In no way questioning the achievements of the Russian anesthesiology and intensive care, the author pays special attention to certain topical issues. From his point of view, these issues point out at the fact that anesthesiology and intensive care system is falling behind healthcare reforming. The author expresses his concerns about the current situation, especially about the growing gap between high requirements to the quality of care provided by anesthesiologists and emergency physicians and constraints interfering with it due to various reasons. The author suggests striving for the division of anesthesiology and intensive care into the relevant levels, elaboration of clear requirements to primary (basic) training of graduates from medical residences and expresses some other opinions. Considering the novelty of his proposals, the author invites to discuss them in the publications of this journal and during the 2nd Congress on Topical Issues of Critical Care Medicine (May 11-14, 2019).

The article describes the system of pain management in the USA, and it highlights the fact that despite the difference in organization of medical care provision, Russia and the USA aim at similar objectives in this field. Managing patients with pain syndrome is an important part of medicine; anesthesiology is a core of pain management, but only the collaborative approach involving different specialists can provide the required result. Treatment of patients suffering from chronic pain can be a success if it is comprehensively planned and coordinated.

The authors reviewed the literature and presented results of their own research of post-operative cognitive dysfunction confirming its social importance. The development of post-operative cognitive dysfunction is to be perceived as a real fact despite the differences in the published epidemiological data. Currently, there are no grounds to correlate it directly with the general anesthesia given to patients, and there is no evidence that a certain method of anesthesia or a certain drug can reduce the frequency of post-operative clinical decline. There are numerous factors within genesis of post-operative cognitive decline and they are not studied well. All suspected mechanisms (neurotoxicity of the used agents, and other factors of anesthesia and surgery; impairment of information neuro-transmission mechanisms; neuroinflammation developing as a response to trauma) can initiate the complex neuro-physiological reactions causing cognitive dysfunction.

The authors presented experimental data about morphofunctional changes in neurons and cerebellar cortex microglia after laparotomy and anesthesia with sevoflurane followed by the exposure to it in a special box for 6 hours (induction of 8 vol. % with the air flow of 2 l/min., maintaining 2 vol. % of sevoflurane with the air flow of 1 l/min.). They demonstrated that neuroinflammation was not the key factor of the detected neuronal damage. Purkinje neurons were damaged the most, since they were fairy sensitive to energy metabolic disorders, promoting the death of other neurons of the molecular layer. Neurons of the granular layer with the low level of energy metabolism were the most resistant to the impact provided by surgery/anesthesia. These data confirmed the importance of multifactorial approach when assessing the genesis of cognitive dysfunction. This research is to be continued and aimed to find out predictors of post-operative cognitive decline and to optimize anaesthesiologic support of surgery and other invasive interventions to provide a balance between their aggressiveness and effectiveness of protection, especially in senile patients who already have some cognitive dysfunctions. 

Failed tracheal intubation which is not detected in time is a dangerous state. Capnography being the most frequently used tool to assess tracheal intubation does not always allow diagnosing this state in a prompt manner, for instance when the effective cardiac activity stopped.

The objective of the study: to define specific features of ultrasound verification of the position of endotracheal tube (ETT).

Methods. 20 patients undergoing surgery in a maxillofacial surgery ward were examined. All patients had ultrasound scanning of trachea before, during and after endotracheal intubation. Ultrasound examinations were done with four positions of the ultrasound sensor: longitudinal (supra-tracheal along the middle line), suprasternal, transcricoid and transthoracic positions.

Results. The direct method in the longitudinal position allowed visualizing ETT in 100% of patient (n = 20), while in the other positions of the sensor (but for transthoracic one) it was possible to distinguish ETT only in 80% of cases (n = 16). The indirect methods (esophageal intubation, transthoracic position) detected the position of ETT in 100% of patients (n = 20).

Conclusions. Ultrasound can be used to confirm the position of ETT during intubation providing high accuracy and reliability. It is possible but difficult to visualize endotracheal tube in trachea since it can be easily confused with the interface of tissue and air or some other anatomical formations. The use of reinforced tubes or filling the cuff with fluid greatly facilitates the finding of the endotracheal tube in trachea with ultrasound, especially in the longitudinal position of the sensor. The ultrasound is the fastest method of detecting esophageal intubation by finding the phenomenon of the "double way". The transthoracic position is one of the additional methods to confirm that ETT is in trachea by identifying the phenomenon of pulmonary pleurae "sliding". 

The surface block of cervical plexus in combination with general anesthesia provides nociceptive protection at all stages of the surgery. However, its use is associated with the risk of puncture of large vessels of the neck and resulting complications: unintentional intravascular administration of a local anesthetic and formation of a hematoma.

The objective: to demonstrate the advantages and effectiveness of superficial cervical plexus block with the use of ultrasound guidance in carotid surgery.

Subjects and methods. The method of inplane ultrasound-guided single-insertion was used. The superficial cervical plexus block was performed under ultrasound guidance (Fujifilm Sonosite Edge Inc. – US) with a linear sensor (Sonosite HFL38 13-6MHz).

Results. The superficial cervical plexus block with ultrasound guidance allowed choosing the most appropriate area for the administration of local anesthetic, visualizing the movement of the puncture needle in the neck structures and minimizing the risks of damage to large vessels and nerves, excluding the possibility of intravascular injection of a local anesthetic. 

Prevention of cardiovascular complications, which often result in fatal events in the peri-operative period, is one of the most crucial issues of modern anesthesiology.

The objective: to investigate the changes in arrhythmic activity and conduction disorders during anesthesia and in the peri-operative period in the patients undergoing open cholecystectomy under general anesthesia.

Subjects and methods. 57 patients of 60.1 ± 3.8 years old were enrolled in the study; they all underwent planned open cholecystectomy under combined anesthesia with tracheal intubation and artificial pulmonary ventilation. Group 1 consisted of 28 patients suffering from coronary heart disease (CHD) in the form of exertional angina of functional classes of I and II; and Group 2 included 29 patients without CHD. The frequency of episodes of group and polymorphic premature ventricular contractions, supraventricular tachycardia and atrioventricular block of degree II, was analyzed by daily Holter ECG monitoring for certain time periods during anesthesia and the peri-operative period. Stages of the study: I – on the eve of the surgery (18 h); II – within 6 hours before the surgery; III – immediate preparation and induction of anesthesia (62.0 ± 6.7 min); IV – maintenance of anesthesia (57 ± 14 min); V – recovery from anesthesia (48 ± 11 min); VI – the 2nd day after surgery (18 h).

Results. A significant increase in the frequency of episodes of group and polymorphic premature ventricular contractions, supraventricular tachycardia and atrioventricular block of degree II, was found out at the stages of induction, maintenance and recovery from anesthesia in patients with CHD and in patients without concurrent cardiovascular disorders. Increased frequency of episodes of group and polymorphic premature ventricular contractions was observed in patients with CHD at the stages of induction and recovery from anesthesia (by 242 and 225%). The highest increase in the frequency of polymorphic premature ventricular contractions was observed in patients with CHD during recovery from anesthesia (by 284%) and in those without cardiovascular pathology at the induction stage (by 461%); the increase in episodes of supraventricular tachycardia was maximum at the induction stage in the patients without cardiovascular pathology (by 291%).

Conclusion: Open cholecystectomy in general anesthesia is associated with increased arrhythmic activity and higher conduction disturbances incidence at all stages of anesthesia in patients with coronary heart disease and those without concurrent cardiovascular disorders. 

Atrial fibrillation (AF) remains to be one of the most common complications that occur after thoracic surgery; its frequency makes from 4 to 37%. This type of complication can significantly extend the recovery period for the patients after anatomic lung resection and increase the short-term and long-term mortality.

Subjects and methods. Data of 183 patients who underwent extensive anatomic lung resections due to malignant neoplasms were retrospectively analyzed. The following was evaluated: the impact of surgery approach (thoracotomy or VATS) and the type of anatomic lung resection, peri-operative fluid balance and severity of pain syndrome as per Visual Analogue Scale on the incidence of AF. Statistical analysis was performed using Student's t-test, non-parametric χ2 test and Mann – Whitney test, as well as a multidimensional logistic regression with standardization of indicators and odds ratio calculation.

Results. In the early post-operative period, AF developed in 40 patients. It was found out that with increasing age, the rate of intra-operative infusion and positive fluid balance during the first day of the post-operative period, the risk of post-operative AF went up in thoracic patients. 

The objective: to investigate the correlation of renin concentration and uric acid content in pregnant women with pre-eclampsia and vitamin D deficiency and their impact on the course of pregnancy, childbirth, and infant status.

Subjects and methods. The content of uric acid, vitamin D, endothelin and renin concentration were studied in pregnant women with pre-eclampsia and the control group; enzyme immunoassay and spectrophotometric tests were used. Venous blood was used as a specimen for tests.

Results. Hyperuricemia (435.61 ± 24.05 μmol/l) and a 10-fold increase of renin concentration were observed in patients with severe pre-eclampsia and vitamin D deficiency (11.23 ± 1.60 ng/ml). Vitamin D deficiency is associated with a higher need for epidural administration of local anesthetics during labor analgesia in patients with pre-eclampsia versus the control group; it is also associated with unfavorable perinatal outcomes.

Conclusions. The following was detected in the patients with pre-eclampsia: low levels of vitamin D, hyperuricemia, elevated blood renin concentration, which was associated with the severity of pain and increased blood pressure. For adequate analgesia and blood pressure control during labor, they needed a higher rate of local anesthetic administration. Perhaps, replenishing vitamin deficiencies during pregnancy may improve perinatal outcomes. 

Cold injury is a medico-social problem in regions with a sharply continental climate. The article describes approaches to the diagnosis and conservative treatment of frostbite of the extremities. Particular attention is paid to early prediction of the degree of cold damage and intensive therapy methods.