Volume IX № 4 2013
EDITORIAL
5 1269
Abstract
This review addresses the issue of postoperative pain relief in Russian medical institutions and provides the analysis of the causes of inadequate administration of the opioid analgesics that lead to inadequate pain relief in patients who undergo operations. In Russia opioid analgesics are hard-to-reach even for incurable patients with oncological diseases and chronic pain syndrome. In order to improve the situation with the postoperative pain relief in Russia wide discussion of this topic is necessary. Poor availability of effective analgetics for patients is caused by administrative barriers within the medical institutions. These barriers are the consequence of the present system of reporting and control of narcotic analgetics administration and usage in Russia. This system is based on the strict requirements of Federal Service of the narcotics control and related orders and directions of Ministry of Health that block the appropriate administration of opioid analgetics by physicians. All these prescriptions must be coordinated with authorities. This situation contradicts with international principles of supply of patients with acute and chronic pain with analgetics. These principles are secured by official documents and publications by UNO, WHO and International Narcotic control Board (INCB) which are available in Russian on the INCB website cited in the article.
BLOOD LOSS. HEMOSTASIS
18 1753
Abstract
Objective: to estimate the level of peripheral venous blood lymphocyte apoptosis and intraoperative hypoxia in victims with acute massive blood loss. Subjects and methods. Twenty-two patients with open and close chest and abdominal traumas complicated by acute massive blood loss were examined. All the patients were emergently operated on to stop bleeding. Tissue metabolism was evaluated from gases, acid-base parameters, and plasma lactate, glucose, potassium, and sodium levels. Apoptosis of mononuclear cells was studied and dead leukocytes were counted using flow cytometry. Results. Preoperatively, the victims were found to have venous hypoxemia, hyperlactatemia, hyperglycemia, moderate leukocytosis, and higher dead leukocyte counts. There were also raised counts of lymphocytes coming into the process of apoptosis. A significant relationship was found between monocyte counts and hypoxia values. At the end of surgery, oxygen balance values became stable and exerted an effect on the count of leukocytes, the relative level of granulocytes, the relative and absolute counts of dead and damaged leukocytes, and the concentration of lymphocytes in the victims’ venous blood during the early stages of apoptosis, as evidenced by nonlinear regression models. Conclusion. The indicators of immunocompetent cell apoptosis and the count of venous blood dead leukocytes along with lactate levels and venous hypoxemia parameters reflect the degree of tissue hypoxia and may be used as specific markers.
23 4416
Abstract
Objective: to reveal the patterns of hemostatic disorder development in the venous and arterial bed in relation to the type of energy deficiency. Subjects and methods. One hundred and ninety-nine patients who had undergone extensive abdominal surgeries (gastrectomy, pancreatoduodenectomies, hemicolectomies, hepatectomies, etc.) were examined. Among the patients, there were 5 groups: a control group without energy deficiency and 4 groups of patients who were recorded to have one of the types of energy deficiency: substrate, hypermetabolic, hypoxic, and enzymatic. Results and discussion. The nature and degree of existing metabolic disturbances and changes in the arteriovenous difference in hemostasiological parameters have a statistically proven relationship (on the basis of ROC analysis). Substrate energy deficiency was characterized by the insignificant changes in the hemostatic system as a whole, which affect only its coagulation component; the arteriovenous difference in hemostasiological parameters was similar to that in the patients without energy deficiency. In hypermetabolic energy deficiency, the venous bed demonstrated the most pronounced hemostatic changes (hypercoagulation, suppressed fibrinolysis, and enhanced platelet aggregation). The hemostatic changes that were more significant than those in the above group were responsible for the formation of a significant arteriovenous difference in the hemostasiological parameters; however, the direction of this difference did not differ from that in the patients without energy deficiency. In hypoxic energy deficiency, hemostatic disorders were heterodirectional in the arterial and venous bed (these were most marked in the arterial bed — hypercoagulation, activated fibrinolysis, and enhanced platelet aggregation) therefore there was a significant arteriovenous difference in the hemostasiological parameters, which was opposite as compared to that in the patients without energy deficiency. In enzymatic energy deficiency, the arteriovenous difference in the hemostatic parameters was slight as this deficiency was accompanied by the same hemostatic changes in the venous and arterial blood samples: hypocoagulation, thrombocytopenia, decreased platelet aggregability, and suppressed fibrinolysis. The degree of metabolic and hemostatic disorders was maximal among the considered types of energy deficiency, which was attended by a loss of the arteriovenous mechanism responsible for regulating the functional status of the hemostatic system. Key words: energy deficiency, arteriovenous difference, hemostatic system.
FUNDAMENTALS OF ANESTHESIOLOGY AND REANIMATOLOGY
K. Yu Borisov,
V. V. Moroz,
O. A. Grebenchikov,
E. Yu, Plotnikov,
D. I. Levikov,
R. A. Cherpakov,
V. V. Likhvantsev
30 1425
Abstract
Objective: to estimate the magnitude of the cardioprotective properties of sevoflurane and propofol, when they are used alone and in combination in the acute experiment on rats after total ischemia/reperfusion (I/R). Materials and methods. The investigation was conducted on 50 male albino outbred rats weighing 202±19 g (M±ff), by using a total I/R model. The animals were randomized into 5 groups: 1) intraperitoneal chloral hydrate 300 mg/kg; 15-minute mechanical ventilation (MV); 2) inhalation induction with sevoflurane in an exsiccator; MV; injection of about 2—2.5 MAC sevoflurane in the expiratory breathing circuit for 15 minutes — anesthetic preconditioning simulation (APS); 3) anesthesia and APS with sevoflurane; then 10-minute ischemia simulation, followed by resuscitation and 5-minute reperfusion; 4) chloral hydrate anesthesia; injection of propofol 2.5 mg/kg in the right internal jugular vein; APS simulation; 5) chloral hydrate anesthesia; injection of propofol 2.5 mg/kg in the right internal jugular vein; and simulation of APS with sevoflurane. The hearts were extracted from all the animals and homogenized for further examination. The concentrations of total and phosphorylated glycogen synthase kinase-3/8 (GSK-3/8 and pGSK-3/8, respectively) were estimated by Western blotting. Results. The concentration of total GSK-3/8 was comparable in the groups. Group 2 showed a 1.5-fold increase in pGSK-3^ concentrations (p<0.05), a more increment (by more than twice) was observed in Group 3 (p<0.05). The concentration of pGSK-30 rose slightly in Group 4. In Group 5, the level of pGSK-30 decreased approximately twice that in Group 1 (p<0.05). Conclusion. Sevoflurane can be expected to have cardioprotective properties manifested as a considerably elevated p-GSK-Эв level. Propofol fails to exert a significant cardioprotective effect and when it is used in combination with sevoflurane, the latter is likely to completely deprive of the cardioprotective properties, by lowering the level of p-GSK-3^ below the reference values, which may be associated with the antioxidant properties of propofol. Evidently, further investigation should be continued to form ischemia/reperfusion groups when these anesthetics are co-administered. Key words: anesthetic preconditioning, sevorane, glycogen synthase kinase-3/3, Western blotting.
36 2013
Abstract
Study Objective: to assess the efficacy and safety of different combinations of antiemetic drugs and adjuvants as part of anesthetic care in prevention of postoperative nausea and vomiting in oncological patients. Materials and methods: 165 patients who undergone surgical treatment for female oncological diseases on the II—III stages with common anaesthesia were included. Depending on the scheme of postoperative nausea and vomiting prevention participants were divided into 4 groups. Patients from group С (comparative, n=43) received treatment with ondansetron (8 mg) and dexamethasone (8 mg) in the induction stage. Patients from group E (n=40) additionnaly received continuous infusion of esmolol 0,59±0,94 mg/kg/h. Patients from group D (n=41) on the traumatic stage of operation received bolus of intravenous droperidol 0,038±0,055 mg/kg. Patients from group K (n=41) on the traumatic stage of operation received bolus of intravenous of clonidine 0,0013±0,0004 mg/kg. Postoperative nausea and vomiting episodes were monitored during 24 hours after the surgery. Results: in group С postoperative nausea and vomiting developed in 15 patients from 43 (34,9%). In group E this complication was detected in 8 from 40 patients (20%). In group D – in 8 from 41 patients (19,5%). Groups E and D did not have statistically significant differences from group С in terms of the frequency of postoperative nausea and vomiting. In group С this complication was detected in 6 from 41 patients with the rate of 14,6% which is significantly lower than in group С (p=0.03). The intensity of the nausea and vomiting was lower in groups E,D, and K as compared with group С. Conclusion: the inclusion of clonidine in scheme of postoperative nausea and vomiting prevention lead to statistically significant decrease of the frequency of this complication. Administration of esmolol and droperidol leads to decrease of postoperative nausea and vomiting intensity. Key words: oncosurgey, postoperative nausea and vomit_ ing, antiemetics, esmolol, droperidone, clonidine.
ACUTE RESPIRATORY FAILURE
11 1485
Abstract
Acute respiratory distress syndrome (ARDS) is one of the major problems of reanimatology. Current technologies allow diagnosis of early-stage ARDS. At the same time, no objective parameters for assessing structural damage to the air-blood barrier are available. Biomarkers are promising in this respect. Objective: to estimate the informative value of the plasma and bronchoalveolar lavage (BAL) fluid levels of surfactant protein D (SP-D) as a candidate biomarker for early-stage ARDS. Subjects and methods. A multicenter observational study was conducted at the Clinics of the V. A. Negovsky Research Institute of General Reanimatology (RIGR), Russian Academy of Medical Sciences (RAMS), in 2010—2012. It enrolled 70 patients in accordance with inclusion and exclusion criteria and 30 healthy donors. ARDS and its stages were diagnosed using the criteria developed by the RIGR, RAMS. Blood and BAL SP-D levels were measured by the enzyme immunoassay Human Surfactant Protein D ELISA, RD194059101, BioVendor, USA. Statistical analysis of the findings was performed using a Statistica 7.0 package. ROC analysis was made to determine the sensitivity and specificity of SP-D. The difference was considered significant at pResults. During all study days (1, 3, 5, and 7), the plasma SP-D levels were significantly higher in the patients with ARDS than in those without this condition. On the same study days, these were significantly lower in patients with Stage 1 ARDS than in those with its Stage 2. On the same study days, the plasma SP-D content was significantly higher in deceased patients with ARDS than in survivors with this condition. The SP-D level of >115.8 ng/ml on study day 1 had a sensitivity of 82.5% and a specificity of 80.0% in diagnosing ARDS (area under the curve 0.87; 95% confidence interval 0.778-0.984; p=0.0026). That of Conclusion. The plasma SP-D level of >115.8 ng/ml is a sensitive and specific biomarker °f ARDS and that °f Key words: acute respiratory distress syndrome, surfactant protein D, biomarker, diagnosis, sepsis.
FOR PRACTIONER
V. V. Lomivorotov,
V. A. Shmyrev,
S. M. Efremov,
D. N. Ponomarev,
G. B, Moroz,
D. G. Shakhin,
I. A. Kornilov,
A. N. Shilova,
V. N. Lomivorotov,
S. I. Zheleznev
42 1587
Abstract
Background. Hypothermal extracorporeal circulation has been used in cardiosurgery over 50 years. However, recent trials have not shown its predominant effect on the protection of the brain, lung, and myocardium in patients during surgery. We have presumed that when normothermal extracorporeal circulation used in patients with acquired heart disease, its pathophysiological effect on the body is comparable with that of hypothermal extracorporeal circulation. Subjects and methods. One hundred and forty patients who were to undergo acquired heart disease correction were randomized into two equal groups: that using hypothermal or normothermal extracorporeal circulation. Perioperative troponin I and NT-proBNP concentrations, postoperative clinical course, and hospital morbidity and mortality rates were estimated. Results. There were no significant differences in the concentrations of troponin I and NT-proBNP at the study stages. In the normothermal extracorporeal circulation group patients with isolated aortic stenosis, the concentration of troponin I was higher than that in the hypothermal extracorporeal circulation group. Analyzing the postoperative course indicated that the duration of mechanical ventilation was significantly lower in the hypothermal extracorporeal circulation group than in the normothermal extracorporeal circulation group. There were no differences in hospital complications and mortality rates. Conclusion. Hypothermal versus normothermal extracorporeal circulation in the correction of acquired heart diseases has no predominant effect on tro-ponin I and NT-proBNP concentrations, postoperative clinical course, and hospital complications and mortality rates. Key words: extracorporeal circulation, hypothermia, acquired heart disease, troponin I, NT-proBNP.
50 1944
Abstract
The incidence of fat embolism ranges from 0.5 to 30% in injuries with long and pelvic bone fractures; it also occurs in other diseases and conditions. Moreover, mortality accounts for 3 to 67%. There is still no clear idea on the pathogenesis, prevention, and treatment of fat embolism. This review gives current views on this problem. Key words: fat embolism, poly-trauma.
59 2064
Abstract
Early treatment for anemia with epoietin (EPO) and intravenous iron after replacement of the large lower extremity joints permits an 8 g/l increment in hemoglobin concentration to be achieved by postoperative day 10 versus day 2. Objective: to evaluate the efficiency of medical stimulation of erythropoiesis in the treatment of anemia after large joint replacement. Materials and methods. The medical records of patients who had undergone hip or knee joint replacement in January 2010 to August 2011 were retrospectively analyzed. Group 1 (EPO group) included 32 patients who postoperatively received iron saccharate 600 mg and subcutaneous epoietin alfa 40,000 IU. In Group 2 (IRON group), 27 patients took iron saccha-rate 600 mg without epoietin. In Group 3 (CON group) 62 patients had no parenteral erythropoietic stimulants. Blood hemoglobin levels on postoperative days 1, 2, and 10 were a main control indicator. Blood transfusion therapy was not performed in the identified groups. Results. In the first two days, hemoglobin levels were statistically significantly higher in the CON group than those in the EPO group and on day 10 intergroup differences were absent. By day 10 versus day 2, a statistically significant increase in hemoglobin concentrations was found in the EPO and IRON groups. In the EPO group, the hemoglobin concentration increment was significantly higher than that in the CON group. There were no clinical signs of thrombosis and thromboembolic events in the patients of the study groups. Conclusion. The co-administration of intravenous iron and epoietin enables an 8 g/l increase to be achieved on postoperative day 10 versus day 2. Key words: joint replacement, anemia, epoietin, iron saccharate, intravenous iron.
ISSN 1813-9779 (Print)
ISSN 2411-7110 (Online)
ISSN 2411-7110 (Online)