[Russian multicenter observational clinical study «Register of respiratory therapy for patients with stroke (RETAS)¼: a comparative analysis of the outcomes of stroke]. / Rossiiskoe mnogotsentrovoe observatsionnoe klinicheskoe issledovanie «Registr respiratornoi terapii u patsientov s ONMK (RETAS)¼: sravnitel'naya kharakteristika iskhodov insul'ta.

OBJECTIVE: To analyze the treatment of patients with severe stroke requiring respiratory support, and identify predictors of death. MATERIAL AND METHODS: A multicenter observational clinical study «REspiratory Therapy for Acute Stroke¼ (RETAS) was conducted under the aegis of the «Federation of Anaesthesiologists and Reanimatologists¼ (FAR). The study involved 14 clinical centers and included 1289 stroke patients with respiratory support. RESULTS: We found that initial hypoxemia in the 28-day period was associated with higher mortality than in absence of hypoxemia (in patients with 20 or more NIHSS scores) (76.22% versus 63.45%, p=0.004). Risk factors for lethal outcome: hyperventilation used to relieve intracranial hypertension compared with group of patients who were not treated with hyperventilation (in patients with 20 or more NIHSS scores) (79.55% versus 72.75%, p=0.0336); volume-controlled ventilation (VC) versus pressure-controlled ventilation (PC) (in patients with 20 or more NIHSS scores) (p<0.001); use of clinical methods for monitoring ICP in comparison with instrumental ones (87.64% versus 62.33%, p<0.001). It has been proved that the absence of nutritional insufficiency in patients with stroke is associated with a higher probability of a positive outcome (GOS 4 and 5) in comparison with patients with signs of nutritional insufficiency, for the group with NIHSS less than 14 points (p<0.001). CONCLUSIONS: A group of factors associated with a deterioration in the prognosis of outcomes in patients with stroke who are undergoing ventilation has been identified: hypoxemia at the start of respiratory support, lack of instrumental monitoring of ICP, the use of hyperventilation to correct ICP, ventilation with volume control (VC), as well as the presence of nutritional insufficiency.

Voluntary breath-holding duration in healthy subjects with obesity: Role of peripheral chemosensitivity to carbon dioxide.

OBJECTIVE: The present study aimed to explore the peripheral chemoreflex sensitivity in healthy subjects with high body mass index (BMI). METHODS: We studied 26 healthy men with obesity and 23 healthy men without obesity. All participants performed the breath-holding test in the morning, and the single-breath carbon dioxide (SB-CO2) test on the next day. RESULTS: The sensitivity of peripheral chemoreceptors to CO2 did not differ between two groups (P = .47). In contrast, the duration of breath-holding was significantly lower in participants with elevated BMI (40.6 ±â€¯10.5 s versus 47.2 ±â€¯8.7 s; P < .05). In the multifactor regression model, only differences in waist-to-hip ratio (WHR) and SB-CO2 remained statistically significant (R2 for the model = 0.62, P < .001). CONCLUSIONS: The sensitivity of peripheral chemoreflex to CO2 was preserved in healthy men with obesity. The higher sensitivity of peripheral chemoreflex to CO2 and higher WHR were associated with a decrease in the duration of voluntary apnea in subjects with obesity.

PREDICTION OF VARIOUS FORMS OF POSTOPERATIVE ACUTE LIVER FAILURE.

165 patients over 18 years in the period from January 2014 to March 2015 were studied. The aim was to investigate the prognostic significance of known scale assessment of organ dysfunction in respect ofpostoperative hepatic failure. The development of acute liver failure was assessed on the basis of clinical and laboratory data, severity of the condition by scales MELD, Child-Turcotte-Pugh, Maddrey, Schindl, BILE score, SOFA. The paper identified the incidence offorms of acute liver failure (hepatic encephalopathy, hepatic coagulopathy, hepatorenal syndrome, systemic hemodynamic disorder mixed form) in patients after surgery on hepatobiliary system, and the dependence of the probability of their occurrence on the severity of the condition, calculated using a scales in the preoperative period. Calculated sensitivity and specificity in predicting scales investigatedforms of acute liver failure based on ROC-analysis. It was shown that the specialized rating scales have good predictive accuracy in respect of certain forms of hepatic insufficiency (Child-Tur-cotte-Pugh -for hemodynamic options and hepatic coagulopathy, MELD and SOFA scales -for hepatic encephalopathy SCHINDL -for hepatorenal syndrome and mixed forms of hepatic failure). None of the analyzed scales do not possess predictive value with respect to all forms of hepatic failure.

EVALUATION OF EFFICACY AND SAFETY POSTOPERATIVE PAIN MANAGEMENT BY INTRAMUSCULAR ANALGESIA AFTER DIFFERENT TYPES OF ANAESTHESIA: PILOT CLINICAL PROSPECTIVE STUDY.

MATERIAL AND METHODS: Efficacy Safety Score (ESS) with "call-out algorithm" developed in Kongsberg hospital, Norway was used for the validation. ESS consists of the mathematical sum ofscorefrom: 2 subjective (Visual Analog Scale: VAS at rest and during mobilization) and 4 vital (conscious levels, PONV circulation and respiration status) parameters and ESS > 10 is a "call-out alarm "for visit ofpatient by anaesthesiologist. Hourly registration of ESS, mobility degree and amounts of analgetics during the first 8 hours after surgery was recorded in the specially designed IPad program. According to the type ofanaesthesia all patients were allocated in 4 groups: I spinal anaesthesia (SA), II general anesthesia (GA), III peripheral blockade (PB) and IV Total intravenous anaesthesia (TIVA). RESULTS AND DISCUSSION: A total of 223 patients were included in the study. Statistically low levels of both VAS and ESS in the first 2-4 postoperative hours were found in SA and PB groups compared to GA and TIVA groups. During 8 post-operative hours, VAS> 3 was recorded in 10.5% of SA, 13.9% in GA, 12.8% in PG and 23.5% in TIVA patients. CONCLUSIONS: Intramuscular postoperative analgesia was effective in SA, GA and PG groups. More attention of anaesthesiologist must be paid to patients ofter TIVA.

THE SIGNIFICANCE OF CUMULATIVE WATER BALANCE IN THE DEVELOPMENT OF EARLY COMPLICATIONS AFTER MAJOR ABDOMINAL SURGERY.

THE AIM: a comprehensive assessment of the water balance on the basis of daily, cumulative balance and 10% of the body weight gain and their role in the development of early complications after major abdominal surgery. MATERIALS AND METHODS: A retrospective study of the perioperative period in 150 patients who underwent major abdomi- nal surgery was performed. The physical condition of the patients corresponded to ASA 3 class. The average age was 46 (38-62) years. The following stages ofresearch: an analysis of daily balance and cumulative balance in complicated and uncomplicated group and their role in the development of complications; the timing of development ofcomplications and possible relationship with fluid overload and the development of complications; changes in the level of albumin within 10 days of the postoperative period. RESULTS: The analysis of complications didn't show significant differences between complicated and uncomplicated groups according to the water balance during the surgery and by the end of the first day. When constructing the area under the ROC curve (A UROC) low resolution ofthe balance in intraoperative period and the first day and the balance on the second day to predict complications was shown. Significant diferences according to the cumulative balance was observed from the third day of the postoperative period Also with the third day of the postoperative period there is a good resolution for prediction ofpostoperative complications according to the cumulative balance with the cut-offpoint > of 50,7 ml/kg. CONCLUSION: the excessive infusion therapy is a predictor of adverse outcome in patients after major abdominal surgery. Therefore, after 3 days of postoperative period it is important to maintain mechanisms for the excretion of excess fluid or limitations of infusion therapy.

[THE CRITICAL INCIDENTS IN THE COMBINED ANESTHESIA DURING MAJOR ABDOMINAL SURGERY IN ELDERRY AND OLD PATIENTS: ROLE PREOPERATIVE LEVEL OF WAKEFULNESS.]

THE AIM: to determine patterns during combined anesthesia andfrequency ofcritical incidents, depending on the initial level of wakefulness and patient age. MATERIALS AND METHODS: 158 patients of planning operated under combined anesthesia for colon tumors were divided into two groups of elderly patients (n= 79) and old (n= 79). Each group was divided into 3 subgroups, depending on level of wakefulness, the estimatedfor level of direct current potential: low, optimum and high levels ofwakefulness. Relations of age and level ofwakefulness with afrequency of critical incidents. In the number of registered incidents included hemodynamic incidents: hypotension, hypertension, bradycardia, arrhythmia and tachycardia; respiratory incidents: hypoxemia, hypercapnia, the needfor prolonged postoperative mechanical ventilation; metabolic incidents: hypothermia, slow recovery of neuromuscular conduction, slow postoperative awakening has been studied. RESULTS: The most frequent incidents in our study were hemodynamic incidents, which prevailed in the structure of hypotension and hypertension. Among of the respiratory incidents dominated by hypoxia and hypercapnia. In the group of elderly patients the most incidents occurred in the subgroup with low level of wakefulness, while in the oldest patients statistically group significant differences between the groups were not found Conclusion. Frequency of critical incidents does not only depend from the age but also from a preoperative level of wakefulness; frequency was lower in elderly patients with an optimum level of wakefulness, and the low level of wakefulness - was high regardless of age.

[PERIOPERATIVE CARE FOR PATIENTS WITH UNDERLYING ARTERIAL HYPERTENSION (CLINICAL GUIDELINES)].

These clinical guidelines apply to the implementation of health care for all patients with concomitant hypertension in the perioperative period in a hospital. The guidelines specify the method of stratifying the risk of perioperative cardiac complications. We described methods for the treatment of urgent conditions with hypertension and hypertensive crises and identified the main features of the preoperative evaluation and preparation of patients with concomitant hypertension. The clinical guidelines contain recommendations on the management of intra- and postoperative period

[THE EFFICACY AND SAFETY OF DEXMEDETOMIDINE FOR SEDATION OF PATIENTS DURING PROLONGED MECHANICAL VENTILATION IN INTENSIVE CARE UNITS (RUSSIAN MULTICENTER STUDY RESULTS)].

A multicenter prospective study investigated the efficacy and safety dexmedetomidine of sedation in 103 patients during long-term (> 12 h) mechanical ventilation and in cases of delirium. Protocol of sedation included intravenous infusions of dexmedetomidine 1.4/kg/h and administering of analgesic drugs, and if necessary--sedative drugs (propofol, midazolam). Group 1 included 69 patients in whom dexmedetomidine sedation was performed for prolonged mechanical ventilation. Group 2 consisted of 34 patients in whom dexmedetomidine was used due to development of delirious state. Dexmedetomi- dine was used as an infusion of 0.7 mg/kg for 1 hour with further correction of dosage. We recorded a level of sedation by RASS, the need for the appointment of other drugs with sedative effects, the duration of mechanical ventilation, length of ICU stay. The infusion of dexmedetomidine can provide a target level of sedation for RASS from 0 to -3 at 80-90% of patients with surgical and therapeutic profile who underwent prolonged mechanical ventilation. The frequency of adverse events appeared due to the development of bradycardia, hypotension. In the use of dexmedetomidine bolus injection should be avoided.

[EFFICACY AND SAFETY OF LUNG RECRUITMENT MANEUVER IN PATIENTS WITH DIFFERENT PERIPHERAL CHEMOREFLEX SENSITIVITY].

BACKGROUND: The concept of open lungs, which includes a maintaining of positive end-expiratory pressure (PEEP) and lung recruitment maneuver (LRM), proven in the prevention of atelectasis occurring during anesthesia with mechanical ventilation (MV). However, it adversely affects the central hemodynamics, and can increase the incidence of perioperative complications, especially in elderly patients. The sensitivity of the peripheral chemoreflex (SPCR) is a marker of disturbed neuroreflex regulation of the cardiorespiratory system. The aim of the study was to evaluate the influence of LRM on the cardiorespiratory system in patients with different SPCR. Methods: The study was conducted in 85 elderly patients which were undergone abdominal surgery under general anesthesia and mechanical ventilation with LRM and the subsequent maintenance of PEEP The patients were divided into two groups, according to the SPCR level determined using Shtange test: Group B had a high SPCR (n = 35); Group C--the middle SPCR (n = 50). RESULTS: The respiratory system compliance and arterial blood oxygenation were increased and airway resistance was decreased in both groups. LRM led to a decrease in cardiac index in both groups, but in the group C this decrease was offset by an increase in peripheral vascular resistance, which did not occur in Group B. The observed changes in Group B have caused a more frequent hypotension, use ofvasopressors and infusion. CONCLUSION: LRM improves oxygenation and biomechanical properties of the respiratory system. In patients with impaired reflex regulation of the cardiorespiratory system LRM increases the risk of hemodynamic disturbances.

[Assessment of prophylaxis and treatment of blood loss in patients with pre-eclampsia].

OBJECTIVE: To improve treatment results of women with massive obstetrical blood loss. Subjects and methods: 96 female patients with average and heavy degree preeclampsia worsened massive blood developing were involved into the investigation. The women were divided into two groups: main (n=55) (basic) - it's patients were treated with complex of offered wiays control (n=41) - it's patients were evaluated retrospectively. During the investigation the parameters of hemostasis system and periphery blood values were performed as dynamic evaluations, acidity-basic state and water-electrolyte balance parameters, medical history were monitored. RESULTS: As a result of the investigation it was found out that these offered actions complex application about reducing massive obstetric blood accelerates restoration of clinic, bio-chemical paramnleters during the early post-operating period CONCLUSION: The application of the offered methods has reduced both inltraoperative blood loss in women with preeclamsia and use of blood components and the time spent on the hemostasis system correction for all the women of the base group.

[Dynamics of intracerebral and cerebral perfusion pressure during major abdominal surgery].

UNLABELLED: Purpose of the study was to compare an influence of anaesthesia with sevoflurane and propofol on intracerebral and cerebral perfusion pressure by data of ophthalmo-dynamometry of the central retinal vein. MATERIALS AND METHODS: The article deals with study of 75 patients which were undergoing major abdominal surgery. Combined anaesthesia with sevoflurane and fentanyl and total intravenous anaesthesia with propofol and fentanyl were used during the operations. Subgroups were identified in the groups of patients depended on the basic intracerebral pressure (ICP); subgroup of patients with normal ICP (< or = 12 mmHg) and subgroup of patients with intracerebral hypertension (ICP > 12 mmHg) RESULTS: Intracerebral pressure increased by 56% and cerebral perfusion pressure decreased by 35% in patients with intracerebral hypertension during the application of combined anaesthesia with sevoflurane. ICP decreased to normal parameters during application of total intravenous anaesthesia with propofol in patients with intracerebral hypertension. There was no changes of intracerebral and cerepral perfusion pressure (CPP) in patients without cerebral hypertension. Awaking time in patients with intracerebral hypertension was longer by 1.6 times after anaesthesia with sevoflurane than after anaesthesia with propofol. CONCLUSION: Combined inhalation anaesthesia with sevoflurane causes the increasing of ICP and decreasing of CPP and increasing of awaking time. Total intravenous anaesthesia with propofol and fentanyl provides stable cerebral haemodynamics. Total intravenous anaesthesia with propofol is a technique of choice in patients with underling intracerebral hypertension.

[Effect of anaesthesia on incidence of postoperative delirium after major abdominal surgery in elderly patients].

Delirium can be caused by haemodynamics abnormalities during anaesthesia. The main role in delirium appearance is given to decreasing of cerebral perfusion pressure. Especially it can happen in patients with underlying intracranial hypertension. Anaesthetics effects on intracranial pressure are different therefore cerebral hypoperfusion can happens in these patients even without systemic hypotension. Purpose of the study was to define an effect of cerebral perfusion pressure decreasing during different technics of anaesthesia on frequency of delirium in elderly patients after major abdominal surgery. The article deals with results of study of 182 patients (medium age 69 y.o.) underwent elective major abdominal surgery. Delirium frequency was 11%, continuing of delirium was 3 days. The frequency of delirium was higher in patients who had got anaesthesia based on sevoflurane. Additionally these patients had higher frequency of cerebral perfusion pressure decreasing. Conclusions; Anaesthesia based on sevoflurane is characterized by higher frequency of postoperative delirium in elderly patients after major abdominal surgery.

[Prediction of mortality in patients with acute hepatic failure].

The article deals with a study of 243 patients (from 18 to 65 years old) with acute hepatic failure. Purpose of the study was to evaluate the predictive capability of severity scales APACHE III, SOFA, MODS, Child-Pugh and to identify mortality predictors in patients with acute hepatic failure. Results; The best predictive ability in patients with acute hepatic failure and multiple organ failure had APACHE III and SOFA scales. The strongest mortality predictors were: serum creatinine > 132 mmol/L, fibrinogen < 1.4 g/L, Na < 129 mmol/L.

[Specification of the development risk of thromboembolic complications in abdominal surgery].

The retrospective research included 1983 patients with different abdominal surgical pathology. Parameters of homeostasis were estimated in preoperative period and early postoperative period. Frequency of occurrence and relevance of different clinical risk factors of thrombosis were analyzed. The rate of development of thromboembolic complications was investigated in studied subgroup of patients. It was revealed, that high risk groups of thrombosis progress were the patients with malignant disease of the pancreas, the esophagus, the large and straight intestine as well as obstructive jaundice of malignant genesis. The most significant clinical factors were the presence of malignant process, accompanied by cardiac pathology, dehydration and high number (3 and more) on ASA scale.

[Hemostasis during MARS therapy and hemodiafitration in patiens with acute renal-hepatic failure].

OBJECTIVE: to study the dynamics of the haemostatic system, depending on coagulopathy type and efferent therapy method (HDF, MARS) in patiens with acute renal-hepatic failure. As a complex of intensive therapy, all the patients were trated extracorporeal techniques: HDF therapy in group I (n = 121) and MARS in group 1 (n = 62). Patients were aged from 18 to 67 years. RESULTS AND DISCUSSION: MARS - is an effective therapy and has effects on haemostasis system: observed recovery of platelet-vascular disorders of coagulation and haemostasis. HDF is effective in patients with coagulation type of laboratory disseminated intravascular coagulation (DIC), and was dangerous in fibrinolytic DIC type because of haemostasis status decompensation risk.

[Diagnostics and correction of coagulopathy in pregnant women and puerperas with gestosis].

INTRODUCTION. Gestosis is a complication of normal pregnancy which for long years takes the 2-3rd place in maternal and perinatal mortality and women morbidity structure. 396 patients with moderate and heavy gestosis from 2007 to 2011 were studied. In 53 women (13.4%) it was accompanied by complex haemostasis disturbances and part of women had sepsis. Therefore the retrospective differential analysis of haemostasis disturbances with algorithm presented in this article was carried out. Haemostasis status, complete blood count, biochemical blood analysis data were analyzed. Correction of haemostasis disturbances in the postnatal period was performed according to legacy recommendations. As a result of retrospective differential diagnostics of haemostasis disturbances, the chronic disseminate intravascular clotting (DIC) syndrome, a HELLP-syndrome, thrombotic thrombocytopenic purpura (TTP) and a haemolytic uremic syndrome (HUS) were revealed. The received results indicate that in obstetrics there are essential difficulties with coagulopathy timely diagnostics, especially, TTP and HUS. The most difficult problem is differential diagnostics between a HELLP-syndrome, TTP and HUS. Clear algorithm of differential diagnostics appeared only in 2010. We analyzed all coagulopathy cases since 2007. TTP and HUS were diagnosed by 3rd days of the postnatal period, also specific therapy of these syndromes was late that was reflected in ICU length-of-stay, frequency of sepsis and need of uterectomy respectively.

[Validity of APACHE II, APACHE III, SAPS 2, SAPS 3 and SOFA scales in obstetric patients with sepsis].

RESEARCH OBJECTIVE: to estimate efficiency of APACHE II, APACHE III, SAPS II, SAPS III, SOFA scales for obstetric patients with heavy sepsis. MATERIALS AND METHODS: 186 medical cards retrospective analysis of pregnant women with pulmonary sepsis, 40 women with urosepsis and puerperas with abdominal sepsis--66 was performed. Middle age of women was 26.7 (22.4-34.5). RESULTS: In population of puerperas with abdominal sepsis APACHE II, APACHE III, SAPS 2, SAPS 3, SOFA scales showed to good calibration, however, high resolution was observed only in APACHE III, SAPS 3 and SOFA (AUROC 0.95; 0.93; 0.92 respectively). APACHE III and SOFA scales provided qualitative prognosis in pregnant women with urosepsis; resolution ratio of these scales considerably exceeds APACHE II, SAPS 2 and SAPS 3 (AUROC 0.73; 0.74; 0.79 respectively). APACHE II scale is inapplicable because of a lack of calibration (X2 = 13.1; p < 0.01), and at other scales (APACHE III, SAPS 2, SAPS 3, SOFA) was observed the insufficient resolution (AUROC < 0.9) in pregnant women with pulmonary sepsis. CONCLUSION: Prognostic possibilities assessment of score scales showed that APACHE III, SAPS 3 and SOFA scales can be used for a lethality prognosis for puerperas with abdominal sepsis, in population of pregnant women with urosepsis--only APACHE III and SOFA, and with pulmonary sepsis--SAPS 3 and APACHE III only in case of additional clinical information.

[Intracranial pressure and jugular venous oxygenation influence on outcome in patients with severe traumatic brain injury].

Different criteria are used to predict outcome of TBI including jugular venous oxygenation (SjvO2) and ICP. However, there is no data on their combined use. ICP measure by ophtalmodynamometry (ODM) of central retinal vein (CR V) never was used for outcome prediction. The aim of the study is to assess the effectiveness of combined use of ICP and SjvO2 measures for outcome prediction in patients with severe TBI. 80 cases of severe TBI with GCS score 8 and lower were studied. In addition to the standard monitoring and intensive therapy SjvO2 and ICP by ODM during acute period of TBI were measured. Positive outcome of acute TBI can be predicted if SjvO2 rate ranges from 55% to 75%. Poor outcome can be predicted if SjvO2 rate is lower than 55%. Patients with normal ICP in this group died from secondary intracranial complications and patients with high ICP died from primary and secondary intracranial injury. Patients with high SjvO2 ( > 75%) also have poor prognostic outcome. The main risks for them are extracerebral complications. It is necessary to use complex monitoring that includes ICP and SjvO2 for accurate prediction of the outcome of TBI. ICP should be measured by minimally invasive method.