[Cardiorespiratory exercise tolerance tests: a preoperative surgical risks assessment in elderly patients].

This study focuses on the most topical issue: non-cardiac surgery safety in elderly patients. According to different authors data, the mortality rate due to cardiovascular pathology %, and postoperative cardiac events incidence -from 2 to 4.4 %. For this reason we decided to conduct prospective risk assessment in the most dificult elderly patients group. Within the framework of this study we performed cardiorespiratory exercise testing (KAREN-test) in 17 elderly patients with various located colon cancer Concomitant diseases were: ischemic heart disease (12 patients), postinfarction cardiosclerosis (4 patients), arterial hypertension (12 patients), rhythm disturbances of varying degrees (11 patients), CHF (2 patients), and others. Patients were aged from 58 to 94 years. Subsequently, 14 of 17 patients were operated on, 11 of them underwent radical intervention. Cardiorespiratory exercise tolerance test was carried out according to moderate treadmill-test protocol for elderly patients developed in our clinic. Test duration was more than 4 minutes in all patients. During exercise stress peak, submaximal heart rate was observed in all patients, the peak oxygen consumption to a maximum current oxygen consumption ratio amounted to 94% on the average in a group, the oxygen consumption at the aerobic threshold level exceeded 11 mI/min/kg in all patients. There was no acute myocardial infarction and cerebrovascular events during perioperative period; the hospital mortality rate was 0%. Actual age by itself is not a contraindication for surgery. KAREN tests should become one of the key components for the assessment and treatment tactics choice.

[Intubating laryngeal mask efficacy in obese and overweight patients].

UNLABELLED: We evaluated the Intubating Laryngeal MAsk (ILMA Fastrach) efficacy for airway management, ventilation and blind intubation in obese and overweight patients. Methods. 50 adult patients (22 men and 28 women) with predicted difficult trachea intubation (PDTI), undergoing general anaesthesia with ILMA were included in this study. ILMA was selected according to gender: ILMA No 5 for men and No 4 for women. PREMEDICATION: diazepam and H,-blockers. Anaesthesia induction: midazolam 0. I - 0.15 mg/kg, propofol 1.6-2.5 mg/kg, fentanyl 0.1-0.15 microg/kg, rocuronii bromide or atracurii besilate 0.6 mg/kg. RESULTS: 21/2/3 patients had morbid obesity with BMI over 40/45/55 kg/m'. 5 and more difficult trachea intubation (TI) predictors were found in 48 patients. The ILMA was placed successfully at the first try for 7.2+/-2.9 sec in all patients. Ventilation was successful in 100% of cases; TI via ILMA - in 94% of cases (90% - at the first try). Total TI time was 7,5+/-4,8 sec, ILMA removal time - 9,2+1,5 sec. 2 patients had 2 or 3 DTI predictors, but conventional TI was unsuccessfild; TI via ILMA was performed at the first try. There was one "can't intubate, can't ventilate" case, TI via ILMA was made at the first try. TI via ILMA was unsuccessful in 3 patients, ILMA was replaced by Proseal LM or Supreme LM, TI was performed conventionally. There were no complications observed. CONCLUSION: ILMA Fastrach was used successfiully in obese patients with PDTI for both ventilation and TI. Technique is simple in training, but a preliminary experience is essential for ILMA use in difficult cases.

[Successful anaesthesia for abdominal reconstructive surgery in a myasthenia gravis patient].

This article presents a clinical case of colon disease surgical treatment in a 34-year old patient with. generalized myasthenia. Perioperative management peculiarities in these patients are clarified. Different approaches to anaesthesia choice were discussed on a case study. The importance of tactics individualization, rational drugs selection, including neuromuscular block reversal agents as well as intraoperative neuromuscular transmission monitoring.

[The difficulties of using intubating laryngeal mask in a patient with concomitant morbid obesity].

This is a case report of tracheal intubation with Intuhating Laryngeal Mask (ILMA) in a patient with morbid obesity.

[Total intravenous and combined general anaesthesia].

In this review TIVA and combined general anaesthesia are not opposed to each other, but considered as having common physiological, clinical, pharmacological, technological and methodological features. This approach will help to borrow useful qualities of each anaesthesia method.

[Prevention of stress-induced damage of the upper gastrointestinal mucosa in patients during early postoperative period].

UNLABELLED: Stress-damage of upper gastro-intestinal tract (GIT) mucous membrane and gastro-intestinal hemorrhage (GIH) increase the lethality of patients in the departments of reanimation and intensive care unit. The purpose of this study is to evaluate effectiveness and safety of pantoprazole use in patients with at least one risk factor of upper GIT mucosa stresses-damage and GIH. An important part of this study was examination of 24-hour intragastric pH - control results in patients during 1-st day after the surgery. MATERIALS AND METHODS: Pantoprazole antisecretory therapy conducted in 40 patients, 38 of which had at least one risk factor of upper GIT mucosa stresses-damage and GIH. If there are risk factors, in the postoperative period prescribed pantoprazole (controlok) 80 mg/day bolus intravenously, then went to 40 mg/day per os. The criteria of the preventive therapy efficiency were absence of manifest and/or clinically significant GIH symptoms, the need for emergency upper endoscopy and emergency surgery, caused by the GIH. Among the patients with risk factors were marked out 15 patients: liver cirrhosis, portal hypertension syndrome (esophagus and stomach varix), liver failure (Child-Pugh A/B), high risk of hemorrhage. Within 24 hours, a constant intragastric-Ph monitoring ws carried out. RESULTS: During observation in all patients, which were undergoing upper GIT mucosa stress-damage prevention, there was no need for emergency upper endoscopy. No patients needed to carry out emergency surgery, caused by the GIH. Lethality rate in this group was absent. CONCLUSIONS: The use of pantoprazole demonstrates its good efficiency and tolerance.

[The efficacy of the multidisciplinary approach in colorectal cancer surgery in elderly patients].

Publications of the last few years indicate a steady rise of colorectal cancer in the world. Colorectal cancer is on the second place in the structure of oncological mortality in developed countries, including Russia. The majority of colorectal cancer deaths (up to 50%) occur in elderly. The octogenarians are more likely to have comorbidities and age-specific deteriorating organ function, which could make their tolerance of surgery. To determine the short- and long-term outcomes of the multidisciplinary approach in elective colorectal surgery in patients ≥75 years of age. A review 70 octogerians who underwent colorectal cancer surgery between April 2006 and November 2010 was performed from prospectively collected database. The median age was 79 (75-95) years. Every patient was examined by multidisciplinary team before surgery. Conservative therapy was prescribed or corrected if any organ failure detected. After the period of treatment decision on their suitability for surgery was made. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates. The mean index of comorbidity was 7.3 (6-11) and 81% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM scoring model was 14.8%. All patients with comorbidities were treated conservatively during mean period of 12.2 days, nine patients (13%) required implantations of pacemakers to control heart rate in perioperative period. In 64 (91%) cases surgical resection of the colon or rectum with primary anastomosis were performed, in 6 (9%) - abdominoperineal resection of the rectum and in two cases - Hartmann's operation. Postoperative complications were noticed in 40 (57%) cases. Postoperative mortality rate (death within 30 days of surgery) was 5.7%, the 2- and 3-year overall survival rate according to Kaplan and Meier was 78.3±5.6% and 74.9±6.3% respectively. Using the multidisciplinary approach in the management of elderly allows reaching the acceptable mortality level (5.7% in comparison with predicted 14.8%) and high 2- and 3-year survival rates. This means that chronological age alone should not be contraindication to the elective curative surgery of colorectal cancer in elderly if overall assessment of the perioperative risk is possible. The study aimed to asses the intermediate and long-term results of the multidisciplinathe colorectal cancer in elderly patients. 70 patients, aged 75-95 years, were prospectively chosen to participate the study. The comorbidity Charlson index and ASA scale were used to measure the perioperative risks. The CR-POSSUM scale was used for postoperative lethality rating. The use of the above listed scales and measurements in combination with multidisciplinary conservative preaparation of patients before the operation allowed to achieve the satisfactory lethality rate of 5.7% and higher long-term survival rates after the colorectal surgery.

[New possibilities of complex monitoring of the cardiovascular system during thoraco-abdominal surgeries].

The aim of the study was to compare effectiveness of combined cardiovascular monitoring in assessment of quality of anesthetic protection during combined general anesthesia with thoracic level epidural analgesia during thoraco-abdominal surgeries. The study included 56 patients (ASA II-IV). The preoperative examination consisted off: ECG (rest), ECG (stress), 24 hour ECG monitoring. The intraoperative hemodynamic parameters (BPsist., BPdiast., BPmed., HR) were monitored both by invasive and non-invasive methods. Using the measurements of cardiac output (extrasternal dopler) the cardiac index, specific peripheral vascular resistance and stroke index were calculated. During intra and postoperative period (1st and 5th day) ECG monitoring was made. The received data was compared according to the following parameters: character of rhythm, circadian index, supraventricular and ventricular ectopic activity, dynamics of the ST segment. The results show that inclusion of thoracic epidural blockade combined with general or total intravenous anesthesia during thoraco-abdominal surgeries is accompanied by more favorable hemodynamic restructuring, heart rate stability and well expressed anti-ischemic effect. Thus, inclusion of modern combined cardiovascular monitoring methods during anesthesia widens the diagnostic abilities and noticeably increases the patient safety during high risk surgeries.

[Nutritional status, anesthesia and early postoperative complications in patients with radical operations on the esophagus].

The material of the research were 63 patients operated on benign strictures and esophageal cancer in the RSCS after B.V. Petrovsky. We studied the occurrence and the character of postoperative complications, dependence on initial nutritive (alimentary) status and anesthesia techniques. The main postoperative complications were of respiratory system and cardiovascular insufficiency and mainly depended on the initial degree of nutritive and used anesthesia techniques. No significant difference in the structure of postoperative complications for the patients with benign and malignant diseases of esophagus has been identified.

[Cholinesterase blockers in anesthesiology: a replenishment of former arsenal].

Cholinesterase blockers are widely used in various fields of clinical medicine. In anesthesiology they are used for the means of decurarisation, as well as for performance of central segmental blockades. In recent years, along with the most frequently used neostigmine again an opportunity arose to use the well-known galantamine. A brief overview of the pharmacological properties of galantamine is completed by the study of its efficacy and safety in 30 patients (first group) who underwent general anesthesia with total myoplegia at a range of abdominal surgeries. The comparison group (second group) included 30 patients who were applied neostigmine. The method of clinical functional evaluation, the accelerometry and frontal electromyography confirmed that galantamine although inferior to neostigmine in efficiency, has a higher safety threshold.

[Problem of neuromuscular block reversion: neostigmine and sugammadex].

The review covers the history of neuromuscular block reversal. It states that indications for decurarization have been changed due to the extremely high rate of residual curarization even after the use of average-acting myorelaxants. The paper provides the pharmacological characteristics of sugammadex, a new selective relaxant-binding agent for aminosteroids (rocuronium and vecuronium) with the unique mechanism of action. It also gives data on the efficacy and safety of sugammadex versus anticholinesterase agents and estimates the prospects for its clinical application.

[Efficacy and safety of sevoflurane in various anesthesia modes (according to the results of a multicenter study)].

The paper presents the results of the limited multicenter sevoflurane study initiated by Abbott Lab, which was conducted in 2006. The study was undertaken to examine the efficacy and safety of sevoflurane in various anesthesia modes in patients (ASA I-III) with surgical diseases during surgical interventions into abdominal and thoracic organs and lower extremities. The study covered 96 patients. The analysis indicates that the use of sevoflurane for mask induction and anesthetic maintenance is possible and safe for patients with ASA I-III.

[Possibilities of estimating the depth of myorelaxation by a frontal electromyogram].

The authors studied the changes occurring in a frontal electromyogram (fEMG) recorded by commercial anesthesia depth monitors (Alaris AEP Monitor/2, Aspect A-2000 XP, and CSM 2) as a criterion for evaluating the reduction of a neuromuscular block. Two hundred and two patients who had undergone various abdominal and colorectal interventions under total intravenous anesthesia (TIVA) or combined balanced anesthesia using volatile anesthetics were examined. The findings allow a preliminary conclusion that fEMG shows a moderate diagnostic accuracy in predicting relaxation release particularly under TIVA. fEMG is as a useful complement to clinical criteria for myoplegia management, but it is not an alternative to traditional accelerometry.

[Central hemodynamics under conditions of combined anesthesia on the basis of a thoracic epidural block].

The authors set themselves a task of assessing systemic hemodynamic parameters under combined general anesthesia on the basis of a thoracic epidural block (TEB) versus combined general anesthesia during thoracoabdominal interventions. Thirty patients were examined. Their physical status was in ASA Class II-IV. The preoperative examination was as follows: electrocardiography (ECG) (at rest), ECG (during exercise), and 24-hour ECG monitoring. Hemodynamic parameters, such as systolic blood pressure (BP), diastolic BP, mean BP, and heart rate), were intraoperatively measured by invasive and noninvasive techniques. By using the measurements of cardiac output (extrasternal Doppler study), the authors calculated cardiac index, specific peripheral vascular resistance (SPVS), and stroke index (SI). They made 24-hour ECG monitoring intra- and postoperatively (on days 1 and 5, respectively). The findings suggest that inclusion of TEB in a complex of anesthetic maintenance of thoracoabdominal operations along with combined or total intravenous anesthesia shows better hemodynamic changes, as indicated by a 31% increase in SI and a 32.6% decrease in double product with the stable values of mean BP and heart rate, which was not noted in the control group. The dose of narcotic analgesics was decreased by 2.6 times.

[Does pre-emptive analgesia really pre-empt?].

The paper discusses the theoretical background and practical rationale for a concept of pre-emptive analgesia. It gives the results of studying the efficacy of lornoxicam that outstrips the infliction of a surgical injury in different anesthesia modes (combined total and intravenous combined multicomponent anesthesia with epidural block). A hundred thirty-seven patients who had undergone laparoscopic cholecystectomies (Group 1) and expanded interventions for colorectal cancer (Group 2) were examined. The examination provided no evidence for the efficiency of pre-emptive analgesia with lornoxicam during perioperative anesthesia in patients undergone moderately and highly traumatic abdominal interventions.

[Use of average-acting nondepolarizing myorelaxants in abdominal surgery].

The efficiency and safety of use of average-acting nondepolarizing myorelaxants, such as atracurium, vecuronuim, rocuronium, and cisatracurum, during abdominal surgical interventions under general anesthesia (combined or total intravenous anesthesia) were investigated in 162 patients. There is evidence that the use of the above agents ensures a qualitative myorelaxation during different types of operations (laparoscopic and laparotomic) and no impact on hemodynamics (according to the data of continuous non-invasive monitoring) allows these myorelaxants to be used in patients with concomitant cardiovascular diseases. Rocuronium is the myorelaxant of choice for rapid tracheal intubation. The high degree of predictability of the duration of an effect produced by atracurium and cisatracurium enables these myorelaxants to be used without monitoring neuromuscular conduction. With the equally good quality of myoplegia and with virtually comparable consumed diseases, the infusion procedure of relaxation maintenance is preferable for early activation of patients. Insignificant effects on histamine release make it possible to use vecuronium, rocuronium, and cisatracurium in patients with the compromised immune system.

[Epidural block as a component of anesthesiological provision during abdominal operations].

Two modes of general anesthesia with artificial ventilation in combination with epidural block differing in a hypnotic component (inhalational or intravenous) were studied in 27 patients. A combination of general and epidural anesthesia afforded the best protection from surgical stress during major abdominal operations. Inhalational or intravenous anesthetics may be equally used to induce unconsciousness. The fact that there may be blood loss is not an absolute contraindication to epidural anesthesia. The safety and controllability of combined anesthesia increase when its individual components are monitored and the protocol is strictly observed. There is a need for further development of objective criteria for efficient regional block under general anesthesia.

[Use of different types of target propofol concentration-control infusion: theoretical and practical aspects].

Examinations were made in 105 patients who had undergone total intravenous anesthesia on the basis of the immune circulating components (ICC) of propofol by different pharmacokinetic models--Marsh and Schnider, by aiming at plasma or an effector zone. Along with good controllability of ICC-anesthesia, with theoretical and practical differences of the employed models are shown. The capacities of an up-to-date universal perfusor are demonstrated, by using Asena PK as an example. Practical recommendations on its application are given. The prospects of anesthesia automation are briefly discussed.

[Safety and quality of myoplegia in different types of abdominal surgeries]. / Bezopasnost' i kachestvo mioplegii pri razlichnykh tipakh abdominal'nykh vmeshatel'stv.

The efficiency of new non-depolarized myorelaxants, i.e. of rocuronium and cisatracurium, in abdominal surgery with general anesthesia (combined or total intravenous anesthesia) of 114 patients was evaluated clinically and accelerometrically. The use of the above drugs at 2 x ED95 was confirmed to ensure a high-quality myorelaxation in different surgery variations (laparoscopy or laparotomy). A lack of effect on the hemodynamics (according to continuous non-invasive monitoring) and release of histamine (according to radioimmunology assay) make it possible to use the myorelaxants in patients with concurrent cardiovascular disease and with burdened allergic history. A bigger degree of prognosticated effect duration is typical of cisatracurium versus rocuronium, whereas the latter is a myorelaxant of choice in case a fast trachea intubation is needed.

[Effect of carboxyperitoneum on duration of the action of some non-depolarizing muscle relaxants]. / O mekhanizme vliianiia karboksiperitoneuma na dlitel'nost' deistviia nekotorykh nedepoliarizuiushchikh miorelaksantov.

Changing pharmacokinetics of muscle relaxants with the organ-dependent metabolism (pipecuronium), which is related with the effect exerted by carboxyperitoneum on the patient-body temperature hemostasis and on the renal function are under discussion in the paper. It was demonstrated that carboxyperitoneum affects independently the decreasing body temperature and prolonged effect duration of pipecuronium. The conclusion is that the use of muscle relaxants with the prevailing organ-dependent elimination (atracurium and cysatracurium) is more preferable versus pipecuronium in laparoscopic surgery.