Ultrasound imaging of muscles and subcutaneous fat has been used in recent years to assess the nutritional status, but there are no common approaches for selecting muscles for it.
The aim of the study was to examine the variability of thickness of different muscles and subcutaneous fat using ultrasonography to identify optimal cutaneous and muscle landmarks for the assessment of nutritional status.
Materials and methods. It was a prospective observational study with participation of 14 patients. All patients underwent ultrasound examination of thickness of the following muscles: m. rectus femoris; m. tibialis anterior; m. biceps brachii; m. deltoideus and m. sternocleidomastoideus, as well as the thickness of skin and subcutaneous fat over the muscles. The ultrasound assessment was done on admission to ICU, on days 7, 14, 21, 28, 42. On days 7, 14 and 21 the intravenous load test of 1000 ml of 0.9% sodium chloride solution was performed. On days 5 and 10 the test with the patients in the lateral decubitus position was carried out.
Results. We found that m. tibialis anterior changed its size when patients were turned laterally by 2%, m. deltoideus by 6%, m. sternocleidomastoideus by 10%, m. rectus femoris by 20.5%, and m. biceps brachii by 26%. After infusion of 1,000 ml of 0,9% sodium chloride solution, the variability of m. tibialis anterior size was 2%, m. deltoideus 2%, m. sternocleidomastoideus 6%, m. biceps brachii 8%, m. rectus femoris 12%.
The thickness of subcutaneous fat over m. biceps brachii and m. rectus femoris changed more than the anteroposterior size of the muscles (P<0.05).
Conclusion. The m. deltoideus and m. tibialis anterior are optimal for ultrasound assessment of the nutritional status because their size is less affected by the patient's positioning and infusion therapy. Intravenous fluid infusion increases the variability of subcutaneous fat thickness.

The aim of the study: to improve the efficacy of erector spinae plane (ESP) fascial block for pain management in patients with multiple rib fractures.
Materials and methods. We observed 4 patients with multiple rib fractures who were treated with ESP fascial block with subsequent prolonged administration of local anesthetic for pain relief. To evaluate the efficacy of the ESP block, the visual analogue scale (VAS) for pain intensity, cough performance index and forced vital capacity (FVC), as well as a modified 3-item scale were used. The distribution of local anesthetic (10% lidocaine solution) and contrast (iohexol solution, 350 mg iodine/ml) media was analyzed by computed tomography and correlated with the data on reduced pain perception according to the thoracic vertebrae (Th) levels.
Results. After the ESP block in patients with multiple rib fractures, we found a decrease in VAS pain intensity at rest by 3-4 points and on coughing by 3-6 points, an increase in cough performance by 1 point and in the modified 3-item scale by 1-3 points. The distribution of the local anesthetic solution was registered mainly in the cranial-caudal and anterior direction to the intertransversal space without significant leakage in lateral and medial directions. In all 4 cases the local anesthetic and contrast media spread from the catheter tip cranially several levels of thoracic vertebrae farther than in caudal direction.
Conclusion. ESP block in patients with multiple rib fractures is a reasonably effective method of pain relief. Catheterization of the fascial plane of erector spinae muscle should be performed at the level of vertebra corresponding to the underlying fractured rib. The data obtained may serve as a basis for further studies with more patients included.

The choice of drug for initial fluid therapy in the early postoperative period is important in terms of clinical efficacy and cost-effectiveness of the combination treatment.
The aim of the study was to compare the effects of a succinate-containing solution and 0.9% NaCl solution when used as a drug of initial intravenous fluid therapy in early postoperative period in children.
Materials and methods. A prospective randomized trial was conducted with participation of 43 patients having ASA II—III score after elective surgical interventions with a duration of 1-3 hours. In Group I («N») (n=23) the patients received continuous infusion of 0.9% NaCl solution in the early postoperative period (within 3 hours after the operation), in Group 2 («R») (n=20) continuous infusion of a succinate-containing solution was administered in 2.3 (1.6; 2.8) mode. The inter- and intragroup differences during the study were estimated by the changes of water-electrolyte and acid-base balance, basal metabolism, and phase angle (estimated integral index of cellular membranes condition) values. The data were recorded during the 5 stages of the study: 1 — immediately upon ICU admission (baseline), 2 — 60 minutes, 3 — 90 minutes, 4 — 120 minutes, 5 — 180 minutes after the ICU admission.
Results. Significant differences in plasma potassium level between the groups 60 minutes (P=0.01) and 180 minutes (P=0.04) after the initiation of drugs infusion were found. In group N, at the 2nd stage, a 7% decrease in the potassium level was observed, while in group R, it increased by 2.1% as compared with the baseline. By the end of the study, potassium level decreased by 6.9% in group N and by 6.5% in group R. The intragroup differences were significant in Group N at the 2nd (P=0.02) and 5th (P=0.01) stages. In group R, no significant differences vs the baseline were found at any stage. In all cases, the values were within the reference values. In group N, at the 2nd stage the sodium concentration increased compared with the 1st stage by 2.1% (P=0.01). In group R, at the 5th stage, a significant decrease of Cl- concentration by 2.7% (P=0.01) was observed. The acid-base status showed a trend towards mixed acidosis at the 2nd stage in both groups, with the similarly significant pH reduction by 1.3% vs the baseline, whereas at 5th stage the decrease of pH was more significant in Group N (by 1.2% vs the baseline) than in Group R (by 0.9%) (P=0.01). In group N, the phase angle value was found to decrease by 8.6% at the 2nd stage and by 6% at the 5th stage (P=0.01). In group R no significant differences in the phase angle values were found.
Conclusion. The succinate-containing solution has more favorable effect on the water-electrolyte and blood acid-base balance, as well as the state of cell membranes compared with the 0.9% NaCl solution.

Massive lymphorrhea can cause severe dysfunction of organs and systems and result in death due to loss of vital metabolites from the body
Aim. To demonstrate low efficacy of conservative therapy and late lymph duct ligation in continuous massive postoperative lymphorrhea.
Results. We treated a patient with previous subtotal gastric resection with single-plane pancreatic resection, D2 lymph node dissection, peritoneal draining due to poorly differentiated carcinoma in the lower third of stomach and total hysterectomy who developed external lymphorrhea through peritoneal drainage tubes 3 days after surgery. A fat-rich diet, endolymphatic sodium etamsylate administration, and lymphatic duct ligation were not successful in terminating the lymph leakage. Despite the intensive care including extracorporeal detoxification, the multi-organ failure progressed and on day 28 after the surgery the patient was pronounced dead.
Conclusion. Damage to lymph ducts and lymph nodes can be complicated by massive lymphorrhea. If the source of lymphorrhea can be identified, an urgent surgical intervention is warranted to stop the lymph leakage, as well as the restoration of homeostasis to replenish the lost metabolites and prevent death of the patient.

Despite the progress in the modern resuscitation science, optimal duration of a cardiopulmonary resuscitation (CPR) attempt is not defined yet.
It seems appropriate to initiate an open discussion within the Russian medical research community, concerning the development of uniform legislated criteria for stopping resuscitation, considering the best scientific evidence and current international guidelines, with subsequent introduction of harmonized amendments to the clinical practice guidelines for CPR.

Sudden out-of-hospital cardiac arrest (OHCA) is the third leading cause of death in industrialized nations.
While educating lay bystanders in CPR is clearly the most important way to increase survival in this third leading cause of death and the community programs are helpful, it is less easy to reach the entire population if programs are not obligatory. Therefore experts see the need for obligatory inclusion of CPR education in schools. And this is exactly our clear expectation to all politicians involved in health care and school politics worldwide. Until this is reality in all countries, we invite everyone to help to convince the responsible politicians and to take part in campaigns like KIDS SAVE LIVES and WRAH.

The aim of the study: to examine the anti-inflammatory effect of lithium chloride by exposing the human neutrophils to serum of patients with septic shock in vitro.
Material and methods. The study was carried out on neutrophils extracted from the blood of 6 healthy donors, which were activated with serum from patients with septic shock. The neutrophil activity was evaluated with fluorescent antibodies to the CD11b and CD66b markers of degranulation. The level of human neutrophil apoptosis and necrosis was assessed 22 hours after extraction; quantitative assessment was made using annexin V and propidium iodide with flow cytofluorimetry. Intact and activated neutrophils were treated with 0.3, 3.0 and 9.0 mmol lithium chloride solution.
Results. The level of CD11b expression on the surface of intact neutrophils (healthy donors) was 3434.50 [3311.0-3799.0] arbitrary fluorescence units (AFU). Incubation of neutrophils with serum of patients with septic shock increased CD11b expression 2.5 times to 8589.0 [7279.0-11258.0] AFU (P=0.005) vs intact leukocytes, and increased CD66b expression 2.7 times up to 27 600.0 [22 999.0-28 989.0] AFU ((P=0.005) vs intact neutrophils. Lithium chloride in concentrations of 0.3, 3.0 and 9.0 mmol in a dose-dependent manner reduced the level of expression of CD11b and CD66b molecules on the surface of activated neutrophils. Septic serum reduced spontaneous neutrophil apoptosis, and 3.0 mmol and higher lithium chloride solution induced spontaneous neutrophil apoptosis.
Conclusion. Lithium chloride reduces the activation of neutrophils preactivated by serum of patients with septic shock, reduces expression of CD11b and CD66b molecules on the neutrophil surface, inhibiting the process of their activation (degranulation). Lithium chloride in concentration of 3.0 mmol and higher is able to induce spontaneous apoptosis of neutrophils activated by serum of patients with septic shock.

Aim of the study: to evaluate the effect of sublethal dose of clozapine on the rat cardiovascular system 24 hours after administration of the drug.
Materials and methods. The experiments were carried out on 17 male Wistar rats weighing 220-270 g. Under general anesthesia with sevoflurane, the animals of Group I were enterally given 0.9% NaCl solution, Group II animals received clozapine in a dose of 150 mg/kg diluted in 2.0 ml of NaCl solution 0.9%, Group III animals were given clozapine in a dose of 150 mg/kg diluted in 2.0 ml of 40% ethanol. Blood pressure (BP), heart rate (HR), skin microcirculation using laser Doppler flowmetry (LDF), NADH and FAD+ fluorescence were estimated 24 hours after the drug administration. After euthanasia, autopsy with sampling of internal organs for morphological study was done. Then paraffin heart sections with subsequent H&E staining were made, which were studied using the Nikon Eclipse Ni-U light microscope.
Results. Spectral analysis of local skin blood flow fluctuations showed that clozapine reduced Amax and amplitude in all frequency ranges of active microcirculation regulatory system in comparison with the controls. No differences in blood gases and acid-base status were seen between the groups of animals 24 hours after administration of the drugs. However, the animals from clozapine groups (II and III) had lower hemoglobin and hematocrit than in the control group.
Histological examination of rat hearts in groups II and III revealed congested venules, haemorrhages by dia-pedeses, perivascular and interstitial edema. The signs of blood stasis and marginalization of granulocytes were noted in the vascular lumen. Irregular staining of myocardium due to cardiomyocytes with hypereosinophilic and occasionally homogeneous cytoplasm, fragmentation and deformations of cardiac cells were revealed. Car-diomyocytic nuclei were polymorphic and irregularly stained, and perinuclear edema was observed.
Conclusions. The results of the study demonstrate the toxic effect of clozapine manifesting as progressive myocardial alteration and disordered central and peripheral circulation. However, control of bradycardia, restored skin perfusion and metabolic improvement (diagnosed by NADH fluorescence and blood acid-base status) after 24 hours may be due to the activation of compensatory mechanisms, particularly through changes in neurogenic and humoral regulation of homeostasis.