[Early progressive organ failure in patients with severe acute pancreatitis].

The aim of the study was to investigate the role of early multiple organ failure in 152 patients with severe acute pancreatitis admitted to the intensive care unit for the period from 2002 to 2009. The group of patients with early progressive multiple organ failure had high early (29%) and overall mortality (45%) rate, infectious complications rate (39%) and long intensive care unit stay (median - 8 (5; 18) days). Based on the statistical analysis of data the criteria to predicted risk progression of multiple organ failure on admission were: APACHE II score ≥12, SOFA score ≥4, failure >2 organs/systems, Ranson score ≥7.

[Pattern dynamics of bacteriemia and sepsis pathogens in ICU patients of emergency service].

The results of microbiological tests of 2382 blood specimens from 698 patients of three ICUs of the N. V. Sklifosovsky Research Institute of Emergency Service were analysed for a period of 2009 to 2012. No microbial growth was detected in 1160 specimens (48.7%). In the subsequent tests 816 isolates were used. The quota of grampositive isolates in the pathogen pattern decreased from 51.68 to 35.9% and that of gramnegative isolates increased from 38.26 to 48.1%. The number of the Candida isolates increased from 7.38 to 15.2%. The frequency of the S. aureus and Enterococcus spp. isolates lowered from 26.2 to 13.3% and from 15.4 to 11.5% respectively. The quota of K. pneumoniae isolates and Acinetobacter spp. increased from 8.1 to 18.9% and from 14.1 to 17.4% respectively. Most of the S. aureus isolates were methicillin resistant. All the staphylococcal isolates were susceptible to vancomycin and linezolid. All the strains of K. pneumoniae isolated in 2009-2012 produced extended spectrum beta-lactamases. In 2012 7.8% the K. pneumoniae isolates were resistant to carbapenems. In 2012 25.5% of the Acinetobacter spp. isolates were susceptible to carbapenems and 70.2% were susceptible to cefoperazon/sulbactam.

[Permanent venovenous hemofiltration in the complex therapy of severe acute pancreatitis].

Regardless of modern achievements in intensive therapy the mortality from severe acute pancreatitis progressed to a polyorganic insufficiency reaches 60%. Analysis of mortality structures shows that more than 50% of patients die from severe acute pancreatitis in first 72 hours, which is indicated as early severe pancreatitis. In the recent years the experimental and clinical studies proved that continuous vein to vein hemifiltration in the early stage allowes to lower the severity of poliorgan insufficiency and early death. The aim of the study was to measure the efficiency of vein to vein hemifiltration in the complex treatment of early severe acute pancreatitis. The retrospective analysis consisted of 106 patients, which were divided into 2 groups. 1st with vein to vein hemifiltration in the dose of less than 30ml/kg/h (n = 45) and more than 30 ml/kg/h (n = 20) respectively, the 3rd group did not receive vein to vein hemifiltration (n = 41). The study showed the decrease of early mortality (14 days) in the 2nd group (p = 0.022) and a tendency of decrease in the 2nd group (p = 0.093) compared to the 3rd group. The median interval from admission to death in the first two groups was 14 days while in the 3rd group it was only 5 days. The use of vein to vein hemifiltration in complex therapy of early severe acute pancreatitis patients allows to lower the early mortality. The best results were reached in the 2nd group.

[Selective adsorption of endotoxin in the complex treatment of patients with severe sepsis].

Severe sepsis and septic shock remain the most serious problem of critical care medicine today with a mortality of 25-80%. Bacterial endotoxin is of considerable importance in the pathogenesis of sepsis. A selective hemosorbent in which endotoxin adsorption is accomplished via its binding to a synthetic peptide (LPS-A) has been recently designed in Sweden. The purpose of the study was to evaluate the efficiency of using the LPS-A in the complex treatment of patients with severe sepsis. Eight patients in whom the course of the underlying disease was complicated by the development of gram-negative sepsis in the postoperative period were examined. The patients had an APACHE II score of 20.4 +/- 4.5 LPS-A was performed using the hemosorbent Alteco LPS (Lund, Sweden) and an Aquarius hemoprocessor (Edwards Lifesciences) (U.S.A.). The use of LPS-A caused a significant reduction in endotoxin levels by 2.9 times. The level of procalcitonin was increased in all patients; after a LPS-A session, it was significantly decreased by 1.9 times. The use of LPS-A resulted in diminished tachycardia, elevated blood pressure and could reduce the doses of vasopressor amines. There was an improvement in lung gas exchange parameters. A study of the effect of LPS-A on the immune system showed a significant reduction (36.6%) in neutrophil oxygen-dependent metabolism according to the data of the spontaneous HCT test, a 2.4-fold decrease in large circulating immune complexes, and a rise in the count of mononuclear cells that died both by necrosis and apoptosis, the count of the cells significantly increased by 5.3 times in late apoptosis. A LPS-A session caused a significant drop in the blood level of endotoxin and procalcitonin and it was accompanied by a trend toward better hemodynamics and lung gas exchange and alleviated organ dysfunction. At the same time LPS-A showed the ambiguous effect on immune system parameters, which calls for further study.

[Apoptosis of mononuclear cells and dead leukocytes in venous blood of septic patients].

Apoptosis of mononuclear cells, dead leukocyte and CD95+ lymphocytes content in venous blood of 15 patients were evaluated by flow cytometry within 2-3 day after diagnosis of sepsis. The number of CD95+ lymphocytes increased in 40% of the cases and that of lymphocytes expressing Fas receptor decreased in 27%. The number of mononuclear cells in venous blood increased 7 times compared with physiological norm; this rise was a reliable predictor of the unfavourable outcome of the disease. Elimination of dead leukocytes by granulocytophoresis produced good therapeutic result.

[Immunomodulatory effect of extracorporeal hemocorrection in patients with surgical sepsis].

The study was undertaken to evaluate the immunomodulatory effects of various methods of extracorporeal hemocorrection in septic patients. Thirty-two patients in whom the course of the underlying disease was complicated by the development of sepsis were examined. A package of therapeutic measures involved debridement of an infection focus, de-escalation antibacterial therapy, nutritional support, and immunomodulatory therapy. All the patients underwent procedures of plasma filtration and continuous venovenous hemofiltration; granulocytopheresis was carried out in 5 patients. Granulocytopheresis was shown to eliminate dead leukocytes from the bloodstream within a few hours, which contributed to clinical improvement. Plasmafiltration in patients with sepsis resulted to a reduction in the degree of a systemic inflammatory reaction, to normalization of coagulation homeostasis, which indirectly affected immunological parameters. Continuous venovenous hemofiltration made it possible to make continuous elimination of the low and average molecular-weight substances, corrected liquid balance, and well affected gas exchange in the lung.

[Integral assessment of endogenous intoxication in patients with purulent mediastinitis].

The parameters of endogenous intoxication (EI) were studied in patients with purulent mediastinitis (PM). The integral index of E1--the coefficient C(EI) that included the relative indices (as to the normal values) of the total and effective concentrations of albumin, medium molecular-weight peptides, leukocytic intoxication index, and malonic dialdehyde, was developed. The values multiplied together are C(EI) and reflect the manifestation of EI. The level of EI in patients with PM was ascertained to be much increased on postoperative days 1 and 3. Extracorporeal hemocorrection (plasmapheresis, prolonged venovenous hemofiltration) used in complex therapy diminishes the degree of EI by several times, on day 10 after surgery in particular. The use of C(EI) is shown to considerably increase the diagnostic sensitivity of the early stage of EI, to prescribe adequate detoxifying therapy in time, and to evaluate its efficiency.

[Immunological aspects of the early application of extracorporeal hemocorrection techniques in the complex therapy of purulent mediastinitis].

Acute purulent mediastinitis (APM) is one of the most complicated forms of surgical infection, showing a high incidence of sepsis--from 45 to 100%, mortality rates of 17 to 80%. Sixty-eight patients with APM admitted to the N. V. Sklifosovsky Research Institute of Emergency Care in October 2002 to March 2007 were examined. Postoperatively, all the patients received extracorporeal hemocorrection techniques (EHT): plasmapheresis (PA) via filtration and continuous venovenous hemofiltration (CVVHF). According to the time of initiation of EHT, the patients were divided into 2 groups: 1) 34 patients in whom EHT was initiated within the first 24 hours after surgery; 2) 34 patients in whom it was started on postoperative day 2. The efficiency of early use of EHT in the complex therapy of APM was evaluated. The early initiation of EHT (PA and CVVHF) caused a reduction in endogenous intoxication and the magnitude of a systemic inflammatory reaction, which resulted in the rapidest restoration of the size of major populations and subpopulations of lymphocytes and prevented the development of immune system incompetence. The early use of EHT caused a significant reduction in hospital mortality (11.8 and 35.3% in the early and late EHT use groups, respectively).

[Early application of plasmapheresis for complex treatment of purulent mediastinitis].

Acute purulent mediastinitis (APM) is one of the most difficult forms of surgical infection with severe clinical course and lethality from 17 to 80%. Overall 80 patients with APM were treated; plasmapheresis in postoperative period was used at 66 of them. The main criteria of negative prognosis at the patients with APM were elderly age, high score on APACHE-2, SAPS-2 and SOFA scales, higher level of creatinine and urea serum concentration, hyperglycemia, leucopenia. Early application of plasmapheresis was associated with lower lethality (12.5% at the group with early beginning of plasmapheresis, 35.3% at the group with late beginning, 36.2% at the control group). Plasmapheresis promotes normalization of hemostasis, microcirculation and immune parameters, reduction of intoxication and systemic inflammation syndrome.

[Albumin dialysis (MARS therapy) in patients with hepatic graft dysfunction].

A primary nonfunctioning graft, the complication that develops in less than 5% of patients within the first 24-48 hours after hepatic transplantation, is responsible for high death rates in recipients. Its manifestations are an extremely grave clinical condition, hypotension, unconsciousness, progressive signs of hepatocytic insufficiency with increases in bilirubin levels and serum transaminase activities, addition of renal failure, and development of multiple organ dysfunctions. Eight patients underwent a total of 17 albumin dialysis sessions (1 to 5; mean 2.1). Each session lasted 6 hours. Albumin dialysis caused a significant reduction in the levels of serum bilirubin and its conjugated fraction, by an average of 24.7 +/- 15.1% per session. The activity of the serum enzymes of cytolysis and cholestasis significantly decreased with the parameters being stabilized within 7 days. Stabilization of hemodynamic parameters and better neurological status were noted in patients during treatment. The survival rate was 75% on days 7, 20, and 30. Hepatic retransplantation was made in 2 patients; 4 were discharged home and 2 died from multiple organ dysfunctions. Albumin dialysis used in patients with graft dysfunction provides a possibility of maintaining the patient in the critical period of searching for a donor's organ or regenerating the graft's function.

[The level of dead blood leukocytes in sepsis and the significance of their elimination by extracorporeal hemocorrection techniques].

Sepsis with 18-to-33% mortality also remains the most serious problem of modem medicine today. Forty-five patients treated at the N. V. Sklifosovsky Research Institute of Emergency Care in June 2006 to February 2008 were examined. Twenty-seven primary blood donors were examined to determine the physiological concentration of dead leukocytes. Two groups of patients were formed according to the signs of a systemic inflammatory reaction (SIR). A study group included 29 patients in whom the course of the underlying disease was complicated by the development of sepsis. All the patients from the study group underwent extracorporeal hemocorrection techniques (EHT): plasma filtration (PF) and continuous venovenous hemofiltration (CVVHF). A granulocytopheresis procedure was performed in 4 patients. A control group comprised 16 patients without clinical signs of SIR. The blood taken from patients with sepsis showed the significant increase in the levels of dead leukocytes as compared with both the physiological normal values and the values obtained in patients without signs of systemic inflammation, which significantly correlates with the severity of organ dysfunction. The elevated content of dead leukocytes is an independent risk factor for a poor outcome. Plasma filtration used in sepsis patients facilitates a significant reduction in the blood concentration of dead leukocytes. The first experience with granulocytopheresis in patients with severe sepsis, a leukemoid reaction and high absolute concentrations of dead leukocytes is indicative of its clinical effectiveness, which is manifested itself by the elimination of dead leukocytes.