[Analgesia in hemophiliac patients during orthopedic surgery].

AIM: To develop an effective and safe analgesic regimen (by minimizing the proportion of narcotic analgesics) in hemophiliac patients in the perioperative period during high-trauma surgeries (total knee and hip replacements). SUBJECTS AND METHODS: The prospective study included 24 patients aged 22 to 57 years (median age 38 years) with severe congenital hemophilia A (n = 22) and B (n = 2), who had undergone knee (n = 18) or hip (n = 6) replacements in the Hematology Research Center, Russian Ministry of Health of the Russian Federation, in 2013. Two analgesic regimens (a) paracetamol with trimeperidine; b) paracetamol and ketamine with trimeperidine) were used. To assess pain intensity, the authors used scoring scales: a visual analogue scale (VAS) and a numeric rating scale (NRS). The effect of paracetamol on hemostasis was evaluated on the basis of thromboelastogram and coagulogram readings. Possible paracetamol hepatotoxicity was assessed analyzing liver enzymes. RESULTS: An interview has shown that 66% of the hemophiliac patients regularly take analgesics for chronic pain syndrome, among them 29% use narcotic analgesics. It is difficult to achieve perioperative analgesia in these patients. The dosage of narcotics can be decreased (that of trimeperidine on an average from 80 to 45 mg/day) in the early postoperative period if non-narcotic analgesics, such as paracetamol 4 g/day, are incorporated into the analgesic regimen. Paracetamol promotes pain relief to moderate and mild (not more than 40-50 VAS scores and 3-4 NRS scores), without affecting hemostasis (the thromboelastogram readings differed statistically insignificantly; the coagulation index was 0.6-1.6) and without having a hepatotoxic effect. CONCLUSION: The systemic use of analgesics in hemophiliac patients considerably makes postoperative analgesia difficult. The use of paracetamol with trimeperidine within the first 24 hours after high-trauma surgeries in hemophiliac patients (even if they have hepatitis C) is rather effective and safe.

[Thrombocytopenia and postoperative analgesia].

OBJECTIVE: To develop effective and safe measures of postoperative multimodal analgesia (optimizing the use of narcotic analgesics) in surgical treatment of hematological patients with thrombocytopenia. DESIGN: A pilot and prospective comparative controlled study. METHODS: We studied 27 patients with acquired thrombocytopenia who underwent laparoscopic splenectomy. Three schemes of anesthesia were used: 1) Nefopam 20 mg/day + trimeperidin (n = 7); 2) Paracetamol 4 g/day + trimeperidin (n = 10); 3) paracetamol + trimeperidin + glucocorticosteroids (GC) (through treatment of the underlying disease) (n = 10). Analgesic properties and effect of each scheme were assessed according to a rating scale of pain NRS (10 points) and VAS (100 points) studied. Additionally we evaluated the effect of nefopam and paracetamol on the functional properties of platelets and hemostasis, platelet levels while monitoring and indicators of thromboelastogram (TEG). RESULTS: Application of paracetamol + trimeperidin accompanied with effectively reducing of postoperative pain (less than 5 points on the NRS). The level of postoperative pain was lower in patients who were treated with corticosteroids within the therapy of the underlying disease before surgery and who continued to receive it in postoperative period (2-3 points NRS). Nefopam use in the perioperative period is not only inferior to the analgesic effect of paracetamol, but also causes frequent side effects. Consumption of narcotic analgesic--trimeperidin when applying nefopam averaged 43 mg/day, the appointment of paracetamol--28 mg/day, using a combination of paracetamol + GC--20 mg/day. Thus, GC within the underlying disease treatment substantially reduces the need for opioid analgesics. A monitoring of the number of platelets and TEG did not shows negative effect of paracetamol and nefopam on platelet and plasma hemostasis. CONCLUSIONS: Nefopam and paracetamol may be used in patients with thrombocytopenia, as do not affect the hemostasis and platelet count. Application of postoperative analgesia scheme paracetamol + trimeperidin in patients receiving corticosteroids provides the maximum reduction of pain with the least consumption of narcotic analgesics.

[Fibrinolysis system in patients with sepsis in state of myelotoxic agranulocytosis].

PURPOSE: Hemostasis disorders are the part of multiple organ failure (mOF) in sepsis. This work objective is to evaluate the system parameters in septic patients. PATIENTS AND METHODS: 55 oncohaematological patients were included in study: 45 with sepsis and 10 patients in control group (no signs of infection). Septic patients were subdivided into septic patients without multiple organ failure, patient with multiple organ failure and patients with septic shock. The C-reactive protein (CRP), procalcitonine (pCT), interleukine-6 (IL-6) serum concentration and fibrinolysis parameters were measured Patients were examined daily during first 5 days, later once a week during 28 days, control group was examined one time. RESULTS: Levels of CRP IL-6 and PCT were raised since 1st day. PCT and IL-6 concentrations were higher in sepsis and MOF group and septic shock group, than in sepsis without MOF group. CRP was raised in all patients. PCT went to normal at 7th day, CRP and IL-6 have started to decrease after 7th day, but both were higher than in control group. T-PA and plasmin inhibitors were comparable to control group and haven't changed significantly. Septic shock patients and patients with MOF have shown a decrease of plasminogen activity. Patients without MOF have shown an initially decreased plasminogen activity, but after 2 days it was similar to control group. PAI-I activity was increased only in septic shock and MOF groups in first days, and was similar to control group in cases of no MOF. Exended XIIa-dependent fibrinolysis time in average was present in all septic patients since 1st day, and extended twice in MOF and septic shock groups. Clot lysis time tended to decrease starting from 8th day, but it was longer than in control group till 28th day. A raised D-dimer concentration compared to control group was present in 75% of patients, but no difference was found among subgroups. A raised D-dimer serum concentration was relevant for prognosis. CONCLUSION: The most sensitive diagnostic test in sepsis is XIIa-dependent fibrinolysis. Plasminogen and PAI-I activity changes are mostly present inpatient with MOF and septic shock. The 28-day survival rate was 60% in MOF and septic shock groups and 95% in no MOF groups. A raised D-dimer concentration was found in 75% of septic patients.

[Combined chemotherapy for hemoblastoses and therapy for acute respiratory failure in intensive care conditions].

AIM: To study the efficiency of polychemotherapy (PCT) for hemoblastoses in acute respiratory failure (ARP). SUBJECTS AND METHODS: The case histories of 63 hemoblastosis patients with ARF who received PCT were examined. The patients were divided into 3 groups: 1) 40 patients with acute leukemia (AL); 2) 15 patients with lymphomas; 3) 8 with multiple myeloma (MM). RESULTS: The duration of lung lesion in leukemia was less than that in myeloma and lymphomas (2.5 +/- 5.3 versus 12.8 +/- 30.6 and 21 +/- 10.2 days, respectively). In the patients with leukemia and lymphomas, PCT was initiated earlier than in those with myeloma (1.5 +/- 0.5 versus 1.75 +/- 3.1 and 8.3 +/- 10.9 days, respectively). In 65.1% of the patients, PCT resulted in agranulocytosis, the rate and duration of which did not differ in the groups. APACHE II scores were 23.5 +/- 4.2; PaO2/FiO2 was 182.1 +/- 60.5. The groups did not differ in disease severity. Noninvasive ventilation was made in 22 patients. Artificial ventilation (AV) was used in 39 patients; it was successfully completed in 13 (33.3%) patients. The most common infectious complications were sepsis (60%), septic shock (27%), and bacteremia (16%). Sepsis was encountered twice more frequently in lymphomas and myeloma, and septic shock was 4 times more commonly in leukemias. In myeloma, bacteremia was seen more frequently than in leukemia (50 and 10%; p = 0.024); serum procalcitonin was > 10 ng/ml (100 and 35%); p = 0.028). In leukemias, lymphomas, and myeloma, 28-day survival was 60, 60, and 75%, respectively. The baseline APACHE II disease severity, the degree of hypoxemia, and the presence and duration of agranulocytosis did not determine prognosis. The poor predictors were consciousness impairment, AV, renal failure, and no response to chemotherapy.

[Treatment of life-threatening airway obstruction in patients with malignant lymphomas].

Case histories of patients with hemoblastosis admitted to a hospital for acute respiratory failure due to tumor-induced obstruction were retrospectively analyzed. The causes of obstruction, antitumor therapy, methods for provision of airway patency, and major critical syndromes were analyzed. Ten patients with life-threatening tumor-induced airway obstruction were hospitalized from 1995 to 2007. The patients suffered from malignant lymphomas in all cases. The causes of impaired airway patency were the compression of the trachea and large bronchi with a tumor, lymph nodes, affected thyroid, as well as the superior vena cava syndrome, and tumor-induced lesion of soft tissues of the neck and chest. Airway patency was effected with tracheal intubation in 9 cases, it was maintained by noninvasive mask ventilation in 1 patient. Translaryngeal tracheal intubation and tracheostomy were used for artificial ventilation (AV) in 6 and 3 patients, respectively. Multidrug therapy (MDT) was performed in all the patients. Airway patency restored in 9 patients after MDT initiation. The duration of AV was 5.8 +/- l.7 days. The length of stay in an intensive care unit was 90%; intrahospital survival was 70%; 28-day and 3-year survivals were 90 and 24%, respectively. Two of the 3 patients who had undergone were observed to have serious complications (cicatrical stenosis, tracheoesophageal fistula). Hemoblastosis patients with tumor-induced obstruction need for provision of airway patency and for immediate initiation of MDT and/or radiotherapy. Orothracheal or nasotracheal intubation of the trachea is the methods of choice in providing airway patency. Tracheostomy is not indicated in most cases. Short-term prognosis is good in this cohort of patients. Long-term prognosis is determined by a lot of factors of which tumor sensitivity to cytostatics and radiation is most important.

[Lung biopsy in the diagnosis of causes of lung involvement in hemoblastosis]. / Biopsiia legkogo v diagnostike prichin porazheniia legkikh u bol'nykh gemoblastozami.

AIM: To ascertain the role of lung biopsy in diagnosis of lung lesions in hemoblastosis (HB) patients. MATERIAL AND METHODS: The results of diagnostic biopsies of the lungs obtained from 22 HB patients are presented. Ten patients had no respiratory insufficiency (RI), twelve patients had RI. The biopsy was transbronchial in 1 case, thoracoscopic in 10 and open in 11 cases. RESULTS: In RI-free patients lung biopsy was informative in all the cases. The biopsy provided information which allowed therapy modification resulting in improvement of the patient condition. In RI patients biopsy was informative in 8 of 12 patients. Nonspecific changes in the lungs were identified histologically in 2 of 12 patients. In 2 RI patients lung biopsy confirmed the diagnosis made after examination of the bronchoalveolar lavage. Modification of therapy after the biopsy was conducted in 58.3% HB patients with RI. Improvement was seen in 2 of them. 10 of 12 patients with RI died within 1-2 weeks after biopsy. CONCLUSION: Lung biopsy in HB patients should be obtained only after examination with noninvasive methods and before development of RI as prognosis after lung biopsy in the presence of RI is unfavourable. The histological material should be examined for all expected pathogens.

[Dilatation tracheostomy in patients with hemorrhagic syndrome]. / Osobennosti dilatatsionnoi trakheostomii u bol'nykh s gemorragicheskim sindromom.

Specific features of dilatation tracheostomy (DTS) were studied in 45 patients with hemorrhagic syndrome; 37 of them had thrombocytopenia; 6 patients had thrombocytopenia and disseminated intravascular coagulation (DIC); and 2 patients had congenital coagulopathy. Besides, there were patients, among the examined ones, with hemoblastosis (36), with idiopathic thrombocytopenic purpura (1), with aplastic anemia (1), with HELLP-syndrome (1), with diabetes mellitus (1), with rheumatoid arthritis, with stomach cancer (2) and with hemophilia A (2). Commercial sets were made use of for DTS ("Portex"). DTS can be safely made provided the blood platelets' level is not below 40-50 x 10(9), and the time of bleeding is below 3 min; in hemophilia, the procedure is possible after the administration factor's preparations; and in DIC--after plasma transfusion and after ensuring the normal coagulation. Obturation of lumens of the trachea and bronchi with blood grumes is an often complication in DTS, which makes it necessary to make bronchoscopy immediately after DTS.

[Procalcitonin--marker of infectious inflammation: clinical value and application]. / Prokal'tsitonin--marker infektsionnogo vospaleniia: klinicheskoe znachenie i oblast' primeneniia.

The development of septic shock is accompanied by an essential increase of the level of Procalcitonin (PCT). The growth of the PCT level in blood is often associated with bacteremia. A-->2 ng/ml PCT increase in patients with agranulocytosis makes it possible to distinguish between the pneumonia as a local focus of infection and the pneumonia in sepsis. A high PCT level in bacterial and fungus infections makes it possible to distinguish them from viral and non-infection diseases.

[Tumor necrosis factor, interleukin-6, endotoxin and procalcitonin in septic shock in patients with hematologic neoplasms]. / Faktor nekroza opukholi, interleikin-6, éndotoksin i prokal'tsitonin pri septicheskom shoke u bol'nykh s opukholevymi zabolevaniiami sistemy krovi.

AIM: To study changes in proinflammatory markers and mediators in septic shock in patients with hematologic malignancy (HM). MATERIAL AND METHODS: The examination of 33 patients with HM and septic shock included measurement of plasma concentrations of tumor necrosis factor (TNF), interleukine-6 (IL-6), endotoxin, procalcitonin (PCT) 12-24 hours before and each 12 hours after shock; registration of central hemodynamics parameters, the condition severity by APACHE II. RESULTS: Out of 33 patients 18 died of refractory shock, 15 survived the shock. Within the first shock hour TNF fell from 571.2 +/- 195 to 115.8 +/- 71.1 pg/ml (p < 0.02), later being stable. In those who died and survived TNF was the same. IL-6 fall was seen 36 hours after shock and was observed in the survivors; in those who died IL-6 was unchanged. Endotoxin in the blood was detected in 21 of 33 patients. In the survivors endotoxinemia declined after 2 days of treatment. 72 hours after beginning of the shock the survivors had no endotoxin. In shock APACH II severity of the patient's condition was graver in patients with endotoxinemia than without it (31.6 +/- 1.6 and 28.1 +/- 1.6 scores, p < 0.05). Blood endotoxin levels and APACHE II scores correlated (r = 0.24, p < 0.05) positively and negatively with deficiency of buffer bases (r = -0.29, p < 0.05) and blood pH) r = -0.3, p < 0.05), left ventricular contractility index (r = -0.46, p < 0.01) and right ventricle (r = -0.52, p < 0.01), mean AP (r = -0.22, p < 0.03). PCT concentration was lower before shock than on its hour 1 (4.2 +/- 2.9 and 6.9 +/- 1.1 ng/ml, p < 0.05). No significant changes in PCT were found later. CONCLUSION: PCT is a specific marker of a severe infection. Rapid elimination from the blood of TNF and IL-6 makes them inadequate in sepsis diagnosis. Endotoxinemia aggravates the patients condition. Positive LAL-test results were obtained in gram-negative and fungal infections.

[Diagnosis of pulmonary lesions in acute respiratory insufficiency in patients with depressed hemopoiesis]. / Porazheniia lëgkikh pri ostroi dykhatel'noi nedostatochnosti u bol'nykh s depressiiami krovetvoreniia.

AIM: To analyse causes of acute respiratory failure (ARF) and methods of diagnosis of pulmonary lesions in patients with depressed hemopoiesis (DH). MATERIAL AND METHODS: 50 patients with DH and ARF were examined according to the protocol including x-ray, computed tomography, fibrobronchoscopy with bronchoalveolar lavage, cytological, bacteriological, virusological studies of the lavage fluid, biopsy of the lung. The algorithm of the protocol is provided. RESULTS: Sensitivity of the lavage fluid in diagnosis of fungal, bacterial, pneumocystic and cytomegaloviral infections was 84, 78, 93 and 93%, respectively. The cytologic examination of the lavage fluid may detect lung infiltration with blood tumors. In complicated diagnostic cases lung biopsy verified pulmonary lesion but its conduction aggravated the patients' condition. ARF patients with DH, bacterial flora, fungi, cytomegalovirus and pneumocystic infection, pulmonary tumor involvement, pulmonary lesions in ATRA-syndrome, non-infectious lesions of the lungs after bone marrow transplantation were found in 38, 18, 40, 18, 8 and 4% of cases, respectively. CONCLUSION: DH patients with ARF should be examined by the protocol including both non-invasive and invasive diagnostic methods. Accurate diagnosis of ARF causes is the basic reserve in the treatment of such patients.

[Noninvasive ventilation of the lungs in the treatment of acute respiratory failure in immunocompromised patients]. / Neinvazivnaia ventiliatsiia legkikh v lechenii ostroi dykhatel'noi nedostatochnosti u immunokomprometirovannykh bol'nykh.

The purpose of this study was to evaluate the efficiency and place of noninvasive ventilation of the lungs (NVL) in the treatment of hypoxemic acute respiratory failure (ARF) in patients with tumorous diseases of the blood. The study was carried out in 12 patients (3 men and 9 women) with tumorous diseases of the blood system, in whom NVL was used for treating ARF. Central hemodynamic and oxygen transport parameters were studied using Swan-Hanz catheter. NVL was uneventfully carried out in 5 (41.7%) of 12 patients (group 1). Group 2 consisted of 7 patients intubated after the beginning of NVL: 2 had to be transferred to forced ventilation of the lungs (FVL) because of loss of consciousness and 5 because of augmenting severity of ARD. All patients transferred to FVL died. During the first 3 h of NVL, oxygen delivery increased from 371.3 +/- 84.9 to 443.9 +/- 92.7 gm/m2 and oxygen consumption from 123.9 +/- 35.9 to 173.5 +/- 34 m/m2, oxygen alveolar-arterial difference decreased from 400.8 +/- 165.3 to 210 +/- 57.5 mm Hg, pulmonary shunt from 41.8 +/- 11.9 to 19 +/- 7.9%, PaO2/FiO2 from 140.4 +/- 210 +/- 84.9, left-ventricular stroke index increased from 38.2 +/- 14.9 to 50.6 +/- 21.8 ml/m2, left-ventricular output index from 37 +/- 19.5 to 47.4 +/- 23.7 gm/m2, and heart rate decreased from 119.2 +/- 17.5 to 111.4 +/- 23.8 min-1. In group 2 greater fraction of inhaled oxygen and higher positive pressure at the end of inspiration were required than in group 1. Heart rate and oxygen alveolar-arterial difference were higher in group 2. Side effects of NVL were skin maceration, hematomas on the bridge of the nose, and conjunctivitis. A specific complication associated with thrombocytopenia was the hemorrhagic syndrome (nasal bleeding, hemorrhagic stomatitis). Hence, NVL is the first stage of respiratory support in hypoxemic ARF. In immunocompromised patients NVL is effective only in cases when the cause of damage to the lung is rapidly diagnosed and effective pathogenetic therapy promptly started.

[Multiple-organ pathology in septic shock in patients with hemoblastoses]. / Poliorgannaia patologiia pri septicheskom shoke u bol'nykh s gemoblastozami.

A prospective study of 20 patients with hemoblastosis and septic shock (SS) was carried out by invasive monitoring of the central hemodynamics and oxygen transport, evaluation of biochemical and coagulological parameters, and assessment of the severity of clinical condition by the APACHE II and SOFA scores. Septic shock was effectively treated in 12 patients, 5 of them were discharged from the department (group 1) and 7 died in intensive care wards from various complications (group 2). Eight patients died during the first 2 days from SS resistant to therapy (group 3). Group 2 patients were in need of a longer inotropic support than group 1 patients (5.8 +/- 1.6 vs. 2.7 +/- 0.8 days, p < 0.01). The deficit of bases was more expressed in groups 2 and 3 in comparison with group 1 (-11.3 +/- 3 and -2.7 +/- 9.1 mmol/liter vs. 1.4 +/- 4.4 mmol/liter) and left ventricular stroke index (LVSI) and oxygen delivery were lower. LVSI and base deficit were in linear correlation (rho = 0.4, p < 0.05). XIIa-dependent fibrinolysis was suppressed in all patients, which was more pronounced in group 3 in comparison with groups 1 and 2 (135 +/- 47.4 vs. 103 +/- 27 and 88.3 +/- 42.3). According to SOFA score, the severity of cardiovascular disorders during day 1 of SS was the same in all groups, while starting from day 2 it decreased in patients who survived. Acute respiratory failure was lower in group 1 only on day 1 according to SOFA. More pronounced (according to SOFA) hepatorenal failure was observed in group 2 in comparison with other patients. Organ involvement in hemoblastosis was detected at autopsy in 8 out of 13 cases. Hence, the need in prolonged cardiovascular support of SS patients is associated with development of polyorgan involvement. Fibrinolysis suppression is a frequent early manifestation of hemostasis disorders. Specific neoplastic organ involvement was observed in 61.5% patients with hemoblastosis who died from SS and its complications.

[Clinical manifestations, diagnosis and course of Pneumocystis carinii pneumonia in patients with hematologic diseases]. / Klinicheskie proiavleniia, diagnostika i techenie pnevmotsistnoi pnevmonii u bol'nykh s zabolevaniiami sistemy krovi.

AIM: To characterize clinical, diagnostic and course features of pneumonia caused by Pneumocystis carinii (PC) in hematologic inpatients. MATERIALS AND METHODS: 27 patients with blood diseases were studied. 22 of them had acute respiratory insufficiency and 5 had unclear lung affection. The data from bronchoalveolar lavage (BAL), lung biopsy, serum tests for IgG, IgM anti-PC-antibodies were used for diagnosis of PC-pneumonia. RESULTS: PC-pneumonia was diagnosed in 8 of 27 patients. Clinical manifestations characteristic for PC-pneumonia were not found. In 5 patients the diagnosis was made on the evidence provided by BAL. Lymphocyte count in BAL was elevated to 27.7 +/- 8.7%. Open biopsy of the lung and transbronchial biopsy diagnosed PC-pneumonia in 2 and 1 patients, respectively. Previous BAL examinations failed to detect PC-pneumonia in 2 of them. In all the patients PC-pneumonia was associated with another infection (bacterial, cytomegaloviral). Histologically, the picture of the disease was determined by the severity of the lung affection or its complications. 5 of 8 patients failed treatment with trimethoprim-sulphamethoxazole and died. Marked respiratory insufficiency was registered at PC-pneumonia diagnosis in all the lethal cases. CONCLUSION: Clinical and x-ray pictures of PC-pneumonia in hemoblastosis patients are not specific. All such patients with symptoms of lung infection resistant to antibacterial and antifungal therapy should be examined for PC-pneumonia.

[Criteria of systemic inflammatory response syndrome are unacceptable in the diagnosis of sepsis in patients with leukopenia]. / Kriterii sindroma sistemnogo vospalitel'nogo otveta nepriemlemy dlia diagnostiki sepsisa u bol'nykh s leikopeniei.

Twenty-two patients with hemoblastosis were examined in order to evaluate the possibility of using the criteria of the total system's inflammatory response syndrome (TSIRS) for the diagnosis of sepsis in hemoblastosis patients with leukopenia. The patients were examined before and after chemotherapy. Twelve patients with myelotoxic leukopenia developed TSIRS in response to a concomitant infection. No intensive care and resuscitation were needed in 9 of them; antibiotic therapy rapidly improved the clinical status. Three of these patients had to be transferred to intensive care wards. These patients differed from patients with TSIRS who needed no intensive care and from patients without TSIRS by higher fever (39.6 +/- 0.9, 39.1 +/- 0.4, and 36.5 +/- 0.7 degrees C, respectively), tachycardia (114.1 +/- 19.1, 105.3 +/- 12.8, and 84.0 +/- 10.0 stroke/min, respectively), thrombocytopenia (35.4 +/- 33.2.10(9), 55.1 +/- 34.5.10(9), and 89.2 +/- 95.1.10(9)/liter, respectively), prolongation of XIIa-dependent fibrinolysis (161.0 +/- 67.5. 64.7 +/- 57.0, and 46.2 +/- 45.8 min, respectively), decreased content of antithrombin III (79.6 +/- 8.1, 102.0 +/- 16.2, and 98.9 +/- 11.9%, respectively), and a more grave status according to the APACHEII score (20.4 +/- 5.2, 15 +/- 2.0, and 10.8 +/- 3.2, respectively). The APACHEII score and XIIa-dependent fibrinolysis were in direct correlation. We consider that the TSIRS/sepsis criteria are highly sensitive but not specific. They just permit singling out the group of patients part of whom may have sepsis.

[The course and prognosis of septic shock in patients with hemoblastoses and aplastic anemia in a state of agranulocytosis]. / Techenie i prognoz septicheskogo shoka u bol'nykh gemoblastozami i aplasticheskoi anemiei v sostoianii agranulotsitoza.

The course and prognosis of septic shock developing during agranulocytosis were retrospectively studied in 59 hematological patients (52 ones with hemoblastosis and 7 with aplastic anemia). Out of 59 patients with septic shock hospitalized at department for anesthesiology and reanimation, in 5 shock was arrested and they were transferred to other departments of the hospital. All patients with failure of more than three organ systems, with SAPS score of 21 at admission, and a history of splenectomy died in the anesthesiology and reanimation department. The diagnosis of the underlying disease, resistance to chemotherapy administered, disease stage, persistent agranulocytosis, and artificial ventilation of the lungs which had to be resorted to did not influence the prognosis of septic shock. Even after effective antishock therapy all patients with aplastic anemia died, as did the patients with resistance to chemotherapy administered for the underlying disease and those without signs of granulocytopoiesis recovery. Hence, the prognosis is unfavorable for patients with septic shock in a state of agranulocytosis, if their SAPS score on admission is higher than 21, if they develop polyorgan failure with involvement of more than three organ systems, have a history of splenectomy, their hemoblastosis is resistant to chemotherapy, and there are no prospects for granulocytopoiesis recovery.

[Acute respiratory insufficiency in hemoblastoses: evaluation of treatment effectiveness by survival rate]. / Ostraia dykhatel'naia nedostatochnost' pri gemoblastozakh: otsenka éffektivnosti terapii po vyzhivaemosti.

Acute respiratory failure (ARF) is a typical complication of chemotherapy for hematologic malignancies. Despite the effective correction of gas exchange by mechanical ventilation, the mortality in this population is expected to be extremely high due to unavoidable fatal infection of immunocompromised host and the poor prognosis of primary malignancy. However, modern specific treatment of leukemia and lymphoma has made these conditions curable in many cases, and even severe myelotoxic neutropenia does not always lead to uniformly fatal outcome. We studied survival in 113 cases of ARF retrospectively selected according to the uniform criteria of this syndrome. No selection was made as to the diagnosis, stage, and response to the treatment of the underlying disease. The group consisted of 51% male and 49% female patients aged 34, on an average; 69% of these with acute leukemia, 22% with malignant lymphoma, and 9% with other conditions. Sixty-five (58%) patients were subjected to mechanical ventilation (MV). Forty-two were treated after a Protocol on intensive care of ARF which contained standard requirements to management of patients. Another group of 71 patients admitted to intensive care units before this Protocol was introduced were historical controls. Total survival was 19.5%. In the MV group survival was 15% with 10 cases of cure, ARF developing during severe neutropenia in 3 out of these 10 cases. The results became evidently better after the Protocol was introduced, improving from 16 to 27%. The primary disease dramatically influenced the results: long-term survival was significantly poorer in patients with relapses and resistant to chemotherapy, with 100% mortality within 8 months after discharge. A conclusion is drawn that intensive care of ARF including MV is justified in patients with hematologic malignancies, except cases when primary malignancy is not properly treated or resistant to specific chemotherapy.