[MODERN TECHNOLOGIES OF THE SAVING OF PATIENT'S BLOOD AND REDUCTION OF THE USE OF DONOR BLOOD DURING OPERATIONS ON THE ASCENDING AORTA AND AORTIC ARCH].

Questions of saving of the patient's blood and limitation of the use of donated blood in the aortic surgery remain relevant in contrast with interventions on the valves of the heart and coronary arteries. In this regard, the aim of the study was to develop and introduce ofcomplex of technologies for saving the patient's blood in order to minimize transfusion of donor blood components during operations on the ascending aorta and aortic arch under hypothermic arrest. The study included 37 patients operated on the ascending aorta and aortic arch under cardiopulmonary bypass (CPB) and hypothermic cardiac arrest (CA) in 2013-2014 (Group 1). 2nd group consisted of 65 patients who at the same time performed reconstructive surgery on the ascending aorta with CBP without stopping the blood circulation. The comparative aspect studied the following parameters: duration of the CBP, CA, temperature, volume of intraoperative and postoperative blood loss, frequency of use of donor blood components autoplasma, washed red blood cells, autologous blood, hemostatic agents, the frequency resternotomy, hematocrit dynamics, glucose, and blood lactate. Comparative studies have shown that the amount of intraoperative blood loss during operations on the aortic arch under the CA was 1294 ± 303 mL, 20% higher than the blood loss during operations on the ascending aorta without CA. Program of saving of the blood of patients with aortic disease included preoperative preparation of autoplasma in 60% of patients, intraoperative collection and laundering of autoerythrocytes in 40-70% of patients and autotransfusion modified method, the improvement of surgical and pharmacological hemostasis and monitoring. Design and implementation of these methods reduced the patients need for donor red blood cells (from 76 to 47%), fresh frozen plasma (from 65 to 35%) during the operation at the aortic arch and the ascending aorta and to completely avoid the use of donor blood in 25% of patients. Proof of the adequacy of the developed strategy of conservation and limitation of the patient's blood was allogeneic blood conservation targets hemoglobin, hematocrit levels and metabolism at the end of the operation.

[Strategy of transfusion in cardiac and aortic surgery].

Current trend in transfusion is a decreasing of the donor's blood use due to possible complications. The article deals with analysis of intraoperative blood loss in different surgeries on the heart and aorta and of a role of blood-saving factors in decreasing of the donor's blood transfusion. We found a correlation between the blood components need and type of surgery and assessed a preoperative provision of autoplasma and intraoperative autohemotransfusion with a blood sampling from the right atrium before the beginning of artificial circulation (Complex use of the blood-saving methods with a prophylactics and treatment of hemostasis disturbances allowed the significantly decreasing of the donor's blood use. 50-70% of patients did not receive components of the donor's blood during cardiac surgery.

[Changes in hemodynamics and volemic status during intraoperative blood exfusion in patients with chronic heart failure].

Forty-five patients with dilated cardiomyopathy, NYHA Functional Classes III-IV chronic heart failure with left ventricular ejection fraction 26.98+/-7%, who had undergone surgical left ventricular remodeling using an extracardiac conduit in combination with mitral or tricuspid valve correction and blood exfusion, were examined. Central hemodynamic monitoring was performed, by using a Swan-Ganz catheter in all the patients at surgery. In 11 patients, transpulmonary thermodilution in combination with pulmonary artery catheterization with a Swan-Ganz catheter (PICCO-Plus + VOLEF, Pulsion, Germany) was used in 11 patients to monitor central hemodynamics. Right atrial blood autoexfusion was carried out at a volume of 6-10 ml/kg prior to extracorporeal circulation. At blood sampling, blood pressure (BP), heart rate (HR), central venous pressure (CVP), and pulmonary pressure were in the normal range. There were no significant changes in HR, BP, and CVP after blood exfusion. A significant lowering was noted in systolic and diastolic pulmonary pressure by 20-25%. Under the influence of blood exfusion, there was a reduction in cardiac pump function, which appeared as decreases in stroke index by 24% (p < 0.05) and cardiac index by 18% (p < 0.05). The parameters reflecting left and right ventricular myocardial contractility (functional state index, global ejection fraction, and dPmax) underwent no negative changes. According to the changes in systolic and diastolic BP and total peripheral vascular resistance index, left ventricular postload did not change either. At the same time, global end-diastolic volume index was reduced by 22% (p < 0.05), right cardiac and right ventricular end-diastolic volumes were decreased by 20% (p < 0.05) and 23% (p < 0.05), respectively; the left ventricular end-diastolic volume index tended to be lower. These data suggested that diminished cardiac pump function was caused by a predominant reduction in global preload, as evidenced by volumetric monitoring. At the same time the changes in CVP, BP, and HR did not reflect the altered volemic status. To prevent destabilization of the circulatory system, blood should be sampled just before extracorporeal circulation after aortic cannulation.

[Clinical aspects of autologous blood donation in cardiosurgery].

The paper presents auto donation protocols and a procedure for autodonor plasmapheresis used in cardiosurgical patients, complications, and their preventive measures on the basis of an analysis of 308 autodonor plasmapheresis procedures performed at the Russian Surgery Research Center, Russian Academy of Medical Sciences, in 2007. The preoperative autoblood preservation safety concept envisaging the safety of autodonors during blood donation, the correct storage and issue of autocomponents, and the prevention of adverse reactions to blood exfusion in patients was introduced. The rate of the reactions was 6.4% of the total number of auto donations in cardiosurgical high-risk patients, moderate reaction being most common. The findings indicated that exfusion of 450 ml of blood without previous infusion of plasma substitutes was a cause of collaptoid reactions in 14 cases of the collapse-complicated procedures of autodonor plasmapheresis in cardiosurgical patients (in 70% of the total number of complications). No association was found between of the frequency and severity of complications and the nosological entity, age, and body mass index; however, a further retrospective analysis of 1500 fresh frozen autoblood preservation procedures that have recently made at the Russian Surgery Research Center, Russian Academy of Medical Sciences, is required to have statistically significant data.

[Ways of reducing donor blood components during reconstructive surgery of the heart valves under extracorporeal circulation].

Blood loss and transfusion tactics were analyzed in 131 patients who had undergone correction of one, two, and three cardiac valves under general balanced anesthesia and extracorporeal circulation. The volume of intraoperative blood loss was 869+/-298 ml with the range of 700 to 2000 ml. Packed red cells (PRC) were transfused to 9% of patients; fresh frozen plasma (FFP) in 10%, PRC and FFP were transfused to 17% patients. Donor blood was not used in 63.5% of patients in order to save the patient's blood. It comprised the preoperative storage of autologous plasma in a quantity of 300-700 ml, the modified intraoperative reservation of autologous blood in a volume of 400-1200 ml, and, in 70% of patients, the use of washed autologous red blood cells. The hemostasis protocol included the use of epsilon-aminocapronic acid, aprotinin (trasilol) not more than 2,000,000 KUE, and packed platelets. For adequate heparin neutralization, after administration of the calculated dose of protamine, it was long administered in a dose of 25 mg/hour for 4-5 hours. The developed and introduced comprehensive program for the patient's blood maintenance and blood loss diminution made it possible to avoid transfusing PRC and FFP in more than 60% of patients with a blood loss volume of as high as 1500 ml; and to maintain adequate oxygen balance and hemostasis in the remaining patients.

[Tramadol hydrochloride in the treatment of postoperative shivering]. / Tramadol gidrokhlorid dlia lecheniia posleoperatsionnoi drozhi.

A double blind study of the therapeutic effect of the opioid tramadol hydrochloride (Gruenenthal, Germany) in the treatment of postoperative trembling was undertaken in 2 groups of patients (50 patients in each) versus that of placebo. The results obtained denoted that tramadol at 1-2 mg/kg arrested completely the postoperative trembling or cut significantly its intensity in 49 (98%) patients. Such high efficiency of tramadol as compared to that of other opioids can be explained by its dual mechanism of action. The dependence of an effective tramadol dose on intensity of shivering and on degree of impaired temperature hemostasis was demonstrated. A comparison of hemodynamic parameters observed before and after the administration of tramadol did not reveal any valuable changes in arterial pressure or cardiac beat rate. Mildly intensified sedation was registered in 17 patients, which is typical of all opioids.

[Currently available blood saving methods in a patient at cardiac surgery under extracorporeal circulation]. / Sovremennye metody sokhraneniia krovi bol'nogo pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

Different blood saving methods are analyzed in 2000 cardiac surgical patients undergoing coronary and vascular bypass surgery in 1993 to 2000. The basic blood saving methods are as follows: intraoperative autoreinfusion (normovolemic thermodilution), reinfusion of the patient's blood, preoperative autologous plasma donation in combination with aprotinine, aminocapronic acid, etc. An analysis revealed a decrease in homologous blood components intraoperatively. Red blood cell transfusion decreased from 100% in 1993 to 44% in 2000, fresh frozen plasma and platelet transfusions did from 98 to 39% and from 96 to 1%, respectively. Intraoperative homologous blood transfusion could be avoided in 70% of those undergone coronary bypass surgery.

[Implementation of modern principles of blood saving methods at cardiac surgery under extracorporeal circulation]. / Realizatsiia sovremennykh printsipov beskrovnoi khirurgii pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

The introduction of principles of bloodless surgery into different areas of practical medicine is favoured by not only risks from donor blood transfusion, but also by the results of the researches dealing with the body's adaptation to acute anemia, with the determination of its allowable limits, and with much experience with bloodless operations used in Jehovah's Witnesses. The present study was undertaken to make a scientific-and-practical assessment of actual own blood funds and their introduction in order to decrease or refuse to use donor blood at cardiac surgery under extracorporeal circulation (EC). A retrospective analysis of hemotransfusion policy in 1993-2001 was conducted in over 2000 patients operated on under EC for coronary heart disease, acquired and congenital cardiac diseases at the Open Cardiac Surgery Department, Russian Surgery Research Center, Russian Academy of Medical Sciences. Own blood saving methods, such as intraoperative autohemotransfusion as two modalities, washed autoerythrocytic reinfusion, autoplasma reinfusion, as well as the use of different pharmaceuticals effective in reducing hemorrhage after EC were evaluated. The introduction of the above own blood saving methods may decrease the use of donor erythrocytes and freshly frozen plasma by 2.6 and 1.8 times, respectively, may completely refuse transfusing thromboplasma, assure adequate hemostasis, reduce the incidence of adverse reactions associated with donor blood transfusion in cardiac surgical patients. A complex use of the developed saving donor blood methods and pharmaceuticals aimed at improving hemostasis allowed donor blood transfusion to be completely refused in more than 70% of patients at aortocoronary bypass surgery under EC.

[The effect of serotonin antibodies on the behavior of C57Bl/6 mice in an open field and on the level of monoamines in the brain structures]. / Vliianie antitel k serotoninu na povedenie myshei C57Bl/6 v otkrytom pole i soderzhanie monoaminov v strukturakh golovnogo mozga.

Mice of C57BL/6 strain were singly injected intraperitoneally with antibodies (AB) to serotonin (5-HT). The "open-field" testing in different periods after the AB injection revealed a depression of behavior within 1.5 h which changed for activation within 1 day and, again, depression within 5 days after the injection. The analysis of neurotransmitter content in the sensorimotor cortex and hypothalamus revealed increased levels of serotonin and, especially, dopamine in the cortex within 1 day. The cortex serotonin level within 5 days was also increased. The possible mechanisms are discussed of neurotropic action of AB to 5-HT.

[Clinical, neurophysiological and hemodynamic effects of a new nondepolarizing myorelaxant mivacurium in heart surgery patients]. / Klinicheskie, neirofiziologicheskie i gemodinamicheskie éffekty novogo nedepoliarizuiushchego miorelaksanta mivakuriuma u kardiokhirurgicheskikh bol'nykh.

Thirty patients aged 23 to 65 years with ASA class III operated on the heart under total intravenous anesthesia were examined after the Good Clinical Practice protocol. Mivacurium in bolus dose of 0.2 mg/kg was injected for intubation of the trachea; neuromuscular blocking (NMB) was maintained by a repeated injection of the drug in a dose of 0.15 mg/kg, after which it was infused at a rate of 1 to 10 micrograms/kg/min. Accelerometric control of neuromuscular conduction was carried out by the Organon (Belgium) TOF-Guard device. Central and peripheral hemodynamics was monitored. Side effects of the drug were recorded. Bolus injection of mivacurium in a dose of 0.2 mg/kg caused T1 suppression (90%) after 2.6 +/- 0.7 min. Maximal (97.7 +/- 4.5%) suppression was observed after 4.17 +/- 2.5 min. The conditions of intubation of the trachea after 3.9 +/- 1.8 min in the presence of 78 to 100% T1 suppression (97.7 +/- 4.5%) were considered excellent or good in 96.6% of cases. Clinically and neurophysiologically sufficient muscle relaxation after the first injection of the drug persisted for 27.7 +/- 7.3 min. Minimal rate of infusion for maintaining the NMB at 95 +/- 4% level of T1 suppression was 6.3 +/- 1.7 micrograms/kg/min. Bolus injection of mivacurium in a dose of 0.2 mg/kg for 60 sec involved a 1-3-min drop of the mean arterial pressure by 10.5% and a 10.3% decrease of heart rate. Repeated bolus injection of the drug in a dose of 0.15 mg/kg and its infusion did not change the peripheral and central hemodynamics. The most typical side effect of the drug in a dose of 0.2 mg/kg is short-term reversible reddening of the skin of the face and neck, observed in 20% of patients. The results permit us to consider mivacurium as an effective, safe, and controllable agent, which can be used in cardiosurgical patients.

[Induction of autoantibodies to serotonin and catecholamines in chronically morphine addicted rats with manifestations of abstinence syndrome]. / Induktsiia autoantitel k serotoninu i katekholaminam u khronicheski morfinizirovannykh krys s proiavleniem abstinentnogo sindroma.

The possibility of formation of autoantibodies to neurotransmitters has been studied in experimental model of opiate addiction. Chronic treatment of rats with morphine that leads to formation of dependence, causes induction of antibodies to norepinephrine, dopamine and serotonin. The latter could be considered as indicators of impaired neurotransmitter metabolism. Induction of autoantibodies to neurotransmitters could be a sort of defence mechanism in opiate addiction.

[Changes in protein synthesis in different brain regions following experimental neurosensitization]. / Izmenenie sinteza belkov v raznykh otdelakh mozga krys pri éksperimental'noi neirosensibilizatsii.

Protein resynthesis was studied in CNS structures of rats sensitized with antigens from different regions of the allogenous brain. There was an activation of 35S-methionine incorporation into brain proteins in accordance with the immunization antigen used, and in proteins from other structures. Radiomethionine distribution in brain tissue remained unchanged. Potential mechanisms of protein resynthesis alteration during neurosensitization are discussed.

[Effect of blockaders of cardiac beta-adrenergic structures on the central hemodynamics and contractile function of the myocardium in acute experimental coronary insufficiency]. / Vliianie nekotorykh blokatorov beta-adrenergicheskikh struktur serdtsa na tsentral'nuiu gemodinamiku i sokratitel'nuiu funktsiiu miokarda pri ostroi koronarnoi nedostatochnosti v éksperimente.

The indices of central hemodynamics and myocardial contractile function were studied in 35 dogs before and in different periods after the administration of drugs which block beta-receptors: propranolol, pindolol, and talinolol. The drugs blocking the beta-adrenergic receptors were administered against the background of an intact myocardium to 15 dogs and against the background of acute coronary insufficiency to another 15; acute ischemia was induced in 5 dogs to which the drugs were not given. It was established that beta-adrenergic blocking agents have a beneficial effect in the acute stage of myocardial ischemia; they exert a marked influence on the consumption of oxygen by the myocardium, intramyocardial tension, and the contractile capacity and rhythm of the heart. Talinolol produced the most favourable effect.

[Changes in the state of the blood-brain barrier in rats following experimental neurosensitization]. / Izmenenie sostoianiia gematoéntsefalicheskogo bar'era u krys pri éksperimental'noi neirosensibilizatsii.

The accumulation and distribution of phosphorus radioisotope was studied in different brain areas of rats. These rats were desensitized by antigens of a whole homologous brain and its separate structures. A certain general tendency towards an accumulation of the brain phosphorus was detected after neurosensitization. Besides, in sensitization by separate structures (brain cortex, cerebellum) the most pronounced changes were in the hematoencephalic barrier (HEB) of the corresponding brain areas are less pronounced in other structures. The paper contains data concerning the function of HEB in animals immunized by the medulla oblongata. The found changes in the barrier mechanisms of the HEB in neurosensitization may be one of the pathogenetical mechanisms of certain diseases accompanied by neuroautoimmune processes.