Portal hypertension syndrome is one of the most severe pediatric conditions causing gastroesophageal bleeding which can be fatal. The main challenge in the management of portal hypertension is prevention of bleeding from the portal vein system, which is achieved by vascular surgery, particularly portosystemic shunting. Epidural anesthesia, despite its advantages over the opioid one, is not always performed in children with extrahepatic portal hypertension, and still remains unsolved issue in pediatric anesthesiology.

Aim of the review: to evaluate the scope of limitations of general anesthesia in bypass surgery for extrahepatic portal hypertension in children with thrombocytopenia. We searched PubMed, Medline, Elibrary.ru and other databases and used original clinical observations while performing anesthesiologic support of surgical correction of extrahepatic portal hypertension in children.

We found that general anesthesia for portosystemic bypass surgery in children with thrombocytopenia requires the anesthetic support that does not include epidural anesthesia and high-dose opioid administration. This issue can be resolved by including the central selective alpha-2-adrenergic agonist dexmedetomidine with both analgesic and hypnotic effects in the anesthesia support. Due to its additive effects, this drug significantly reduces the need for hypnotics and opioid analgesics while maintaining a high level of neurovege-tative protection.

Conclusion. In our opinion, optimizing anesthesia in children with thrombocytopenia during bypass surgery for extrahepatic portal hypertension is essential to minimize surgical stress and side effects of drugs.

During the care of patients with novel coronavirus infection at the Lomonosov MSU Medical Research and Education Center from April 21 to June 13, 2020, we observed cases of spontaneous mediastinal emphysema (spontaneous pneumomediastinum) as a manifestation or a probable complication of COVID-19.

The aim of the paper. To provide clinical case descriptions and approaches to the management of patients with spontaneous pneumomediastinum in COVID-19 associated pneumonia, as they are not addressed in the current clinical guidelines, and therefore are worthy of special attention.

Among 224 patients with laboratory-confirmed diagnosis of the novel coronavirus infection COVID-19, five cases of pneumomediastinum without pneumothorax were identified. Of these, in two cases the pneumomediastinum developed during noninvasive lung ventilation (NLV) (one case) and invasive lung ventilation (one case). In three cases, spontaneous mediastinal emphysema was not associated with lung ventilation. By the time of publication, one case of pneumomediastinum was completed, and four patients remained hospitalized. All five patients were males aged from 52 to 84 years.

This paper presents in depth the description of two cases of mediastinal and subcutaneous emphysema in patients with COVID-19.

The aim of the study was to examine the clinical phenotypes of hypoxia in patients with COVID-19 in relation to the severity of acute respiratory failure (ARF).

Material and methods. Sixty patients with severe COVID-19 and manifestations of acute respiratory failure admitted to the infectious disease hospitals of Nizhny Novgorod were enrolled in the study.

The study included patients with transcutaneous saturation (SpO₂) below 93% on spontaneous breathing, who required correction of respiratory alterations according to the Interim Clinical Guidelines for the Treatment of Patients with COVID-19. All patients were divided into 2 groups of 30 patients each according to the nature of respiratory impairment. Group 1 included patients without breathing difficulties who had respiratory rate up to 25 per minute. Group 2 patients had breathing difficulties and respiratory rate over 25 per minute.

In addition to SpO₂, severity of respiratory difficulties, respiratory rate (RR), forced breathing (FB), heart rate (HR), acid-base balance (ABB) and arterial and venous blood gases, capillary refill time, blood lactate level were assessed. The severity of lung involvement was determined using chest computed tomography, and severity of disease was assessed using the NEWS score. Respiratory treatment required for ARF correction and the outcome of hospitalization were also considered.

Results. In group 1, the mean age was 66 (56; 67) years and the disease severity was 8 (7; 10) points. Group 1 patients had minor tachycardia and tachypnoea, there were no lactate elevation or prolonged capillary refill time. Mean SpO₂ was as low as 86 (83; 89)%. Venous blood pH and pCO2 values were within normal reference intervals, mean BE was 6 (4; 9) mmol/l, pO₂ was 42 (41; 44) mm Hg, and SO₂ was 67 (65; 70)%. Mean arterial blood pO₂ was 73 (69; 75) mm Hg, SO₂ was 86 (83; 90)%, and O₂ was 37 (35; 39) mm Hg. Oxygen therapy with the flow rate of 5-15 l/min in prone position helped correct ARF. All patients of this group were discharged from hospital.

In group 2, the mean age was 76 (70;79) years and the disease severity was 14 (12; 18) points. Anxiety was observed in 15 patients, prolonged capillary refill time was seen in 13 patients, and increased lactate level in 18 patients. Mean RR was 34 (30; 37) per minute, HR was 110 (103; 121) per minute, and SpO₂ was 76 (69; 83)%. Mean venous blood pH was 7.21 (7.18; 7.27), pCO₂ was 69 (61; 77) mm Hg, BE was -5 (-7; 2) mmol/l, pO₂ was 25 (22; 28) mm Hg, SO₂ was 47 (43; 55)%. Mean arterial blood pO₂ was 57 (50; 65) mm Hg, SO₂ was 74 (69; 80)%, and pCO₂ was 67 (58; 74) mm Hg. In the group 2 patients, the standard oxygen therapy in prone position failed to correct ARF, and high flow oxygen therapy, noninvasive CPAP with FiO₂ of 50-90% or noninvasive CPAP+PS were administered. Fourteen patients were started on invasive lung ventilation. There were 10 fatal outcomes (33%) in this group.

Conclusion. Two clinical phenotypes of hypoxia in patients with COVID-19 can be distinguished. The first pattern is characterized by reduced SpO₂ (80-93%), no tachypnoea (RR >25 per minute) and moderate arterial hypoxemia without tissue hypoxia and acidosis («silent hypoxia»). It is typical for younger patients and associates with less lung damage and disease severity than in patients with severe ARF. Hypoxemia can be corrected by prone position and oxygen therapy and does not require switching to mechanical ventilation. The second pattern of hypoxia is characterized by significant arterial hypoxemia and hypercapnia with tissue hypoxia and acidosis. Its correction requires the use of noninvasive or invasive mechanical ventilation.

Paroxysmal nocturnal haemoglobinuria (PNH) is a clonal haematopoietic stem cell disease that presents with haemolytic anaemia, thrombosis and bone marrow failure. We report a case of a 51-year-old male with a history of PNH in treatment with Eculizumab admitted to our Hospital for acute chest pain and dyspnoea. The diagnosis was a triple vessel disease and patient was scheduled for coronary artery bypass grafting surgery. To balance the risk between thrombosis and bleeding in this particular clinical setting, we decided to use thromboelastography (TEG) as point of care solution and we used the R parameter as the target of our anticoagulant therapy. The R parameter between 11 and 14 sec can be used as a target value to balance the risk; in addition, there was no evidence of acute hemolysis during the surgery and supplemental dose of Eculizumab was administered in order to minimize any potential exacerbation of intravascular hemolysis.

The aim of the study: to assess the lung histopathology in acute intoxication with baclofen alone and its combination with alcohol (in the same dose) 3 hours after the ingestion.

Materials and methods. The study was performed on 15 male Wistar rats weighing 290-350 g and aged 20 weeks. The animals were divided into 3 groups, 5 animals each: control group that included intact rats; Group 1 composed of rats received baclofen alone; Group 2 that included rats received a combination of baclofen and ethanol. Baclofen was administered orally at a dose of 85 mg/kg animal weight under anesthesia (chloralose), and 40% ethanol, 7 ml/kg animal weight, was orally administered along with baclofen at the same dose. Animals of all groups were sacrificed after 3 hours by overdosing anesthetic agent. Lung tissue samples were examined by light microscopy using a video system at x400 magnification. The following histological characteristics were evaluated: circulatory disorders (engorged capillaries and venules, hemorrhages in interalveolar septa and alveoli, sludge), atelectasis (including partial), emphysema, cellular response (increased WBCs in the interalveolar septal area), thickening of interalveolar septa due to edema, epithelial desquamation into bronchial lumen. The diameter of alveoli and thickness of interalveolar septa were measured.

Results. Three hours after the baclofen administration, circulatory disorders in the lungs (engorged venules and capillaries, hemorrhages in the interalveolar septa, sludge), emphysema, atelectasis (complete and partial) as well as cellular response (leucocyte infiltration of interalveolar septa) were detected. In the Group 2, baclofen resulted in circulatory disorders (engorged venules and capillaries, sludge), emphysema, atelectasis (complete and incomplete), cellular response (infiltration with leukocytes), as well as fluid in the lumen of bronchioles. In Group 1, the alveolar diameter was significantly larger than in the control group and Group 2, while the thickness of the interalveolar septa was lower. In group 2, alveolar diameter was significantly less than in group 1, but still greater than in the control group. The thickness of the interalveolar septa in group 2 was significantly greater than in the control group and group 1.

Conclusion. After administration of baclofen alone and in combination with ethanol, the following alterations were found in the lungs: circulation disorders (venular and capillary engorgement, sludge), increased vascular permeability because of developing hypoxia, leukocyte infiltration of interalveolar septa. The monitoring of morphological alterations may aid in evaluating the severity of pathological processes in intoxication with baclofen alone and in combination with ethanol and in determining the method of intoxication (baclofen alone or in combination with ethanol).

Aim of the study. To investigate the preconditioning effect of sevoflurane on small intestinal mucosa in experimental hemorrhagic hypotension.

Material and methods. The study was performed on a cohort of 106 male rats that included two experimental groups: one exposed to ether (Group 1, n=40) and another one exposed to sevoflurane (Group 2, n=40); two control groups included 20 intact animals, of which 10 were anesthetized with ether and 10 with sevoflurane. Six animals were excluded from the study because they died by the 2^nd hour of hemorrhagic hypotension under ether anesthesia. The study parameters were measured at 15 min, 30 min, 1 h, and 2 h of hemorrhagic hypotension. Amylolytic activity of the small intestine mucosa was determined by E. A. Zabelinsky, B. W. Smith and I. M. Roe technique modified by A. M. Ugolev. The data were statistically analyzed using the nonparametric Mann-Whitney method.

Results. By 15 min of hemorrhagic hypotension, the activity of amylase fractions in all small intestine regions in Group 2 animals was significantly lower vs the Group 1 rats. By 30 min of hemorrhagic hypotension, the activity of the enzyme fractions in all small intestine regions in Group 2 animals remained significantly lower than in Group 1, by an average of 2 to 9 times (P=0.01; P<0.001), and after 1 h of hemorrhagic hypotension, it was 2 and 4 times lower (P=0.02; P<0.001). By the 2nd hour of hemorrhagic hypotension, the activity of nearly all duodenal amylase fractions in the Group 2 animals remained 3-4 times lower compared to Group 1. Meanwhile, a significantly higher activity of slowly desorbing and intracellular amylase fractions vs the control group was observed in jejunum and ileum.

Conclusion. In hemorrhagic hypotension under sevoflurane anesthesia, a decrease of the pancreas excretory function, stabilization of the brush border of the mucosa of all small intestine regions, including enterocyte membranes, was found during the first hour of experiment. Two hours after the hemorrhage, the biochemical evidence of brush border damage in the jejunum and ileum was revealed.

The aim of the study. To study the double-nucleated cellular structures of the brain sensorimotor cortex (SMC) of sexually mature white rats after a 40-minute occlusion of the common carotid arteries.

Methods. Acute ischemia was simulated in white Wistar rats by 40-minute occlusion of the common carotid arteries (OCCA). We performed comparative morphometric evaluation of cyto-, dendro-, synapto-, and glioar-chitectonics of the neocortex in intact animals (n=5), and 1 (n=5), 3 (n=5), and 7 days (n=5) after OCCA. We used Nissl, hematoxylin and eosin staining, and immunohistochemical reactions for NSE, MAP-2, HSP-70, p38, caspase-3, GFAP, AIF1, and Ki-67. Numerical density of pyramidal neurons, oligodendrocytes (ODCs), mi-croglyocytes (MGCs), presence of dystrophic and necrobiotic neurons with one or more nucleoli, hetero- and dikaryons were assessed. Statistical hypotheses were tested using Statistica 8.0 software.

Results. The percentage of dystrophic and necrobiotic neurons, nerve cells with two nuclei or two or more nucleoli, the total number (proliferation) and percentage of hypertrophic astrocytes, ODCs and MGCs increased significantly after OCCA. The total numerical density of SMC neurons decreased by 26.4% (P=0.001) in layer III and by 18.5% in layer V (Mann-Whitney U Test; P=0.01) after OCCA throughout the observation period. Pathological and compensatory changes were diffusely focal and more pronounced in layer III of the neocortex. The density of bi-nucleated heterokaryons and dikaryons remained unchanged on days 1 and 3 after OCCA vs control and was 3.5 (1.5-4.0)/mm², and increased to 6.5 (5.0-8.5)/mm² on day 7 (Mann-Whitney U Test; P=0.002). This increase occurred along with a higher density of ODCs and MGCs than in the control. The maximum number of neurons with two or more nucleoli was also noted in layer III and V during this period.

Conclusion. After 40-minute OCCA in SMC, parallel to the dystrophic and necrobiotic changes of pyramidal neurons and activation of neuroglial cells, there was an increase in the formation of heterokaryons and neurons with amplified nucleolus. These changes were considered as a variant of neuronal response to ischemic damage.

Patients may experience long-term physical, psychological and cognitive impairment after intensive care unit (ICU) discharge, a condition commonly described as post-intensive care syndrome. The relative contribution of each of these components to long-term quality of life was never investigated.

The aim of this study is to identify the type and severity of disability and QoL at the discharge from ICU and up to following 6 months.

Material and Methods. All patients (n=218) discharged from a university hospital ICU between April 2016 and July 2017 were eligible. Exclusion criteria included: age <18 years, brain or spinal injury, life expectancy <90 days, and ICU stay <12 hours. The Short Form Health Survey (SF-36), and 5-level EuroQoL-5D (EQ-5D-5L) questionnaires were administered at ICU discharge, and at 30-, 90- and 180-days. We compared patients requiring short-term ICU monitoring (IM, Intensive Monitoring, n=109) or patients requiring ICU treatment (IT, Intensive Treatment, n=109).

Results. All dimensions of SF-36 and EQ-5D-5L parameters increased from ICU discharge to 180-days, except for the SF-36 Synthetic index linked to mental health (P=0.08). All EQ-5D-5L parameters improved significantly in the IT group, while only Visual Analog Scale Health Perception improved in the IM group.

Conclusion. ICU survivors suffer long-term physical and psychological sequelae. The perception of Quality of Life is reduced after ICU discharge. The psychological and cognitive dimensions were more compromised than physical ones. Patients discharged from the ICU may benefit from specific intensive care follow-up clinics addressing their needs in term of psychological and cognitive support.