Septic shock, as the most severe form of sepsis, is characterized by high mortality reaching 40% despite the use of the most modern standards of diagnosis and treatment. In the thanatogenesis of septic shock, vasoplegia plays a leading role, respectively, and therapy of the condition under discussion involves the use of vasoconstrictors, along with the standard prescription of infusion therapy, antibiotics and symptomatic treatment. The choice of a specific vasoactive drug is a difficult task for a practicing anesthetist, as along with undoubtedly positive properties, vasoconstrictors each have their own spectrum of undesirable side effects, which, of course, must be taken into account when determining treatment tactics.

The aim of review: A comprehensive assessment of the multifactorial effect of various vasoconstrictors on the patient to determine the criteria for choosing the optimal drug (or a combination of drugs) in septic shock.

The search was carried out using PubMed and Scopus databases, the final selection of 89 articles was carried out in accordance with the following criteria: relevance to the topic of this review and the nature of the article — only randomized controlled trials, guidelines and analytical reviews were included in the final analysis.

External and internal mechanisms of vascular tone regulation are considered, including factors produced by endothelium (nitric oxide, prostacyclin, endothelin); vasoactive metabolites and autocoids — signal molecules of local action (serotonin, prostaglandins, thromboxane A2). Accordingly, drugs were analyzed the mechanism of action of which is related to the effect on adrenergic (adrenaline, dopamine, norepinephrine, phenylephrine, dobutamine), vasopressin (vasopressin, terlipressin, selepressin) receptors, synthetic analogues of angiotensin (angiotensin II) and drugs the non-vasopressor effect of which is not linked with the receptor apparatus (methylene blue, levosimendan, hydrocortisone).

Conclusion. The high effectiveness of norepinephrine, its positive hemodynamic effects make the drug under discussion, in many ways, a universal remedy for the relief of septic shock. However, refractory shock may require the introduction of such high doses of norepinephrine that the occurrence of adverse reactions will become practically inevitable. The combined use of adrenergic and ligand V receptors, terlipressin, is intended to prevent these complications. However, to date, there are no clear recommendations on the use of terlipressin in septic shock, which limits its use in clinical practice.

Aim: To compare the safety and efficacy of dexmedetomidine and haloperidol in patients with delirium and acute respiratory failure in non-invasive mask lung ventilation.

Materials and methods. We carried out a retrospective analysis of data on patients with somatogenic delirium and acute respiratory failure (57 men, 4 women) experienced noninvasive ventilation (NIV) in the intensive care unit of the Botkin State Clinical Hospital in 2017–2018. Depending on the type of sedation the patients were divided into two groups: those on dexmedetomidine (n=31) and those receiving haloperidol (n=30). Dexmedetomidine was administered as a continuous infusion at a rate of 0.2–1.4 µg/kg/h while controlling the level of consciousness; haloperidol was administered by intravenous bolus injections until a sufficient level of sedation was reached in a dose of 2.5 mg 2–3 times a day.

Results. The efficiency of sedation to achieve the required level of cooperation and possibility of NIV was 87.1% (27 patients) and 66.6% (20 patients) in dexmedetomidine and haloperidol groups. When estimating sedation in patients of both groups according to the RASS scale the scores did not differ significantly and were equal on the average to 1.7±0.3 (eye contact to voice). In haloperidol group in 10 out of 30 (33.3%) patients a sufficient level of sedation was not achieved, which required immediate tracheal intubation and invasive lung ventilation. Mortality in this group was 20% (6 patients), while in dexmedetomidine group it was 6.4% (2 patients).

Conclusion. The use of dexmedetomidine, despite greater variability of hemodynamic parameters, allows to perform NIV with sufficient cooperation with the patient, reduces the frequency of tracheal intubation, risk of complications and mortality.

Purpose — to carry out a comparative assessment of inflammation based on evaluation of intraoperative and early postoperative dynamics of blood serum cytokines in pulmonary malignant neoplasm patients in different anesthesia and analgesia settings.

Material and methods. 24 patients of 45 to 50 years of age divided into 2 groups were examined. All patients suffered from verified new onset malignant neoplasms without true signs of metastases. Tumor differentiation by morphology was not undertaken since that was beyond the study design. Patients did not receive radio- or chemotherapy. In Group I (the main group, n=12), a multimodal combined anesthesia [1] followed by extended postoperative epidural analgesia was applied. In Group II (the comparison group, n=12), a combined general anesthesia including mechanical lung ventilation followed by morphine analgesia was used. 4 study points were determined: prior to induction, and one, 12, and 24 hours post-surgery.

Results. 12 hours after surgery completion, the concentration of TNFα in the main group was lesser by 57.1% vs. the comparison group; by the end of the first 24 hours, it fell down by 64.3%. Within the same period, in both groups IL-6 turned out to be significantly higher than the upper reference limit. By the end of the first 24 hours, IL-6 tend to decrease in both groups; however, in the comparison group, this parameter was 15% higher than in the main group. Serum IL-10 was within the reference range in both groups. One hour after surgery, concentrationof IL-10 was exponentially growing in both groups and exceeded multifold the upper reference limit, whereas the content of IL-10 in the main group remained reliably higher: the difference amounted to 35.6% percent.

Conclusion. During the postoperative period, patients undergone lung resection displayed significant changes in cytokines concentrations demonstrating an inflammation reaction. Inflammation was significant in patients who received epidural analgesia as evidenced by an altered content of anti-inflammatory cytokines.

Aim: to study orthostatic hemodynamic changes in patients with chronic disorders of consciousness after critical brain damage.

Materials and methods. We studied 30 patients (10 women and 20 men) with chronic disorders of consciousness after severe brain damage aged 45±7 years, 10 of which were in the vegetative state (VS) and 20 had the minimally conscious state (MCS). The main causes of brain damage were traumatic brain injury (53% of patients) and cerebrovascular accidents (CVA) (23.3%). The rest of the patients had posthypoxic encephalopathy or were after brain tumor removal surgery. Passive orthostatic test (POT) 0° to 60° to 0° was performed using an electrically driven tilt table (Vario Line). Hemodynamic monitoring during the verticalization was done using a non-invasive oscillometric recording of blood pressure on the brachial artery, stroke volume (SV) and cardiac minute output (CMO) were measured by impedance cardiography with the multifunctional «Task Force Monitor 3010i» (CNSystem, Austria). Data were statistically analyzed using the Statistica 10 software package.

Results. Orthostatic hemodynamic stability was found in 26 out of 30 patients with chronic disorders of consciousness after critical brain damage. It was manifested by stable systolic blood pressure (SBP) in tilted orthostatic and horizontal position (120.7±2.2 and 121.1±3.6 mmHg, respectively, P>0.05). Orthostatic hypotension was observed in 3 patients and postural tachycardia syndrome (PTS) in one patient. We compared orthostatic hemodynamic changes in the studied cohort versus published data on orthostatic hemodynamic changes uncluding POT revealed in patients with severe brain damage examined before and after brain death.

Conclusion. Orthostatic stability of blood circulation can be maintained for a short period of time in patients surviving after critical diffuse brain damage associated with chronic disorders of consciousness. Critical brain damage resulting in brain death associates with a significant reduction of all hemodynamic parameters and severe orthostatic hypotension with restoration of initial blood pressure values when the patient is returned to the horizontal position.

Professional activity of intensivists consistently ranks high among the most «risky» areas of medicine. In 6 out of 89 criminal «iatrogenic» cases initiated by investigative authorities in the Moscow region in 2016–2018 anesthesiological or intensive care in the ICU was the subject of investigation. In 4 of these 6 cases, iatrogenic complications were detected during the forensic examination. Intensivist is considered an attending doctor and therefore holds responsibility for defects in the provision of medical care and its adverse outcome.

The purpose of the study is to outline the professional risks in the work of an intensivist and identify ways to reduce them by using a case study with a fatal outcome, which led to criminal proceedings.

Materials and methods. We studied and analyzed the criminal case files which included the complaint of the patient’s relatives with the prosecutor’s office, the explanations and interrogation records of the patient’s relatives (4) and healthcare workers (6), the minutes of the Morbidity and Mortality conference, the expert report on patient care quality issued by health insurance company, the final report of sanitary and epidemiological examination, autopsy protocol, emergency call files (3), the inpatient medical records, outpatient records and the final report of Commission of forensic medical examination.

Results. Defects in the provision of medical care were not identified. The differential diagnosis was performed correctly. The severity of the patient's condition was due to brain infarction and associated abnormalities. Underdiagnosis of botulism did not affect the outcome of the disease and was not the cause of death of the patient.

Conclusion. The reasons for filing a complaint with the Prosecutor's office and initiating a criminal case were organizational shortcomings and ethical and deontological aspects.

We followed clinical and EEG examinations of two patients with herpes simplex encephalitis (HSE) in acute condition along with monitoring their early and late outcomes. Patients: M. B., 23-year-old female, who completed home treatment as a severe organic psycho-syndrome, reliant on nursing care, and L. J., now 16-year-old female patient, whose HSE in the 3 rd year of her life went into auto-aggressive Rasmussen encephalitislike condition with epileptic status in the form of Epilepsia parcialis continua (EPC).

The EEG signal was statistically processed using «power spectral analysis» with color maps 3D BM showing the performance of individual frequency bands topographically and the measurement of connectivity in longitudinal and transversal direction by means of the mean coherencies — indexes of connectivity.

On the 9th year of L. J. life when she overcame varicella with a significant eruption of the skin and high temperature the highly active EEG patterns were attenuated both graphically and clinically with a significant reduction in focal epilepsy. The latter was affected by a total thiopentotal anesthesia and bolus corticotherapy, as well as amantadine sulphate.

This patient exhibited central right lower limb mono-paresis in a selfstanding walk and 4–5 short myoclonic abduction cramps in arm joints associated with vocalized «hee-haw», deep inspiring and expiring in full consciousness. MRI proved hyperintense area parasagitally on the left side of the centromotor region and EEG with epileptogenic grapho-elements in adjacent scar. We compared the last sample of the EEG signal to the EEG patterns of her homozygous sister and found them identical with no pathological graphoelements.

These patients survival was the result of continuing anti-viral treatment, intensive medical and nursing care aimed to protect neural cells in the brain, the effect of which was longitudinally monitored by classic and statistical EEG signal analysis.

The late outcome of these patients was diametrically different. L. J. graduated from the 9-year primary school with good results. M. B. was progressively mobilized, despite the clinical signs of severe alterations of psychic sphere as a result of postencephalitic encephalopathy with insufficient response to neuroleptics and sedatives. After parents’ agreement received she was transferred to the regional hospital.

Aim. To study the demand for the massive open online course on basic cardiopulmonary resuscitation (CPR), and to evaluate effects of the training based on the socio-demographic profile of the audience.

Material and methods. The data obtained from a survey conducted on participants of the online course «First Aid in Cardiac Arrest (Basic Resuscitation)» during a one-year period (07.2018–07.2019) were analyzed, including demographic data, initial and final levels of knowledge on CPR, and willingness to resuscitate a stranger. The 5-point Lickert scale was used for self-assessment of knowledge and willingness to attempt CPR.

Results. The analysis includes data collected from 11,924 people, out of which 3,445 (29%) have completed the training. Eighty percent of participants live in the Russian Federation. The mean age of trainees, who completed the course, was 25.7 years, 45% of them were males, 42% had learnt CPR previously, 12% had medical education. As a result of the training, a significant increase (P<0.001) in the willingness to attempt CPR (from 3.26 to 4.16 points) and an increase in self-perceived CPR knowledge (from 2.24 to 3.98 points) were registered. The percentage of trainees who expressed a high level of willingness to perform CPR (4–5 points) increased from 44% to 81% (P<0.001). The course was more likely to be completed by those trainees who had previous training in CPR (p<0.001), who initially demonstrated higher willingness to provide CPR (P=0.003) or a higher level of knowledge in CPR (P<0.001). Trainees who had previous CPR training showed a much higher level of knowledge, higher self-confidence and a higher level of readiness to provide CPR (P<0.001). Approximately 14% of trainees with medical education reported having no previous training in CPR.

Conclusions. The massive open online course promotes knowledge of CPR and serves as an important tool for increasing the willingness of lay people to provide first aid in case of cardiac arrest. Previous CPR training is a motivating factor to continue education in resuscitation.

Purpose. To study the effect of hyperbaric oxygenation (HBO) on the oxygen regime and ammonia metabolism in the neurons of cat cortex in hemorrhagic shock.

Material and methods. Experiments were performed on 164 cats (males). The effect of HBO (3 ATA, 50 min) on cerebral blood flow (CBF), oxygen tension (PO₂), the content of ammonia (Am), glutamine (Gn), glutamate (Gt), α-ketglutarate (α-KG), the activity of glutamate dehydrogenase (GDG), glutamine synthetase (GS), phosphate-dependent glutaminase (PDG) activity was studied in the sensorimotor cortex (SMC); the content of Am, GN and oxygen parameters in arterial (AB) blood and venous blood (VB) of the sagittal sinus in hemorrhagic shock caused by fractional bloodletting of their femoral artery at a rate of 10ml/kg/10 min in an average volume of 24±0.8 ml/kg, which was stopped with a decrease in systolic blood pressure to the level of 60.0±1.5 mm Hg. HBO was commenced on post-hemorrhagic minute 10 following the regimen of 3 ATA for 60 min.

Results. The decrease in CBF and PO₂ in SMC develops as early as the 10th minute of hemorrhagic shock, progressing to the stage of hemorrhagic shock decompensation (60±14 min). Accumulation of Am in the SMC at the stage of hemorrhagic shock decompensation associated with stimulation of PDG and GDG activity, inhibition of hemorrhagic shock activity and deficiency of α-KG. HBO, without eliminating hypoxia in SMC, prevented the development of the decompensation stage in animals with GS, pathological accumulation of Am, and a decrease in the activity of hemorrhagic shock. HBO increases the Gn increment from the SMC, into the blood. Under HBO conditions, the stimulating effect of hypoxia on GDG activity remains, but the concentration of glutamate remains within the normal range, as does the activity of PDG.

Conclusion. Hyperbaric oxygenation, without eliminating hypoxia in SMC, which develops in hemorrhagic shock, prevents a violation of the exchange of ammonia in it, caused by acute non-compensated blood loss.