The objective: to compare effectiveness of pressure support and mandatory ventilation modes at the final stage of general anesthesia.

Subjects and Methods. 58 patients were included in the study. All patients underwent laparoscopic or open surgery under combined general anesthesia with muscle relaxants and tracheal intubation. At the end of the operation, after suturing the muscle layer, patients were randomly divided into two groups, depending on the further mode of ventilation: the mandatory mode group with dual control until extubation (n = 29) and the spontaneous breathing mode group with pressure support (n = 29). The time of awakening, the severity of post-extubation cough, hemodynamic parameters and oxygenation immediately before and 5 minutes after extubation were assessed.

Results. In the groups of patients, statistically significant differences were observed in the time of awakening (252 ± 67 sec and 426 ± 71 sec in PSV and PCV-VG Groups, respectively), extubation (287 ± 55 sec and 464 ± 67 sec in the PSV and PCV-VG groups, respectively), and transfer from the operating room (473 ± 60 sec and 687 ± 77 sec in the PSV and PCV-VG groups, respectively) (p < 0.0001). Also, patients receiving PSV respiratory support had higher saturation levels 5 minutes after extubation (p < 0.0001), and heart rate and mean arterial pressure immediately before extubation were lower than in the mandatory ventilation group (p = 0.013 and p < 0.0001, respectively). In addition, in the mode of spontaneous breathing with pressure support, a lower severity of post-extubation cough was observed (p = 0.003).

Conclusion. The use of a spontaneous breathing mode with pressure support at the end of general combined anesthesia has several advantages versus mandatory ventilation mode. These advantages include faster awakening, extubation and transfer of the patient to the ward, lower severity of post-extubation cough, as well as better gas exchange after extubation, lower intensity of hypertension and tachycardia before it.  

Extracorporeal membrane oxygenation (ECMO) is a method that makes it possible to compensate for critical changes caused by acute respiratory failure, with the ineffectiveness of treatment with rigid modes of artificial lung ventilation (ventilator) in patients with acute respiratory distress syndrome in intensive care units. The search for the optimal state of the hemostasis system is one of the main tasks in the treatment of critical patients in ECMO conditions.

The objective: to study changes in hemostatic parameters in patients with COVID-19 undergoing ECMO and determine the need for their correction.

Subjects and Methods. According to the inclusion and exclusion criteria, 100 patients were included in the study: 72 men and 28 women aged 26 to 75 years old, the median age made 55 years [47; 60]. VV-ECMO was performed in all observations. In 100% of cases, the cause of respiratory failure which required VV-ECMO was COVID-19-associated pneumonia.

Results. 49 episodes of hemorrhagic complications and 76 episodes of thrombotic complications were recorded from the 1st to the 7th day from the moment of ECMO initiation. We found that the chance of developing thrombosis decreased by an average of 0.3% with an increase in the activity of antithrombin-3 by 1%. A statistically significant association of thrombosis risk was also found for prothrombin and prothrombin time.

Conclusion. During the first 7 days of ECMO, patients with COVID-19 demonstrate the increase in APTT, prothrombin time and a decrease in the number of platelets, prothrombin activity, and fibrinogen concentration. The risk of thrombosis in this group of patients significantly decreases with the increasing activity of antithrombin-3 and prothrombin and increases with rising need of the higher dose of unfractionated heparin. The tactics of restrictive anticoagulant therapy when using unfractionated heparin can be taken into account as a way to reduce the risk of thrombosis and requires further research.  

The objective: to develop a predictive model for assessing the risk of developing encephalopathy (EP) in patients with nutritional pancreatic necrosis.

Subjects and Methods. A single-center prospective cohort study was conducted at Faculty Surgery Clinic of Volgograd State Medical University from 2010 to 2020. Logistic regression analysis was used to build a model for predicting the risk of developing EP.

Results. A total of 429 patients were included in the study. It was determined that in the majority of patients EP manifested in the first three days after hospitalization. A statistically significant predictive model of correlation of the risk to develop EP with clinical and demographic variables showed that an increase in the severity of the patient's condition (according to the SOFA scale) by 1 point increased the risk by 1.9 times, and an increase in bilirubin levels by 1 μmol/l, and urea by 1 mmol/l increased the risk of AED by 8.0% and 28.0%, respectively. In non-alcoholic pancreatic necrosis, compared with the alcoholic genesis of the disease, and when using early (before day 3) enteral nutrition, there was a significant reduction in the risk of developing EP by 175.5% and 137% of cases. The specificity and sensitivity of the model were 78.7% and 82.8%, respectively.

Conclusions. In nurtitional pancreatic necrosis, an increase in the severity of the patient's condition, alcoholic genesis of the disease, progression of signs of liver and kidney failure significantly increased the risk of developing EP. At the same time, early enteral nutrition contributed to a significant reduction in the risk of this complication. The presented predictive model is recommended to be used in routine clinical practice.  

The objective: to study hemodynamic and clinical effects of levosimendan depending on the clinical outcome in patients with sepsis and impaired cardiac pumping function.

Subjects and Methods. the retrospective study involved 31 patients of 52.7 ± 2.8 years old with sepsis or septic shock which were treated with levosimendan at the dose of 0.16 [0.15‒0.17] mg/kg (0.11 [0.1‒0.12] μg × kg^-1 × min^-1) on days 1–4 of ICU stay. The patients were divided into the following groups: Group 1 ‒ survivors (n = 19) and Group 2 – non-survivors (n = 12). Central hemodynamics was assessed through transpulmonary thermodilution. The differences were considered statistically significant at p < 0.05.

Results. Most of the hemodynamic parameters and vasopressors and inotropes doses had no differences between the groups before levosimendan administration. There were no differences in the cardiac index (3.8 ± 0.3 vs 3.5 ± 0.3 L/min/m²; p = 0.479) between the groups following levosimendan administration, however, Group 1 demonstrated the following parameters to be lower versus Group 2: central venous pressure (7 ± 0.7 vs 11 ± 1 mm Hg; p = 0.005), blood lactate (1 [0.9‒1.8] vs 2.4 [2.2‒3.3] mmol/L; p = 0.04), norepinephrine dosages (0.2 [0.15‒0.35] and 0.5 [0.4‒0.6] ng/kg/min; p = 0.023 ), global end-diastolic volume index (693 [688‒28] vs 870 [779‒961] mL/m²; p =0,0009) and the level of NT-proBNP (1,590 [1,080‒3,160] vs 35,000 [21,400‒35,000] pg/mL; p = 0,0001). Global heart ejection fraction (23 [21‒27] vs 15 [12‒20]%; p = 0.015) and heart function index (6 [5‒8] vs 3 [ 3-4] min^-1; p = 0.003) ) were higher in Group 1 versus Group 2. APACHE II >19 (AUC 0.906; p < 0.0001), SOFA > 9 (AUC 0.805; p = 0.0002); heart rate > 114 min^-1 (AUC 0.755; p = 0.0095), and index of total peripheral vascular resistance < 1,700 dyn × s × cm^-5 × m² (AUC 0.806; p = 0.001) before levosimendan administration were the independent predictors of death in patients treated with levosimendan.

Conclusion: non-survivors patients with sepsis had significantly higher APACHE II and SOFA scores, higher heart rate and lower index of total peripheral vascular resistance before levosimendan infusion. In survivors levosimendan infusion at a standard dose led to a significant improvement in the heart pumping function accompanying by global heart ejection fraction and heart function index increasing and NT-proBNP decreasing. In non-survivors such favorable central hemodynamics changes did not occur, although the cardiac index increased after inodilator administration. Further studies of levosimendan efficacy in patients with sepsis of varying severity are advisable. It is necessary to specify the indications and contraindications for levosimendan administration to patients with sepsis.

The developers of Clinical Practice Guidelines for Acute Kidney Injury titled The Initiative to Improve Global Kidney Disease Outcomes (KDIGO) point at the need of new biomarkers for diagnosis acute kidney injury (AKI).

The objective: to study and evaluate the diagnostic significance of the levels of neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1) in patients with AKI in the early postoperative period when antibiotic therapy is used.

Subjects and Methods. AKI frequency was assessed in 276 patients during the early postoperative period after the antibacterial drugs had been prescribed. Serum levels of KIM-1 and NGAL, glomerular filtration rate (GFR), creatinine, protein in urine were tested before the start of antibiotic therapy, in 24–48 hours, and in patients with AKI – additionally in 72–96 hours. The normal initial renal excretory function was registered only in 36 patients (13.04%). The majority of patients (242 patients, 86.96%) were diagnosed with chronic kidney disease of various stages.

Results. NGAL and KIM-1 levels were higher in the group of patients with AKI before start of antibiotic therapy versus the group of patients with preserved renal function. However, a statistically significant increase in the level of KIM-1 and NGAL was found only in the group of patients with stages 3A and 3B of CKD versus the groups of patients with stages 1 and 2 of CKD. The second important observation is that a comorbid pathology in patients led to a high AKI incidence when antibiotic therapy was used – 35.86% (30–42%; 95%CI).

Conclusion. The relationship of NGAL and KIM-1 levels with glomerular filtration rate (GFR) and KIM-1 level with the presence of proteinuria as indicators of impaired renal filtration function suggests that NGAL and KIM-1 levels reflect the state of renal filtration function. Based on this observation, it should be accepted that NGAL and KIM-1 levels can be used as markers for the diagnosis of AKI in patients receiving antibiotic therapy. The prescription of antibiotic therapy in the postoperative period in patients with surgical pathology and renal dysfunction leads to a high AKI incidence. Elevated KIM-1 and NGAL levels in AKI during the antibiotic therapy suggests their involvement in the reparation process.  

The objective: to estimate efficiency of local anesthetics in the conversion of epidural analgesia during physiological childbirth into anesthesia for emergency surgery for delivery.

Subjects and Methods: A randomized prospective study was conducted. The patients were divided into three groups depending on the local anesthetic being used. In the first group (n = 49), 2% solution of lidocaine was administered in combination with 0.1 mg of adrenaline, in the second group (n = 48) – 0.5% bupivacaine, in the third group (n = 46) ‒ 0.75% ropivacaine. The study evaluated the onset rate, level, duration of the sensorimotor block, the severity of the pain syndrome, and revealed the frequency of unsuccessful conversion.

Results: In the 1st group, the conversion was not success in 16.3% of women, in the 2nd group ‒ in 14.6%, and in the 3rd ‒ 10.9% of cases, due to that general anesthesia was used. When assessing the pain syndrome, the minimum score on the VAS scale 3 hours after surgery was observed with ropivacaine use. The fastest sensory block developed when using 2% lidocaine solution in combination with adrenaline. The motor block preserved for the longest time after administration of bupivacaine, in this regard, patients from the 2nd group began to activate later.

Conclusions. The use of 0.5% bupivacaine solution as a local anesthetic during the conversion of epidural analgesia into anesthesia provides a sufficient level of anesthesia that allows surgical intervention. However it is accompanied by a more pronounced motor block, and it has a negative effect on the early activation of maternity patients in the postoperative period. The use of 0.75% solution of ropivacaine hydrochloride provides the most favorable conditions for operative delivery which is confirmed by low estimates of the intensity of pain on the VAS scale, both immediately before surgery and three hours after surgery, the minimum time from the moment of induction to the incision of the skin, ensuring adequate sensory block, the absence of pronounced motor block, and early activation of maternity patients.  

The objective: to analyze the contemporary specific parameters of intraoperative management of epidural analgesia (EA) in combined anesthesia in abdominal oncological surgeries in different medical organizations of Russia.

Subjects and Methods. The data necessary for analysis and statistical processing were obtained by developing a formalized questionnaire (21 questions, some of which with the possibility of choosing several answers at the same time – multiple choice), published on the official website of the Association of Anesthesiologists-Resuscitators (https://association-ar.ru/). The survey lasted for 16 days (from May 23, 2022 to June 7, 2022). The survey results were collected using the Google Forms online service and processed using the Google Spreadsheets. Multiple choice responses were processed as absolute numbers and presented as a percentage of the total number of responses to a particular question.

Results. The total number of respondents who took part in the survey was 217 specialists from various medical organizations, mostly from the North-Western Federal District of the Russian Federation (34.1%) with more than 15 years of expertise in the specialty (44.7%). According to the survey results, the following specific features of EA during combined anesthesia practice in Russia have been identified: most participants perform EA in the sitting position (63.6%); ropivacaine is the drug of choice among local anesthetics (LA) (84.2%); as a rule, EA is initiated prior to incision (69.6%). During open surgical interventions, 44.7% use a combined EA method (continuous infusion and bolus injection – bolus-based mode), while during laparoscopic surgeries there is no preferred method (combined method – 33.1%; continuous infusion only – 35.5%; bolus injection only – 31.4%). Low concentrations of LA (0.2 ‒ 0.375%) combined with a low volume of administration (4‒10 ml for bolus, 4‒8 ml/h for infusion) are used more often both in open and laparoscopic surgeries. In most cases, achievement of effective EA is supported by lower doses of systemic opioid analgesics (65.4%). Insufficient degree of intraoperative analgesia is managed in different ways, such as using systemic opioids (68.7%), enhancing epidural analgesia (17.5%), and administration of non-opioid analgesics (13.8%).

Conclusion. At present, there is no unified approach to the method of EA in combined anesthesia. The results of the survey showed the uncertainty of experts' opinions regarding the choice of LA concentrations for EA, the rate and volume of its administration into the epidural space. Finding the optimal method of intraoperative EA in abdominal oncological surgery is the most important clinical objective in terms of reducing perioperative complications.

The objective: to determine the quality of knowledges about the Helsinki Declaration on Patient Safety among Russian anesthesiologists and intensivists and how widely its vision and standards have been adopted in clinical practice.

Subjects and Methods. The study design involved the creation of 44-item online and offline questionnaire. The questions were divided into three blocks: personal information, data on hospitals where respondents work, and questions about implementation of the Helsinki protocol in their practice. Some of the questions required open answers. Persons with higher medical education who have completed residency and/or internship in anesthesiology and resuscitation and are working in this field in the Russian Federation were invited to participate in the survey.

Results. 140 (21.5%) respondents answered all the question of the questionnaire. Of those surveyed, 76.4% were familiar with the Helsinki Declaration on Patient Safety, but only 17.1% felt they had sufficient knowledge of the concept. 43.6% of the respondents apply the Helsinki Declaration on Patient Safety to their clinical practice, while 49.3% of the respondents had difficulty answering whether they follow the Declaration in their work or not. The study showed a satisfactory level of compliance with mandatory standards for monitoring in the perioperative period but all the EBA-recommended standards are applied in only 23% of the hospitals. 26.4% of the respondents use the Safe Surgery Checklist prepared by the World Health Organization. 58.6% of the respondents use the reporting/notification system for adverse events or critical conditions in the perioperative period.

Conclusion. The survey has shown that many of the surveyed anesthesiologists and intensivists have good knowledge of the Helsinki Declaration on Patient Safety and successfully apply it to their clinical practice but some doctors do it unconsciously, not understanding what standards they follow. Organization of additional educational programs could help physicians to improve their knowledge and raise their awareness in order to provide safer patient care. We also suggest introduction of unified checklists and national reporting systems for adverse events or critical conditions in the perioperative period.

The study of neural plasticity and related memory functions is one of the fundamental fields in anesthesiology. Understanding this issue is very important both for the physician - the anesthesiologist-resuscitator, and for the patient. This review of the literature describes structures and processes of the central nervous system which in a sense are the target for the amnestic action of sedation and anesthesia medications. The possibilities of implicit and explicit memory formation depending on different levels of sedation and anesthesia are considered. Special attention is paid to the mechanism of action of GABAergic drugs on the processes of memory consolidation and reconsolidation.

The severe course of the new coronavirus infection (COVID-19) is associated with multiple life-threatening complications that lead to delayed initiation of active rehabilitation and unfavorable long-term treatment outcomes. Tracheoesophageal fistula is one of these complications. The specific feature of this event in COVID-19 is delayed tissue regeneration which requires a non-standard approach to management of such patients.

The article presents a clinical case of a pregnant patient after a complicated severe course of COVID-19 with the development of tracheoesophageal fistula, sepsis, and weakness syndrome acquired in ICU. The combination of complications of the disease led to a prolonged (about five months) period of rehabilitation.

Modern standard components of intensive therapy of such patients including regular monitoring of endotracheal/tracheostomy tube cuff pressure, dynamic assessment of nutritional status and its correction, rational antimicrobial therapy, screening of psychiatric disorders and early rehabilitation, will minimize the number of both early and delayed complications of COVID-19.  

The objective: to show the possibility of anesthesia during liver retransplantation in a child in the absence of adequate vascular access.

A clinical case of liver retransplantation in a 10-year-old patient with liver transplant dysfunction and acquired thrombophilia is considered. In 2011, the child underwent Kasai portoenterostomy, and in 2012, living-related transplantation of the left lateral liver bisegment from a related donor was performed due to liver cirrhosis as an outcome of biliary atresia. Also, the child had multiple surgical interventions due to perforations of the small intestine with underlying segmental venous mesenteric thrombosis. In the long term after the transplantation, irreversible transplant dysfunction developed with manifestations and worsening of hepatocellular insufficiency, encephalopathy, as well as recurrent bleeding from varicose veins of the esophagus and cardiac orifice. The clinical situation was complicated by the lack of adequate vascular access due to total thrombosis of the venous system, thrombosis of the superior and inferior vena cava. The only possible option for ensuring adequate venous access was the implantation of a tunneled catheter into the right atrium of the right atrium for prolonged standing in conditions of single-lung ventilation through right-sided thoracotomy.  

The presented clinical observation and analysis of the literature data draws an attention on the possibility of developing a life-threatening condition such as methemoglobinemia due to the use of the benzocaine preparation. The latter is part of the preparation bellastesin for the treatment of gastroenterological diseases. This drug is often taken by patients at their own at discretion and with no proper control and consideration of existing co-morbidities. In addition, one needs to pay attention on the indicators of oximetry, including the level of methemoglobin, when diagnosing diseases accompanied by cyanosis and respiratory insufficiency.