[PERIOPERATIVE EPIDURAL ANALGESIA IN LUNG SURGERY IN LOW FUNCTIONAL RESPIRATORY RESERVE PATIENTS].

It is now proven that the use of thoracic epidural blockage in thoracic surgery results in a significant reduction in the incidence of pulmonary infection, reduces the duration of postoperative mechanical ventilation and length of stay in the ICU. Moreover, the epidural analgesia is the most effective way of pain relief which is especially important after lung operations. Finding the most optimal variant of the method has drawn attention to a procedure based on the use of small doses of local anesthetic (ropivacaine), opioid (fentanyl) and epinephrine, as proposed by the Norwegian anesthesiologists Breivik and Niemi. Reducing the depth of the epidural block may be offset by the use of a powerful general anesthetic sevoflurane. In this way, implementing the principle of multimodal anesthesia, involves the use of a rational combination of low doses of unidirectional components with different mechanisms of action and levels. In our work, we have once again demonstrated that perioperative epidural analgesia is one of the essential components of secure anesthesia, especially in patients with reduced functional reserves.

[Postoperative analgesia with nefopam and non-steroidal anti-inflammatory drugs in patients after surgery for tumors of head and neck].

MATERIALS AND METHODS: 83 adult patients included in the study were divided into two groups. Patients of the group-1 (n-49) had medium level of pain after cancer head and neck surgery. Patients of the group-2 (n-34) had severe pain. Three first postoperative days their post-operative multimodal analgesia started with tenoxycam 20 mg i.m. after induction of anesthesia, then every 24 hour (58 patients). 25 patients got ketoprofen 100 mg i.m. every 8-12 hours instead of tenoxycam. All patients had nefopam 30 mg i.m. 30 min prior the end of surgery procedure, and every 8 hours afterwards. 7 patients of the group-1 had more than 4 pain scores (day 1), 4 patients--at the day 2. They received tramadol or paracetamol additionally. 7 patients (group-2) also had up to 5 pain scores on the day 1, 5 patients had 4 pain scores on the day 2, and 3 patients 4 pain scores on the day 3. All that patients received additional analgesia with tramadol or trimeperidine once a day. 8.4% of patients suffered from adverse reactions (tachycardia, PONV and sweating). CONCLUSION: This method of multimodal postoperative analgesia is very simple and fairly efficient.

[Radical removal of a malignant mediastinum hemangioendothelioma with restoration of the main blood supply to the brain].

46 year old man appealed to the Cancer Research Center of RAMS in October 2012 with unverified anterior superior mediastinal tumor, which was diagnosed in 2010. Progressive compartment syndrome of the superior vena cava was observed. On examination: CT, MRI, angiography, histological and cytological examination of biopsy material did not allow to confirm the morphological structure of the tumor. Removal of the tumor with bifurcation of the brachiocephalic trunk prosthetics was performed. Immunohistochemical (IHC) study verified malignant hemangioendothelioma.

[Assessment of sugammadex use efficiency and safety for neuromuscular block reversion].

Blockade of neuromuscular conductivity is a considered one of basic part of a patient protection in a concept of a balanced multicomponent anesthesia. The controlled neuromuscular paralysis in a combination of a sedation, an analgesia and a hyporeflection not only provides comfortable conditions to surgeons for carrying out surgeries, but also allows to manage a gas exchange, blood circulation and a metabolism in a patient. However in clinical practice there is such complication after application of muscular relaxant (not depolarizing) as a residual curarization. The residual curarization is interfaced to deterioration of the respiratory answer to a hypoxemia, swallowing dysfunction that significantly increased risk of aspiration and risk of postoperative pulmonary complications. Until recent time acetylcholinesterase inhibitors or prolonged ALV before spontaneous regression of the neuromuscular block were applied in clinical practice for the purpose of restoration of adequate neuromuscular conductivity and elimination of a residual curarization. However there are number of the circumstances limiting application of preparations of this group including it is related with rather high frequency of side effects and lack of efficiency at the deep neuromuscular block. Today in an arsenal of the anesthesiologist there was the latest chemical - sugammadex. Sugammadex realizes a new approach to restoration of the neuromuscular conductivity.

[Efficacious anesthesiological and resuscitation care--the cornerstone of modern oncosurgery].

A few modern concepts of anesthesiological and resuscitation care during complicated surgical interventions are considered with special reference to multimodal anesthesia as a principal tool for the protection of the patient from a surgical trauma based on the rational combination of three-component epidural analgesia (ropivacaine, fentanyl, and adrenalin) with sevoflurane inhalation narcosis and extention of the same epidural analgesia to the early postoperative period. The basic principles of infusion-transfusion therapy for the treatment of massive intraoperative blood loss ensuring its tolerability by the patient are discussed. Special attention is given to the problem of hospital-acquired infections and sepsis in oncosurgery. Methods are proposed for the improvement of the management of septic shock including immunomodulation, respiratory support, infusion and anti-infective therapies. It is concluded that the use of these conceptual approaches permits to perform extensive surgical interventions in patients with the initially low reserve capacity of vital functions.

[Resection and prosthetics of abdominal aorta by surgical treatment of invasive retroperitoneal tumors].

Data of 5 patients, who required resection and prosthetics of abdominal aorta during radical excision of malignant retroperitoneal lesions, were analyzed. Therefore, 2 patients demonstrated retroperitoneal lymph node metastases of nonseminoma hermonogenous tumour, 1 patient had colorectal liver and lymph node metastases, another had ovarian tumor, and the rest--leiomyosarcoma of the aorta. Tubular Gore-tex aortic prostheses were used. Radical tumor excision provided absence of local recurrence in all patients. Only one patient showed further progression of the tumor as liver metastases. Thus, such an aggressive surgical approach could be appropriate in carefully selected group of patients.

[Acute damage to the myocardium and left lung is a complication of high-frequency percutaneous thermoablation of solitary metastasis of renal cancer into the liver (a clinical observation)].

The paper describes a case of severe complication of radio-frequency percutaneous thermoablation of renal metastasis into the liver, which occurred in a young woman with the intact cardiovascular system and manifested itself in the development of alveolar edema of the lung and acute dilation of the stomach. Pulmonary edema resulted from left ventricular myocardial and pulmonary parenchymal lesions and acute mitral valvular insufficiency. The authors' considerations as to the possible cause and mechanisms of development of this life-threatening complication first described in the literature are also given.

[Approaches to anesthesia management of a patient during oncological pulmonary surgery]. / Podkhody k obespecheniiu anesteziologicheskoi zashchity patsienta pri onkologicheskikh operatsiiakh na legkikh.

The results of lungs' excision in 82 patients made under a combined anesthesia of 2 types are comparatively analyzed. A surface low-level endobronchial narcosis by isoflurane was administered in 42 patients concurrently with a "high" epidural anesthesia by bupivakain and fentanyl. The other 40 patients received isoflurane and intravenous bolus injections of fentanyl concurrently with epidural anesthesia by morphine administered at the lumbar level. The epidural analgesia by bupivakain and fentanyl made at the thoracal level or by morphine made at the lumbar level was carried on in the early postoperative period. The results show both variations to ensure a reliable intraoperative anesthesia, a smooth recovery and a good postoperative analgesia. Better results were on the whole obtained by the variant of high epidural anesthesia/analgesia; however, the method of lumbar morphine administration has a number of advantages primarily related with its simplicity.

[Problems and achievements in anesthesiology and intensive care in contemporary oncological surgery]. / Problemy i distizheniia anesteziologii i reanimatologii v sovremennoi onkokhirurgii.

The adoption of aggressive surgery in the Russian Cancer Research Center during recent years as the main treatment philosophy in cancer patients including those at a high and very high risk is very closely connected with appropriate anesthesia and postoperative intensive care. Several organization issues, including technical supply, are discussed in this paper. A concept of anesthesiological support of patients during highly traumatic surgery is presented. The authors share their opinions on infusion therapy, massive blood loss, therapy of perioperative organ and multiple organ failure and sepsis in the light of modern concept of systemic inflammatory response.

[Opinions of anesthesiologists and intensive care specialists on some organizational and medical ethical aspects of present-day cancer surgery]. / Vzgliad anesteziologa-reanimatologa na nekotorye organizatsionnye i mediko-éticheskie aspekty sovremennoi onkokhirurgii.

The authors discuss problems in organization of anesthesiology and intensive care at a large oncological hospital. Disputable problems in relationships between anesthesiologists and intensive care specialists, oncologists, and patients, between cardiopulmonary resuscitation and intensive care of cancer patients are discussed.

[The effect of Clexane (low-molecular-weight heparin) on the hemostatic system and on the incidence of postoperative thrombotic complications in gynecological cancer patients]. / Vliianie kleksana (nizkomolekuliarnogo geparina) na sistemu gemostaza i chastotu posleoperatsionnykh tromboticheskikh oslozhnenii u onkoginekologicheskikh bol'nykh.

Clexane in a dose of 40 mg before and after surgery notably decreased the intensity of chronic intravascular blood coagulation during surgical treatment of oncogynecological patients. Only 3% patients developed thrombosis of deep veins of the lower limbs after Clexane, while in the group administered no Clexane, 20% developed this complication. Preventive administration of Clexane did not cause an increase of the operative blood loss. The incidence of wound hematomas in patients administered Clexane and nonfractionated heparin was negligible and virtually the same.

[Problems and advances in anesthesiology and intensive care in oncologic surgery]. / Problemy i dostizheniia anesteziologii i reanimatologii v onkokhirurgii.

Numerous problems are to be solved by anesthesiology and reanimatology in modern oncosurgery: to protect weak exhausted patients from severe and extremely severe surgical injury, to carry out rational infusion/transfusion therapy and intensive care in massive blood loss, perioperative organ and polyorgan failure, and sepsis. Combined analgesia is used in highly traumatic oncological operations: inhalation narcosis with fluorine drugs with epidural analgesia and anesthesia. Good results were obtained in the treatment of very grave patients. Mortality from highly traumatic operations with blood loss higher than 50% of total circulating blood decreased to 10%. Modern methods of intensive care, such as intraoperative reinfusion of autoerythrocytes, extracorporeal detoxication, immunocorrection for preventing and treating sepsis, etc., are widely used with good effect.

[Severe sepsis and multiple organ failure in surgical patients in intensive care unit of oncological profile]. / Tiazhelyi sepsis i poliorgannaia nedostatochnost' u khirurgicheskikh patsientov otdeleniia reanimatsii onkologicheskogo profilia.

Forty-seven cases with grave sepsis and multiple organ failure in patients operated on for malignant tumors of different localizations and treated in intensive care wards of Cancer Research Center in 1996 are analyzed. In 35 patients sepsis developed due to pyoseptic complications of surgery and led to multiple organ failure, in 12 sepsis complicated multiple organ failure of other origin. Four or five organ systems were involved in 2/3 of patients with "primary" sepsis and in almost all patients with "secondary" sepsis. Sepsis and multiple organ failure in surgical cancer patients are believed to differ much from those in general surgical patients, which is explained by the scope of intervention, a tendency to decrease the number of indications for surgery, and by profound impairment of immunity and metabolism.

[A rare case of BCG vaccinal sepsis in a patient with bladder cancer]. / Redkii sluchai BTsZh-vaktsinal'nogo sepsisa u bol'nogo rakom mochevogo puzyria.

Immunotherapy consisting in intravesical injection of BCG vaccine to a 44-year-old patient with surface relapsing cancer of the bladder resulted in development of sepsis. The vaccine in a dose of 120 mg was injected directly after bougienage of the urethra and catheterization of the bladder. As soon as in 2 h the patient developed chill, fever (38.5 degrees C), and felt bad. The condition progressed, but only in 15 days did the patient applied for medical care. Intensive care including antibiotics and antituberculous drugs in massive doses and repeated sessions of hemoperfusion were of no avail. The patient died with signs of progressive hepatorenal failure. Autopsy confirmed vaccinal mycobacterial sepsis. Intravesical immunotherapy after injury to the urethra was an error, promoting generalization of the infection; another cause of lethal outcome was late application for medical care.

[Prevention of hemostatic disorders at different stages of surgical treatment in patients with colonic cancer]. / Profilaktika narushenii sistemy gemostaza na razlichnykh étapakh khirurgicheskogo lecheniia bol'nykh rakom tolstoi kishki.

The status of the hemostasis system was studied in 40 patients with colonic cancer before, during, and after surgery, who were administered no treatment before the operation, and in 30 ones administered depogen with heparin in the preoperative period. Preoperative treatment with depogen had a favorable effect on both coagulation and platelet components of the hemostasis system. Administration of depogen together with heparin reduced the intensity of subacute chronic intravascular blood coagulation during and after surgery in patients with colonic cancer and was conducive to a reduction of the incidence of postoperative complications.