bispectral index.