Impaired microcirculation due  to endothelial dysfunction in COVID-19  is considered  to be  the most important link in the pathogenesis of this disease. However, due  to  the  complexity of its  instrumental  assessment  in critically ill patients,  the data available  in  the  literature on specific manifestations of endothelial dysfunction are very contradictory.

The objective:  to determine  the most characteristic capillaroscopic signs of microvascular disorders and  to assess  the  state of microcirculation regulation in patients with severe COVID-19.

Subjects  and Methods. When admitted  to  the  intensive  care unit,  60 patients with  COVID-19  and  12  patients with chronic cardiovascular pathology without COVID-19 (Comparison Group) were examined. All patients underwent microscopy of the microcirculatory bed of finger nail bed; the following parameters were assessed: diameters of the venous, arterial and transitional parts of capillaries, height of capillary loops, density of capillaries per  1 mm of the  length of the perivascular zone,  the average  linear velocity of capillary blood  flow (LVCBF), and  thickness of the perivascular zone. The presence of avascular zones,  the number of capillaries in the visualized field with circulating aggregates in the lumen, and the shape of capillaries were taken into account.  In addition, an occlusion test using laser Doppler flowmetry was performed  in 32 patients with COVID-19. The maximum post-occlusive increase in blood flow at the moment of cuff deflation was assessed, as well as changes in the mean value of post-occlusive blood flow relative to the baseline within 3 minutes after cuff deflation.

Results.  In 53 (88.3%) patients with COVID-19, abnormalities corresponding to chronic microcirculatory changes in the form of predominance of pathological capillary forms were detected. Microaggregates in the lumen of capillaries and decreased linear velocity of blood flow were revealed in 100% of cases. When comparing groups of patients with different outcomes, statistically significant differences were revealed between the LVCBF parameters (in the survivors -  354.35 ± 44.78 pm/sec, in the deceased - 278.4 ± 26.59 pm/sec), as well as between the values of the perivascular zones thickness  (95.35  ±  15.96 microns versus  159.93 ±  19.90 microns). The results of the post-occlusion  test revealed  a significant difference between the groups in terms of the maximum post-occlusion gain (39.42 ± 3.85 BPU in the group with a favorable outcome, 27.69 ± 3.19 BPU in the group with an unfavorable outcome, 47.23 ±  1.78 BPU in the control group). In both groups, there was no increase in this parameter relative to the initial blood flow. At the same time, in the control group, the average index of post-occlusive blood flow was higher than the initial level.

Conclusions. Acute microcirculation disorders with decreased linear velocity of capillary blood flow, circulation of aggregates, increased thickness of the perivascular zone were detected in all patients with severe COVID-19 but especially in those with unfavorable outcomes. Vascular tone regulation disorders were manifested by the absence of reactive hyperemia in response to acute ischemia, as well as a decrease in maximal flow-induced increase. These changes fit into the concept of endothelial dysfunction. Signs of chronic microcirculation disorders in most patients increase the risk of severe COVID-19.

Ferritin is one of the biomarkers requiring special attention; its blood level increases significantly especially in the severe course of COVID-19. Information on the effect of hyperferritinemia on the disease outcome is very contradictory as are the ideas about the causes of its development.

The objective: to study the effect of hyperferritinemia on the disease outcome and analyse the possible causes of its development in severe COVID-19.

Subjects and Methods. Data on 479 patients with severe course of coronavirus infection treated in intensive care units (ICU) were retrospectively analyzed. Of them, the proportion of patients with a favorable outcome (Group 1) was 51.0% (n = 241), and with an unfavorable outcome 
(Group 2) - 49.0% (n = 235). The following parameters were assessed: the levels of ferritin, C-reactive protein, fibrinogen, IL-6, IL-10, IL-18, procalcitonin, complement C5a, total, direct and indirect bilirubin, ALT, AST, and the blood level of lactate dehydrogenase (LDH). The changes of erythrocyte count and hemoglobin blood level were also monitored. In order to form a clear view of iron metabolism, free iron, transferrin, and myoglobin levels were assessed in several patients with high ferritin values (more than 1,500 pg/L).

Results. In the unfavorable outcome, ferritin levels increase very significantly, reaching maximum by day 6 of patients' stay in ICU. The difference in the level of ferritin between the groups of survivors and deceased during this period is clear and significant (p = 0.0013). The association of ferritin values with the outcome is detected as early as day 1, but by day 4 it becomes highly significant (the cut-off point is 1,080 pg/l). No data have been obtained that would indicate the association of hyperferritinemia with impaired iron metabolism, the development of hepatic dysfunction, or cellular destruction. In contrast to survivors, those who died on day 6 had elevated IL-6 while C5a level remained unchanged. 

Conclusions. The rapid increase in ferritin blood levels to 1,000 pg/L or higher is an unfavorable prognostic sign indicating a high probability of a lethal outcome. When assessing genesis of hyperferritinemia in COVID-19, the crucial significance should be attributed to the cytokine storm rather than disorders of iron metabolism or hemotoxic effects of the virus. The persistent increase of ferritin level in blood during 4-6 days of stay in ICU should be considered as a reason to intensify anticytokine therapy.

Currently, in pandemic settings, the new coronavirus infection is the leading cause of adult fatalities and may cause death of children with comorbidities.

The objective of the study is to identify predictors of the fatality of the new coronavirus infection in children.

Subjects and Methods. 230 patients with the new coronavirus infections were examined. The main group of 94 patients with severe COVID-19, the fatal outcome occurred in 25 (26.6%) children. The comparison group consisted of 126 children with a moderate degree of severity, and there 
were no lethal outcomes.

Results. Children older than 10 years of age (43%) prevailed in the study cohort. Every fifth patient in the main group suffered from shock, and 79 (84%) children had failure of two or more systems/organs. The presence of pronounced manifestations of the disease was associated with a 20-fold increase in the probability of a severe course of COVID-19 (OR = 0.04). Involvement of two organs and systems doubled the risk of death. An acceptable discriminatory ability of the pSOFA score for predicting COVID-19 outcomes in children was identified: sensitivity 83%, specificity 61%, cut-off point 5.6 points.

Conclusion. Predictors of death in severe new coronavirus infection in children include failure of two or more organs and systems, acute renal injury and the pSOFA score above 5.

Pregnant and postpartum women are at a higher risk of infection with SARS-CoV-2 as well as a higher risk of adverse outcomes for the mother and fetus. Standard approaches to the management of COVID-19-associated multiple organ dysfunction may not always be implemented in this category of patients. In the clinical case of a patient, who developed multiple organ dysfunction syndrome (severe ARDS, coagulopathy) associated with COVID-19 in the postpartum period, we demonstrate the successful use of combined extracorporeal life support that included veno-venous extracorporeal membrane oxygenation, therapeutic plasma exchange and renal replacement therapy with the universal oXiris set.

Anesthetic provision of retroperitoneoscopic adrenalectomy for hormone-active adrenal tumors still requires overcoming certain difficulties. This is due to significant metabolic and functional disorders that persist even after thorough preoperative preparation. In addition, the endovideoscopic intervention itself requires certain conditions, each of which is fraught with additional stress on the circulatory and respiratory systems.

The objective: to develop a technique for anesthetic management of aldosteroma surgery.

Subjects and Methods. The study involved 57 patients (42 women and 15 men aged from 38 to 62 years) who underwent retroperitoneoscopic adrenalectomy for aldosteroma. The patients were divided into two groups depending on the method of anesthesia. In Group 1 (n = 30), the operation was performed under combined anesthesia with low-flow desflurane inhalation as a basis and perioperative analgesia with systemic opioid administration. Patients of Group 2 (п = 27) were operated under anesthesia with low flow desflurane inhalation as a basis in combination with 0.35% ropivacaine solution blockade of the fascial space of the erector spinae plane muscle on the surgery side (ESP erector spinae plane). In order to optimize myoplegia, Group 2 was divided into three subgroups (A, Б, and В), 9 patients each. In patients of subgroup A, muscle relaxation was achieved by continuous administration of rocuronium bromide at the dose of 0.4 mg • kg-1 • h-1 throughout the operation. In subgroups Б and В, muscle relaxation was achieved by bolus administration of rocuronium bromide intravenously at the dose of 0.15 mg * kg^-1 * h^-1. Patients from subgroup A underwent no decurarization. In subgroup Б, for the purpose of decurarization, atropine sulfate 0.01 mg/kg and proserin 0.05 mg/kg were administered. In subgroup Б, sugammadex was administered at the dose of 4 mg/kg. Neuromuscular conduction was monitored, parameters of central and peripheral hemodynamics, anesthesia adequacy, quality of postoperative analgesia, and frequency of postoperative complications were assessed.

Results. Combined anesthesia with desflurane with ESP blockade allows achieving the required level of its depth, providing adequate analgesia in the postoperative period, avoiding the use of high doses of opioid analgesics after surgery and thereby preventing the occurrence of complications associated with their use. The use of rocuronium bromide in patients with aldosteroma provides complete muscle relaxation at all stages of the video endoscopic intervention. The use of sugammadex makes the myoplegia technique manageable, which allows by the end of the operation to restore neuromuscular conduction, transfer to spontaneous breathing and activate the patient, which to a certain extent ensures the prevention of postoperative complications.

Conclusions. The use of ESP block with combined anesthesia is an effective method of perioperative analgesia for retroperitoneoscopic adrenalectomy for aldosteroma, and also reduces the consumption of opioid analgesics and reduces the number of postoperative complications associated with their use. Continuous infusion of rocuronium bromide without deteriorating the quality of the neuromuscular block significantly reduces the consumption of the relaxant, and the use of sugammadex makes myoplegia controllable which is very important for patients with aldosteroma.

One of the options for solving the problem of a “non-standard” patient undergoing a major and traumatic operation, perhaps, is the protocol-personalized approach to hemodynamic management.

The objective: to study the efficacy and safety of using a modified protocol-personalized approach to hemodynamic management during surgical interventions on abdominal organs in elderly and senile patients.

Subjects and Methods. A randomized prospective-retrospective clinical trial was conducted in parallel groups: Group 1 (control) - standard management of the perioperative period; Group 2 - standard management supplemented by the protocol-personalized approach to hemodynamic management.

Results. Patients in the main group had the best parameters as per MACE outcomes (RR: 0.462, [95% CI: 0.251-0.850] p = 0.038). In the intra- and postoperative period, patients in the control group had a relatively higher risk of arrhythmias (RR: 2.517 [95% CI: 1.218; 5,200] p = 0.017).

Conclusion. The use of the protocol-personalized approach results in better MACE outcomes (RR: 0.462, 95% CI: 0.251-0.850; p = 0.038) during surgical interventions on the abdominal organs in elderly and senile patients, and also, reduces the risk of arrhythmias (RR: 2.517, 95% CI:1.218; 5.200) p = 0.017.

The objective: to analyze the incidence and spectrum of cardiovascular complications within 12 months after noncardiac surgery, as well as to assess the association of preoperative values of various cardiac risk indices (CRI) and other potential risk factors with the actual development of complications.
Subjects and Methods. We analyzed data of medical records and telephone interviews of 141 patients aged 65 [60-71] years who had undergone non-cardiac surgery a year before the interview The operations were low risk in 13.5% of observations, medium risk in 64.5%, and high risk in 22%. A retrospective calculation of the Revised CRI (RCRI), Individual CRI (Khoronenko CRI), and the American College of Surgeons Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA) was performed.
Results. Cardiac events (myocardial infarction, decompensation of chronic heart failure, new arrhythmias, stroke, and/or the need to prescribe or escalate the dose of cardiovascular drugs and/or hospitalization for cardiac indications, and/or death from cardiovascular diseases) within 12 months after elective noncardiac surgeries were detected in 27.7% of cases, and in 2.1% of patient's death occurred due to cardiac disorders. Predictors of cardiac events were concomitant ischemic heart disease (OR = 2.777; 95% CI 1.286-5.966; p = 0.0093) and chronic heart failure (OR = 2.900; 95% CI 1.224-6.869; p = 0, 0155), RCRI (OR = 1.886; 95% CI 1.2-8-2.944; p = 0.005), Khoronenko CRI (OR = 3254.3; 95% CI 64.33-164,638; p = 0.0001), MICA (OR = 1.628; 95% CI 1.156-2.292; p = 0.005), creatininemia on the first postoperative day (OR = 1.023; 95% CI 1.010-1.061; p = 0.005), and propensity for bradycardia during surgery (OR = 0.945; 95% CI 0.908-0.983; p = 0.005). Combined analysis of Khoronenko's CRI and postoperative creatininemia provided a very good model: area under the ROC-curve - 0.823 (95% CI 0.728-0.641; p = 0.0002).
Conclusion. All studied CRIs can be used to predict posthospital cardiac events; however, the most promising is a joint assessment of Khoronenko's CRI and postoperative creatinemia.

The objective: to determine the predictive value of TRIPS at the stage of pre-transport preparation in relation to treatment outcomes of newborns.
Subjects: The cohort study included data from 604 visits of the team of the intensive case and consultation center. The TRIPS score was assessed, and the outcomes of the hospital phase of treatment were studied. The AUC ROC curve of the TRIPS score was calculated in relation to the binary outcomes of hospital treatment. The correlation analysis of the quantitative data was performed by Spearman's criterion.
Results. AUC was greater than 0.8 only for the risk of death (AUC 0.827 (0.764-0.891)), the formation of severe IVH (AUC 0.831 (0.786-0.877)) and the development of occlusive hydrocephalus (AUC 0.839 (0.764-0.915)). For other binary outcomes, the score shows AUC below 0.8. A weak but significant correlation was found between the TRIPS score and the duration of intensive care (r = 0.478,p < 0.0001).
Conclusion: TRIPS demonstrated an acceptable level of accuracy (AUC>0.8) in predicting hospital mortality, severe IVH, and the formation of occlusive hydrocephalus. A weak but significant correlation was found with the quantitative outcomes.

Of all cases of acute kidney injury (AKI), 45-70% are associated with sepsis. Lethality in sepsis-associated AKI requiring renal replacement therapy (RRT) ranges from 40 to 50%, and in AKI combined with other organ dysfunctions - 60-80%. In order to improve the results of treatment of sepsis and septic shock, various methods of extracorporeal detoxification (ECD) have been developed. The effectiveness of these methods is controversial. In the treatment of sepsis, RRT is used not only to replace the impaired detoxification function of kidneys, but also to remove excess cytokines from the systemic bloodstream. The literature describes mainly positive results of the use of dialyzers with an adsorbing membrane, however, these data do not have the necessary degree of evidence. Currently, there are no clear criteria for the initiation of RRT, its duration and doses, the choice of methodology determined by specific clinical and laboratory parameters, and staging of this therapy. All this highlights the need for further research in this field.

Thrombotic thrombocytopenic purpura is a disease from the group of thrombotic microangiopathies, the early diagnosis of which is a real challenge in clinical practice. The article presents a clinical case that clearly illustrates the multisystem nature of the damage against the background of thrombotic microangiopathy, specific parameters of diagnosis, and emergency therapy Timely initiation of specific treatment significantly increases the chances of survival in this category of patients.