[History of surgical and non-surgical tracheal intubation]. / Istoriya khirurgicheskoi i nekhirurgicheskoi intubatsii trakhei. Ot trostinki do videosignala.

Anesthesiologist daily encounters the need for maintaining an airway patency. This manuscript is devoted to the development of this technique from ancient times to the present. Three areas including tracheostomy, endoscopy and tracheal intubation are comprehensively described.

[Practical aspects of sedation in dentistry]. / Prakticheskie aspekty sedatsii v stomatologii.

In modern dental practice, the use of sedation to eliminate the fear and anxiety of the patient has become frequent. Unfortunately, according to the legislation, the concept of sedation is inseparable from anesthesia and it can only be performed by an anesthesiologist in a group or Department of Anesthesiology and Resuscitation. The article is devoted to a detailed comprehensive review of sedation in dental and surgical interventions in the maxillofacial area. It details the physiological and pathophysiological data of stress and psycho-emotional discomfort. The article indicates drugs for sedation, methods of their administration, features of application, possible complications. Such methods of parenteral sedation as intranasal, inhalation, intravenous are described in detail. Specific problems of sedation, for example, psychomotor agitation in the application of propofol or cough in deep sedation are indicated. It describes the modern data on intraoperative monitoring as an important component of patient safety during sedation. In addition to the Harvard standard the use of capnography and monitoring the depth of sedation by using bispectral index (BIS) is recommended.

[EPISTAXIS DURING NASOTRACHEAL INTUBATION. ATTILA'S SYNDROME.]

BACKGROUND: Nasal bleeding is a common complication during nasotracheal intubation (NTI). This is due to the ana- tomical prerequisites and the hemostatic system failure. Using of various research methods in practice can reduce the frequency of such complications. The purpose of the study is to identify predictors of high probability of epistaxis associated with the NTI and the pecu- liarities of the anatomical mucous membrane structure of the nasal passages, and to assess significance of blood coag- ulationfailures in these cases. MATERIALS AND METHODS: 45 patients (f-25 and m-20), aged 23 to 47 years, with physical status I-IIASA were analyzed. Depending on the degree of surgical trauma manipulation during intubation were formed three groups of patients in whom the NTI was atraumatic, moderately traumatic and overly traumatic. During preoperative period all patients underwent a rhinoscopy. Intubation trauma of the trachea was assessed by visual analogue scale. The results and discussion. The study of the nasal mucosa structure showed that with atraumatic intubation (Group 1; n=9) were dominated by deep type of bedding nonplethoric nonkinking vessels (66.7% ofpatients (n=6)). During mod- erate trauma intubation (Group 2; n=24), superficial and deep vessels were found equally (50% and 50%). In patients with severe trauma during intubation (Group 3; n=13), 100% of the patients, the vessels were located superficially, 75 % were convoluted, plethoric, mucosa contact bleeding. There were no anatomical changes. CONCLUSION: The source of bleeding are superficial, plethoric, kinking vessels of the mucous membrane. Hypocoagu- lation disorders, observed in patients during reconstructive surgeries, exacerbate such bleeding and can lead to fatal complications.

[THE CHOICE OF TRACHEAL INTUBATION METHOD IN RECONSTRUCTIVE MAXILLO-FACIAL SURGERY WITH DIFFICULT AIRWAYS.]

BACKGROUND: The development of modern video - and endoscopic equipment allows for revision and adjust to modern protocols for maintaining patency of the difficult airway, especially in maxillofacial or ENT -surgery. THE PURPOSE OF THE STUDY: Comparison the efficacy ofvarious methods of maintaining the airway patency in the practice of reconstructive maxillofacial surgery. MATERIALS AND METHODS: 89 patients, who were divided into 4 groups, were examined. Group I (n=57) - classic laryngos- copy with the Macintosh blade, group II (n=14) -fiber-optic bronchoscopy (FBS) in clear consciousness. In group III (n=10) tracheal intubation was performed by the blade D-Blade of videolaryngoscope C-MAC (Karl Storz) or McGrath (Aircraft Medical Ltd.). In group IV (n=12) - retromolar endoscope (RAE) intubation by videostylet Shikani (Clarus Medical) and RME Bonfils (Karl Storz). At the time of laryngoscopy and tracheal intubation the duration of tracheal intubation (t), the maximum values of arterial blood pressure and heart rate, galvanic skin response (GSR) (NASTYA, Neyrok, Russia) were analyzed. The results and discussion. Unexpected difficult tracheal intubation occurredfor 31.6 % of the 1st group patients, need two attempts at laryngoscopy and tracheal intubation occurred in the subgroup 1B patients at 61.1 % (n=11), three at- tempts at 33.3 % (n=6), more than three attempts at 5.6% (n=1). FBS is the method of choice in patients with a planned difficult intubation, in cases of facial skeleton severe deformations . At the same time, local anesthesia and sedation is not capable ofproviding psycho-emotional comfort forpatients during FBS procedure. Visualization in 100% of the hy- popharynx structures at the McCormack I-II degree when using the blade D-Blade is appeared. The use of RME should not be recommended for routine planned and especially unexpected emergency difficult intubation. CONCLUSION: Comparison of methods of maintaining the airway allows to adjust the plan of sequential actions in difficult intubation, both planned and in an emergency situation. The effectiveness of blades type D-Blade is confirmed. In patients with facial skull deformity and impaired mouth opening (less than 1.3 cm) method of choice is awake intubation by fibrobronchoscope. The use if retromolar intubation is also justified, but this method may be accompanied by a lot number of failures.

[INFUSION THERAPY IN RECONSTRUCTIVE MAXILLOFACIAL SURGERY].

UNLABELLED: Restricted infusion strategy in combination with antifibrinolytic agents such as aprotinin and tranexamic acid is effective for blood saving in maxillofacial surgery. But reduction of infusion volume can lead to intraoperative hypovolemia. The goal of this study was to assess compensative effect of different regimes of infusion therapy and antifibrinolytics on intraoperative volume status and electrolyte balance in reconstructive maxillofacial surgery. MATERIALS AND METHODS: 65 patients were included in the study. There were 4 groups: (1) Infusion rate 8-12 mg/kg/h and acute normo/hypervolemic hemodilution; (2) 4-6 mg/kg/h and aprotinin 500,000 - 100,000 IU/4 hours; 3.6-8 mg/kg/h and tranexamic acid 8-10 mg/kg every 4 hours; 4.6-8 mg/kg/h and tranexamic acid 8-10 mg/kg every 4 hours and regional analgesia offacial nerves. We assessed parameters of central hemodynamic, peripheral perfusion, water-electrolyte balance and acid-base status. RESULTS: Different infusion strategies were effective in maintaining positive volume balance despite intraoperative blood loss and continuous diuresis. Hypovolemia or peripheral perfusion insufficiency weren't mentioned in the study. Water-electrolyte and acid-base balance was also secured in every case. Nevertheless, CVP and diuresis in the group with infusion rate 4-6 ml/kg/h were near the critical threshold and could be dangerous in poorly controlled intraoperative bleeding. CONCLUSION: The optimal infusion rate for surgical interventions in reconstructive maxillofacial surgery is 6-8 ml/kg/h. Infusion rate 8-12 ml/kg/h can potentially lead to dilutional coagulopathy and thus to increase the volume of blood loss. Infusion rate 4-6 ml/kg/h is associated with relative risk of hypovolemia and can't be recommended.

[Features of maxillary and mandibular nerves imaging during stem regional blockades. From paresthesia to 3D-CT guidance].

There are difficulties in procedure of regional block of 2 and 3 brunches of the trigeminal nerve despite availability of many different methods of nerves imaging. The difficulties are connected with complex anatomy structure. Neurostimulation not always effective and as a rule, is accompanied with wrong interpretation of movement response on stimulation. The changing of the tactics on paraesthesia search improves the situation. The use of new methods of nerves imaging (3D-CT) also allows decreasing the frequency of fails during procedure of regional block of the brunches of the trigeminal nerve.

[Causes and pathogenesis of hypocoagulation in reconstructive maxillofacial surgery].

Anaesthesia for reconstructive maxillofacial surgery can be accompanied with a significant hypocoagulation and blood loss. Possible causes of a hypocoagulation are dilution coagulopathy and disseminated intravascular coagulation. Coagulograms analysis showed that all patients have disturbances of blood clotting system. The main cause of a hypocoagulation is a disseminated intravascular coagulation.

[Tactics of tracheal intubation in patient with tumor of the tongue base].

Anatomic deformations can cause complications during the tracheal intubation in the maxillofacial surgery and otorhinolaryngology. The article deals with a clinical case of tracheal intubation in a patient with the anatomic deformations. Successful tracheal intubation was performed in the patient in conditions of conscious and spontaneous breathing under the local anaesthesia, when a fibreoptic bronchoscopy was not available. Furthermore the article briefly discusses techniques of the tracheal intubation in conditions of anatomic deformations of the upper airways and methods of local anaesthesia for the guttur and hypopharynx.

[Peripheric blockades in plastic and reconstructive surgery: up-to-date trends and prospects (a 30-year experience)].

The article presents the own 30-year experience in the use of more than 1000 prolonged peripheral nerves and plexus block anaesthesia in reconstructive surgery, based on experimental and clinical studies. The evolution peripheric blockades technique is given:from a separate anaesthesia method to balanced anesthesia based on peripheric blockades. The current state of the problem was analyzed according to the literature.

[Video laryngoscopy and retromolar endoscopy in maxillofacial surgery].

The article presents successful intubation experience in 54 patients. Laryngoscopy was performed with McGrath Series 5 laryngoscopy with a difficult airway blade ("Airway Medical") in 46 patients, and retromolar endoscope Bonfils ("Karl Storz") in 9 patients. Technical traits, resulting from the use video laryngoscopy and retromolar endoscope are discussed. It was shown that video laryngoscopy is a high-performance intubation technique, including difficult ones. The possibility of video laryngoscope conduction in case of significant difficulties with mouth opening (max incisors distance of 1.3 cm) and atlantoccipital immobility make this method a real support to fiber bronchoscope intubation. Retromolar orotracheal intubation with Bonfils stylet training is associated with difficulties in case of insufficient endoscopy skills. During intubation the rule should be used: "to enter prorsad, do everything vice versa". The use of videolaryngoscopy and retromolar intubation is a real support for standard laryngoscopy and fiberbronchoscopy during orotracheal intubation including difficult ones. Difficult intubation may result from mouth opening restriction, atlantoocciital immobility and orolaryngopharynx deformation because of edema and rigidity, for example after an osteotomy or tumors presence. Videolaryngoscopy master is easier than retromolar endoscopy, because videolaryngoscope construction, laryngoscopy technique and larynx structures visualization are similar to the classic MAC blades.

[The autonomous nervous system and blood circulation system--homeostasis and homeokinesis during spine surgery].

In 30-surgical patients, operated for degenerative-dystrophic changes of the spine (microdiscectomy), with due regard for initial condition of the ANS (differentiated by Kerdo index), homeokinesis state has been studied. The circulatory system function was controlled with the use of a standard monitoring and central hemodynamics indices, that has allowed to mark out Hyper-and Hypo - eukinetic circulation types. Microdiscectomy performed under combined anesthesia (N2O/ O2 - 0.5) with fentanyl and sevorane. It was found that 68% of the surveyed patients directly before the surgery had a lack of homeokinesis (vagotonia). Comparison of the reaction of the autonomous nervous system and the circulatory system to premedication revealed that the change in the number of vagotonic patients and patients with hypokinetic type of hemodynamics had a direct linear dependence, and the number of sympathotonic patients and patients with hypokinetic type of hemodynamics -- the reverse one. Surgery, intraoperative pharmacological load, change of the body in sympathotonic patients accompanied with changes in Central hemodynamics (low afterload, eukinetic HI values), characteristic for physiological homeokinesis, which was not observed in vagotonic patients, which have remained unsuccessful (dysadaptative) hypokinetic type of blood circulation.

[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.

[Caudal anesthesia and its determinant factors].

In 130 surgical patients with diseases and injuries in the area of the perineum and lower extremities the clinical effects of three modern local anesthetics: 2% solution of lidocaine, 0.5% solution of bupivacaine, 0.75% solution of ropivacaine and their combinations (2% lidocaine and 0.25% bupivacaine solution 2% lidocaine and ropivacaine 0.375% solution) were followed with regard to the influence of increasing volumes of local anesthetics and different rates of drug administration. It is established that an effective caudal anesthesia is provided with all modern local anesthetics, with increasing use of local anesthetic solution to 40 ml provides duration and the prevalence of sensory and motor blocks, the use of mixture of local anesthetics optimizes the development and maintenance of the caudal blockade.

[Sacral anesthesia, perspectives today].

The paper summarizes the experience of Russian and foreign specialists in dealing with the theoretical and practical aspects of sacral anesthesia. It presents anatomic data and information on the pathophysiological aspects and potentialities of clinical use of sacral anesthesia in modern anesthesiological practice that estimate its perspectives at this stage.

[The autonomic nervous system and blood circulation system during different modes of anesthetic coinduction].

The autonomic nervous system (ANS) at the stage of induction was studied in 128 spinal surgical patients with chronic pain syndrome (CPS) (ASA 2-3). In all groups premedication was similar (diazepam 10 mg i.m.), intramuscular and intravenous atropine 0.5 was additionally injected in Groups 3 and 4, respectively. Introductory anesthesia used 4 coinduction modes: thiopental, fentanyl, and propofol (Group 1); propofol and fentanyl (Group 2); propofol, medazolam, and fentanyl (Groups 3 and 4). BIS monitoring was used to evaluate the impact of anesthesia and sedation on the central nervous system; autonomic screening and the Kerdo index were employed for the ANS. Intraoperative circulatory function was controlled by the values of blood pressure, heart rate, stroke index, cardiac index (CI), total peripheral resistance, and double product. Assessment of the time course of changes in ANS tone in patients with CPS indicated that after premedication, the number of parasympathotonics ranged up to 82% and that of normo- and sympathotonics was reduced to 13 and 5%, respectively. During induction with vagotonic agents, ignoring the baseline ANS tone was followed by a progression of the parasympathetic reaction of the circulatory system as a drop of CI to the low values of relevant dissadjustment in the hypokinetic hemodynamic type. There was a transition of ANS tone to physiological sympathicotonia and, accordingly, to the eukinetic circulatory type during coinduction mode 4 that suppressed vagus reflex.

[Pharmacology of nociception].

The paper reviews the literature on the effect of different groups of pharmacological agents on nociceptive processes. It also describes the mechanisms of possible action of agents both conventionally used in anesthesiological practice and the drugs used to treat pathological pain. The paper allows one to become aware of the currently available approaches to achieving multimodal anesthesia.

[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.

[A method for assessing analgesia--nociceptive evoked potentials: the first clinical cases].

The paper describes a new method for assessing analgesia, which is based on the use of a Caube-type electrode. It provides evidence that, unlike stimulation with the standard electrode for somatosensory evoked potentials, Caube-type electrode stimulation may cause late (long-latent) potentials in healthy volunteers, showing the fundamental capacity of selective nociceptor excitation. By using two cases with the pronounced pain syndrome, the authors show changes in nociceptive evokes potentials during epidural analgesia.

[Psychoemotional comfort--is it a special component of anesthesia?].

The paper provides a rationale for using a special component of balanced multicomponent anesthesia based on regional blocks. Based on their own data and the analysis of the data available in the literature, the authors describe the etiology and pathogenesis of psychoemotional discomfort. Particular emphasis is placed on the causes and mechanisms of psychoemotional disorders and the patients' long positioning on a operating table. Based on the detected pathogenetic mechanisms, the authors show possible ways of achieving the patients' psychoemotional comfort under regional anesthesia--from premedication and various sedation modes to the monitoring of psychoemotional reactions.

[Multimodal approach to postoperative analgesia in patients with neuropathic pain].

Chronic neuropathic pain syndrome observed prior to surgery not only influences the intensity of pain, but also reduces the efficiency of selective use of analgesics. The purpose of the investigation was to study the efficiency of various analgesics and their combinations after lumbar microdiskectomy. Seventy-six patients who had undergone lumbar microdiskectomy and who suffered from chronic back pain were examined. According to the mode of postoperative analgesia, the patients were divided into 4 groups: 1) 20 patients received i. m. promedol 20 mg (a control group); 2) 20 had i. v. tramal (patient-controlled anesthesia); 3) 18 were given i. v. xefocam 24 mg/day; 4) 18 i. v. ketamine 0.1 mg/kg/hour + i. v. xefocam 24 mg/day. Their analgesic effect was evaluated using a visual analogue scale 1, 2, 4, 6, and 24 hours after surgery. The use of xefocam in combination with microdose ketamine was ascertained to cause no increase in the frequency of adverse reactions, to upgrade the quality of analgesia, and to minimize the intensity of pain 24 hours following surgery.