The lecture discusses some aspects of anesthetic and intesive care for patients with blast injuries based on the experience of local conflicts and man-made disasters of recent decades generalized by national and foreign experts.

Such casualties are difficult to treat due to potential significant anatomical damage and development of severe functional disorders. Understanding the role of damaging factors facilitates the choice of diagnostic and therapeutic tactics.

The objective: choosing the optimal method of epidural analgesia combined with general anesthesia for typical laparoscopic colorectal surgeries by comparing three different options for its implementation.

Subjects and Methods. 90 patients aged 60 to 85 years were examined, they all underwent planned laparoscopic interventions for colorectal cancer under combined anesthesia (general + epidural anesthesia). Depending on the method of administration of ropivacaine to achieve an epidural block, they were randomized into three groups. In Group 1, it was administered at a concentration of 0.25% in the form of a continuous infusion at a rate of 8 ml/h during the first hour, then 6 ml/ h until the end of the operation. In Group 2, its concentration was increased to 0.375%, the rate of continuous infusion was 8 ml/ h in the first hour, then 6 ml/h. Patients of Group 3 first received ropivacaine as a bolus before the induction of general anesthesia (0.375% – 8 ml over 5 min), then continued administration continuously but at a concentration of 0.25% at a rate of 6 ml/h. Endpoints for hemodynamic assessment: upon admission to the operating room, after induction of anesthesia, after application of carboxyperitoneum, after 1 hour of laparoscopic stage, after elimination of carboxyperitoneum, after extubation, and 1 hour after transfer to the ICU. The total dose of fentanyl was recorded. The assessment of the sensory block was performed using a cold test, the severity of the pain syndrome ‒ on a visual-analog scale (10 points), the density of the block ‒ on an ordinal scale, its upper and lower levels were noted. The motor block was evaluated using a modified Bromage scale.

Results. The doses of fentanyl, rocuronium and the consumption of desflurane during general anesthesia, the values of the BIS index and the time of awakening of patients in all groups did not differ. The average doses of ropivacaine in the groups were different. The total volume of ropivacaine solution was the largest in Group 3, there were no significant differences in the volume of the injected local anesthetic between Group 1 and Group 2. The number of patients who needed vasopressor support with norepinephrine during anesthesia in Group 1 was less versus Groups 2 and 3. The maximum intraoperative dose of norepinephrine and duration of its use were also lower in Group 1. When applying carboxyperitoneum, the most pronounced decrease in hemodynamic parameters was revealed in patients of Group 3. At the 4th stage of the study, after 1 hour of the laparoscopic stage, hemodynamic parameters were higher in patients of Group 1. There were no significant differences in pain intensity between the groups after surgery.

At the same time, the level of motor block was significantly higher in patients of Group 2, while in Groups 1 and 3, motor block did not develop in most of the patients.

Conclusion: The optimal method of epidural analgesia in typical laparoscopic colorectal operations is the use of 0.25% ropivacaine concentration as a continuous infusion only due to ensuring an acceptable level of analgesia, adequate distribution of the sensory block, the minimum degree of motor block, as well as the least negative effect on hemodynamic parameters which reduces the volume of infusion therapy and doses of vasopressors.

To compare efficacy of spontaneous breathing with pressure support and volume-controlled mandatory ventilation during combined general anesthesia using desflurane and without muscle relaxants.

Subjects and Methods. 100 patients were included in the study. All underwent low-traumatic operations on the lower limbs under general combined anesthesia using supraglottic air devices without muscle relaxants. Immediately prior to the induction of anesthesia, patients were randomly divided into two groups: Group 1 (VCV) where a mandatory volume control mode was used (n = 50) and Group 2 (PSV) where a pressure support mode was used (n = 50). The following parameters were assessed: hemodynamics, gas exchange, depth of anesthesia before induction, during and after the end of general anesthesia; arterial blood gas composition one hour after induction of anesthesia; indicators of pressure in the respiratory tract during mechanical ventilation, as well as time parameters of awakening.

Results. In patients of Group 2 (PSV), according to the analysis of arterial blood gases, a higher level of PaO2 (p = 0.006), Horowitz index (p = 0.005), and carbon dioxide level (p < 0.0001) were noted. In Group 1 (VCV), higher mean and peak airway pressures were found one hour after induction and 10 minutes before the end of surgery (p < 0.05). Also in the groups, there were statistically significant differences in the time parameters of awakening (233 ± 58 sec and 352 ± 83 sec in the PSV and VCV groups, respectively), supraglottic airway device removal time (268 ± 62 sec and 398 ± 84 sec in the PSV and VCV groups, respectively) and transfer to the ward (395 ± 60 sec and 571 ± 66 sec in the PSV and VCV groups, respectively) (p < 0.0001). There were no significant differences in the main parameters of hemodynamics and depth of anesthesia, the consumption of anesthetics used during induction and maintenance of general anesthesia.

Conclusion: The use of spontaneous breathing with pressure support during general combined anesthesia without muscle relaxants has a number of advantages versus mandatory ventilation mode. These include better oxygenation rates, lower airway pressure, faster awakening, supraglottic airway device removal time, and transfer of the patient to the ward. At the same time, acceptable ventilation, stable hemodynamic parameters and depth of anesthesia are maintained.

The incidence of various postoperative complications including pulmonary ones is at a high level in a cardiac surgery.

The objective: to evaluate the effectiveness of high-frequency lung ventilation during cardiopulmonary bypass as a preventive measure for postoperative pulmonary complications compared to low-volume lung ventilation.

Subjects and Methods. 60 patients undergoing cradiac surgery were included in the study. In HF Group (HF ventilation with airway pressure control at the frequency of 300/min, the ratio of duration of inhalation and exhalation is 1:2, mean airway pressure is 8 mbar) and VC Group (lung ventilation during CPB with parameters: tidal volume is 3 ml/kg, respiratory rate is 6/min, and positive end-expiratory pressure is +5 cm H2O).

Results. No significant difference in the analysis of the oxygenation index were observed between groups. Frequency of pulmonary atelectasis on chest radiology in postoperative period made 3 (9%) in VC Group and 4 (12%) HF Group (p = 0.71). The frequency of intraoperative recruiting lung maneuvers was 5 (16%) in VС Group and 6 in HF Group (18%) (p = 0,75). The duration of postoperative ventilation did not differ between the groups.

Conclusion. HF mechanical ventilation during CPB has no significant advantage over low-volume mechanical ventilation. HF mechanical ventilation and low-volume mechanical ventilation has the same protective effect on the oxygenating function of the lungs after CPB.

The objective: to determine principles of intraoperative infusion therapy in patients with morbid obesity under the control of volemic status.

Methods: a prospective randomized study was conducted in 60 patients with BMI of 45.57 (40.01; 48.65) kg/m2 who underwent laparoscopic gastric resection under combined anesthesia based on low-flow desflurane inhalation in combination with prolonged epidural analgesia with ropivacaine. Patients were allowed to consume 200 ml of clear liquid 3 hours before the surgery, and solid foods 6 hours before surgery. Patients were divided into 2 groups (n = 30) depending on the composition of infusion therapy: colloids (gelatin solution) were used in Group 1 with balanced crystalloids in a ratio of 1:1-1.5, balanced crystalloid solutions were used in Group 2. The following parameters were studied: hemodynamics, water sector distribution index (IRVS), hemoglobin, hematocrit, potassium ions, sodium, creatinine, lactate, and CBS. A PLR test was performed intraoperatively.

Results. It was revealed that the patients had an uneven distribution between water sectors with shortage of fluid in the intravascular bed, as evidenced by a positive PLR test, as well as low IRVS. When conducting targeted infusion therapy in Group 1, a smaller volume of infusion solutions was used, however, that made it possible to achieve stabilization of hemodynamic parameters due to redistribution of water sectors, which was also evidenced by changes in laboratory parameters.

Conclusion. Obese patients have intravascular fluid deficiency due to uneven distribution between water sectors. The inclusion of a colloidal plasma substitute to the infusion therapy contributes to the elimination of hypovolemia and reduces the volume of transfused media.

The objective: to trace changes in endotoxicosis in the brain during the postresuscitation period.

Subjects and Methods. Clinical death was modeled on rats by 6.5-minute asphyxia and resuscitation.

The animals were divided into groups corresponding to the timing of brain sampling (from 30 minutes to 21 days) after resuscitation. The content of low and median molecular weight substances (LMMWS) was determined in perchloric acid extracts of the brain.

Results. It was found that 30 minutes after resuscitation the content of LMMWS in the brain of rats increases statistically significantly compared to the "control" group, and after 90 minutes returns to the control level. Then, 6 hours – 21 days after resuscitation a paradoxical decrease in the content of LMMWS below the control level occurs.

Conclusion. The decrease in the level of endotoxicosis after asphyxia and resuscitation explains not by their “healing” effect, but by the death of rats with the highest LMMWS values, which leads to a decrease in the average LMMWS value in groups of resuscitated animals.

The article presents the results of a prospective one-center observational clinical study.

The level of therapeutic drug monitoring antibiotics was studied in patients with sepsis.

The objective: to assess the impact of pharmacokinetics and pharmacodynamics parameters of the main classes of antibacterial drugs using specific indices to improve the effectiveness of ongoing antimicrobial therapy in patients with sepsis asscoaited with the infectious process with pan-resistant nosocomial microflora.

Subjects and Methods. A total of 8 patients with sepsis meetiing the criteria of Sepsis-3 were included. Carbapenems, oxazolidinones, and aminoglycosides were used in the treatment. Concentrations of drugs in blood plasma were studied by high-performance liquid chromatography with mass spectrometry. Analysis of the effectiveness of treatment was performed on the third day of therapy.

Results. The T > MIC index reached 40% of the time interval between the two administrations for MIC for Pseudomonas aeruginosa in only two cases for group II carbapenems.

In both cases, high peak concentrations of the drug (19.5 and 35.4 mg/L, respectively) were observed, a low static volume of antibiotic distribution (0.06 l/kg and 0,09 l/kg) and reduced total clearance of the drug (7.18 and 4.11 ml/hr) were noted. The peak concentration of amikacin was low (3.35 mg/l), while the time to achieve it and the level of static volume distribution (356.5 liters) increased. The peak concentration of linezolid was reduced in all observations and amounted to 4.04 and 3.35 mg/l. The time of its achievement was increased (3.27 and 6.6 hours), the ratio of AUC/MIC was low and made 76.8 and 59.2.

The resolution of organ dysfunction and reduction of manifestations of infectious intoxication were noted only in three patients on the third day of observation.

Conclusion. Static pharmacokinetic/pharmacodynamic criteria may serve as a guideline for antimicrobial therapy.

Limitations in changing the tactics of antimicrobial therapy based on the use instruction nevertheless allow optimizing treatment by controlling the volume of distribution of the drug, presence of renal or hepatic insufficiency that, however, does not guarantee treatment success. The volume of therapeutic drug monitoring of antibiotics sufficient for compilation of static pharmakinetic models, does not meet the requirements of modern intensive care.

Patients with nosocomial infections stay in the hospital 2–3 times longer than patients without signs of infection.

It results in 3–4-fold increase of costs and 5–7-fold elevated risk of death. The choice of rational regimes of antimicrobial therapy in such cases is very difficult.

The objective: to demonstrate the efficacy of a combination of prolonged intravenous infusion of meropenem and inhaled sodium colistimethate in the treatment of the patient with the pulmonary infection caused by Kl. pneumoniae and Ac. baumanii, which were resistant to a wide range of antibiotics.

Rhabdomyolysis (RM) is a clinical and laboratory syndrome accompanied by systemic endotoxicosis, a consequence of myocyte destruction and is manifested by acute kidney injury (AKI). The use of extracorporeal detoxification in the early stages of AKI is currently not recognized due to the lack of proven effectiveness.

The objective: to demonstrate the effectiveness of selective hemoperfusion (HP) and hemodiafiltration (HDF) in a patient with toxic RM complicated by AKI.

Subjects and methods. The article presents a clinical observation of an 18-year-old patient after the use of 4-methylmethcathinone (mephedrone) with development of AKI. Clinical, laboratory, diagnostic, toxicological and instrumental methods of examination were used. HP and HDF were used together with standard intensive therapy.

Results. Combined use of HP and HDF was accompanied by regression of markers of endotoxicosis and AKI. A decrease in myoglobin level was noted by 50.3%, 80.3% and 94.1%, respectively, after the 1st and 2nd procedures and by the 5th day. CPK (creatine phosphokinase) decreased by 47.7%, 81.5% and 97.8%, respectively. Cystatin-C went down by 19.3%, 39.9% and 69.9%, respectively.

Conclusions. Earlier and justified use of HP and HDF was accompanied by a rapid improvement of clinical and laboratory parameters, which is reflected in the duration of ICU stay, hospital stay and the outcome of the disease in general.

There are significant medical, social and economic effects, such as decrease in the frequency of postoperative complications, mortality and reduction of hospital stay. The key aspects of the enhanced recovery program are preoperative preparation, anesthesia, postoperative analgesia, in particular multimodal analgesia and regional analgesia, and early rehabilitation. The implementation of the enhanced recovery program for knee and hip replacement in medical institutions of the Russian Federation based on clinical studies and meta-analyses of a high level of evidence, will improve the quality of medical care and patient satisfaction. It is important to note the need to develop the Russian recommendations taking into account experience of using various methods of enhanced recovery in domestic medical institutions, as well as the specific organization features of the Russian healthcare system. This will serve as a basis for further widespread implementation of protocols for enhanced recovery after surgery in this country.

Despite improvements in healthcare technologies, massive postpartum haemorrhage is still the leading cause of maternal morbidity and mortality worldwide. Delayed and poor-quality obstetric care can result in irreversible consequences. Well-timed assessment of blood loss, effective management of the peripartum period, and participation of multidisciplinary teams are essential to provide a specialized care. This review presents the evidence-based management of patients with the development of obstetric haemorrhage. The article presents existing contradictions in the methods of diagnosis and treatment as well as new advances in this field of medicine which require continuation of research in this direction.