Objective: to reveal changes in the structure and shape of red blood cells depending on blood loss (BL) volume in patients with severe concomitant injury (SCI). Subjects and methods. Eighteen patients (9 men, 9 women) aged 48.6±16.1 years who had sustained severe concomitant mechanical injury (CMI) with different BL volumes and hemodynamic disorders were examined. According to the volume of BL, the patients were divided into two groups: 1) 7 victims with a BL volume of < 750 ml (5.7±1.9 ml/kg), grade 1 BL; 2) 11 victims with a BL volume of > 2000 ml (37.5±5.1 ml/kg), grade 4 BL. A comparison group consisted of 5 apparently healthy volunteers whose mean age was 26.4±2.7 years. The shapes and sizes of red blood cells were examined by light optical and atomic force microscopy (AFM). To study the composition of red blood cells, ten microliters of whole blood were applied to the slides and red blood cell monolayers were prepared using a V-sampler. The membrane surface was scanned by semicontact resonance AFM. The investigators used NSGL 01-A cantilevers with a resonance frequency in the range of 80200 kHz, a probe radius of 10 nm, 512 and 1024 scanning points, and 100X100 ^m and 10X10 ^m scanning fields. Planar and 3D images were obtained. Results. Calculation of 1000 cells by light optical microscopy and AFM showed significantly different counts of macro- and microcytes in the comparison group. The 100X100-^m field exhibited the following types of red blood cells: discocytes (97.9±1.5% and 96±5%), echinocytes (2.1±0.9% and 3±1%), and squamous cells (0.1±0.02% and 1±0.5%). Within the first 24 hours after injury, the victim group displayed lower normocyte counts and higher counts of macrocytes and microcytes than the control group. AFM in the 100X100-^m field revealed that the victims with SMI when admitted to an intensive care unit exhibited a significant decrease in the counts of discocytes counts and increases in those of echinocytes, stomatocytes, and squamous cells, as compared to the controls. Anisocytosis and poikylocytosis was found to depended on the degree of BL. The squamous cells are most likely to be a variety of young erythrocytes. An appreciable increase in macrocytes and squamous cells on day 5 most likely reflects enhanced compensatory erythropoiesis in response to BL. Examination of red blood cell shapes within the first 24 hours after injury in the AFM field revealed profound discocytes with a protuberance in the center. On day 1 of injury changes in the nanostructure of red blood cell membranes included: 9-fold increase of first-order height (hj); 1.5-fold and 3-fold increase of second- and third-order heights (h2 and h3), respectively. The magnitude of changes in hj, h2 and h3 depended on the volume of BL and tended to decrease within the first two weeks of injury. Conclusion. The victims with SMI were observed to possess significant anisocytosis and poikylocytosis. The changes were associated with the volume of BL and included profound discocytes with a protuberance in the center as well aso changes in heights of nanostructural patterns of red blood cell membranes. Key words: severe concomitant injury, blood loss, atomic force microscopy, light optical microscopy, nanostructure of red blood cell membranes.

Objective: to perform an experimental study of the effect of isotonic sterofundin on the morphology of the myocardium, kidney, lung, pancreas, liver, and brain in the late period after hemorrhagic shock. Material and methods. Hemorrhagic shock was induced in 36 male Wistar rats weighing 230—250 g by acute massive blood loss (AMBL) of 2.5 ml/100 g at a rate of 2 ml/min. An hour after AMBL, hypovolemia was replenished to 200% volume for 60 min with Ringer solution and isotonic sterofundin in control and experimental groups, respectively. Then the blood was reinfused at 70% volume of its loss. The magnitude of morphological changes was estimated 3 days following AMBL. Specimens harvested from organs of euthanized animals were examined histologically and images were recorded using a ^Vizo-103 microvisor. Results. The experimental studies demonstrate significant structural damage of tissues within target organs following traditional infusion therapy with polyionic crystalloid solutions that may cause development of multiple organ dysfunction. Malate-containing solution of sterofundin reduces the degree of organ structural damages that may prevent multiple organ dysfunction in the posthemorrhagic period. Key words: acute massive blood loss, hemorrhagic shock, malate, sterofundin isotonic, multiple organ dysfunction.

Objective: to evaluate the clinical efficacy of hypoxen and nutrients used in the combination therapy of patients operated for bleeding gastroduodenal ulcer. Subjects and methods. Seventy-four patients were examined and treated. All the patients were divided into 3 groups: 1) standard therapy + hypoxen in a daily dose of 1 g for a week; 2) standard therapy + hypox-en and nutrients; 3) standard therapy only. Hypoxen and nutrients were administered on postoperative day 1 via an enter-al feeding tube. Systemic hemodynamic and hemostatic parameters were determined using MICAR-RHEO hardware-software rheographic unit APG2-01 analyzer, respectively. Results. It was established that the hyper- and eukinetic hemodynamic types were predominant before surgery and the eukinetic type was prevalent in the early postoperative period. Hypoxen and nutrients were observed to positively affect central hemodynamic parameters, such as blood pressure, cardiac output, circulating blood volume, and heart rate. Hypercoagulation changes (shorter blood clotting time in a study group and elevated serum fibrinogen levels in a comparison group) on postoperative day 10 suggest that the hemostatic parameters should be monitored and corrected as soon as possible. Key words: ulcer disease, hypoxen, nutritional support, blood circulation, hemostatic system.

Objective: to improve the results of treatment in patients with concomitant cerebrovascular diseases, by reducing the incidence of postoperative delirium due to neuroprotective properties of sevoflurane. Subjects and methods. Eighty2two patients with concomitant dyscirculatory encephalopathy were examined. The goals of the study included evaluating (a) efficiency and safety of total intravenous anesthesia (TIVA) using propofol versus inhalational induction and (b) maintenance of anesthesia (IIMA) using sevoflurane in patients with atherosclerotic and hypertensive encephalopathy undergoing noncardiac surgery. Results. The patients from both groups were susceptible to episodes of unintentional cerebral desaturation (rSO2); however, only the TIVA group showed a high correlation between a decrease in rSO2 and increases in the blood levels of S100beta protein, a marker of neuronal damage, and in the incidence of postoperative delirium (r=0.7321; p=0.0000001) diagnosed in accordance to comprehensive clinical examination and MMSE scores. The IIMA group lacked a relationship of MMSE scores to the episodes of cerebral desaturation (r=0.1609; p=0.4860), which is regarded as a manifestation of the neuroprotective effect resulted from anesthetic preconditioning. Conclusion. sevafluran2based inhalational induction and maintenance of anesthesia in patients with atherosclerotic and hypertensive encephalopathy is preferable over intravenous anesthesia with propofol and fentanyl in patients with concomitatnt disregulatory enc encephalopathy. Key words: cerebral desaturation, postoperative delirium, anesthetic preconditioning, europrotection, sevoflurane.

Based on own experience and published data the authors analyze the features and specific components of anesthesia maintenance during mini-invasive cardiac valve surgery. The following clinically relevant aspects of anesthesia and perioperative intensive care were identified: preoperative patient selection and surgical and anesthesia risk prediction; one-lung ventilation; peripheral connection of circulation and specific features of its performance; control of oxygen delivery in the bed of aortic arch branches; and echocardiographic monitoring. The main risks and probable complications due to these interventions, such as cerebral hypoxia, respiratory failure, pulmonary hypertension, etc., are described. The mechanisms of their development and the modes of prevention and treatment are shown. Key words: anesthesia in cardiac surgery, mini-invasive cardiac surgery, one-lung ventilation, anesthesia during cardiac valve surgery.

The problem of predicting the development and outcomes of acute respiratory distress syndrome (ARDS) remains to be solved. Objective: to estimate the informative value of the plasma levels of surfactant protein A (SP2A) as a prognostic biomarker for the development and outcome of ARDS in patients with severe pyoseptic complications in critical conditions. Subjects and methods. This investigation was conducted at the Research Institute of General Reanimatology (RIGR), Russian Academy of Medical Sciences, in 2010—2012. It enrolled 80 patients (including 25 analyzed ones) in accordance with the inclusion and exclusion criteria, as well as 30 apparently healthy donors. ARDS and its stages were diagnosed using the RIGR criteria. Plasma SP2A levels were determined by enzyme immunoassay using a Human Surfactant Protein A ELISA, RD191139200R kit (BioVendor, USA). The findings were statistically analyzed using a Statistica 7.0 package.Sensitivity and specificity of SP2A testing were determined by ROC analysis. The difference between groups at pResults. In patients with ARDS plasma SP2A level was higher than in those without ARDS within the whole study independing on a day of testing. There were no significant dif2 ferences between plasma SP2A levels in the patients with Stages 1 and 2 ARDS. On day 1, the plasma SP2A content of 24.5 ng/ml had a sensitivity of 60.0% and a specificity of 85.7% in predicting the development of ARDS on days 4—5 of intensive care unit admission (the area under the curve 0.74; 95% confidence interval, 0.527—0.872; p=0.0031). On study day 1, the SP2A level of 38.8 ng/ml had a sensitivity of 65.0% and a specificity of 80.0% in predicting a fatal outcome in patients with ARDS (the area under curve 0.74; 95% confidence interval, 0.577—0.866; p=0.0026). Conclusion. On a day when a severe pyoseptic complication was diagnosed, the SP2A level of 24.5 ng/ml served as a sensitive and specific prognostic biomarker for the development of ARDS on days 4—5 of an intensive care unit stay. Within the first 24 hours (on the day when ARDS was diagnosed), the plasma SP2A content of 38.8 ng/ml was a sensitive and specific prognostic biomarker for death prediction in ARDS. Key words: acute respiratory distress syndrome, surfactant protein A, biomarker, prediction, outcomes.

The paper considers the problems of diagnosis of severe thallium salt poisoning in early-stage intoxication, which are associated with the fact that alopecia, a clinical typical symptom of thallium toxicity, appears in the period exceeding two weeks. At the same time, in severe poisoning a fatal outcome occurs much more early and the first signs of intoxication are highly diversified and nonspecific. The clinical manifestations with no specificity at the early period of intoxication in conjunction with the absence of certain history data result in late (sometimes postmortem) diagnosis in the vast majority of cases, particularly, in criminal cases. This comprises a danger of acute severe thallium poisoning since unrecognized intoxication leads to incorrect treatment and patient death. While making a differential diagnosis, attention should be given to a set of a number of symptoms that arouse suspicion of thallium poisoning, which is an indication for chemical and analytical studies of biological environments in these patients. This paper summarizes the available data on ethyology, pathogenesis and cliniu-cal manifestations of severe thallium poisoning and demonstrate own cases of thallium intoxication occurred recently in Yaroslavl and Saint Petersburg. Basic strategy of thallium poisoning treatment is presented and discussed. Key words: acute poisoning, thallium compounds, antidote therapy, diffeferential diagnosis.

Cardiogenic shock is one of the main causes of death in patients with acute myocardial infarction with the mortality rates being as high as 60—80%. Extracorporeal membrane oxygenation (ECMO) is a life-saving technique in patients with cardiogenic shock. Subjects and methods. Veno-arterial ECMO was connected and the coronary arteries were stented in a 53-year-old female patient with acute myocardial infarction complicated by severe cardiogenic shock refractory to drug therapy and intra-aortic counterpulsation (IACP). ECMO was maintained at a volumetric perfusion rate of 4.5 l/min (2.5 l/min/m2). The duration of ECMO was 138.5 hours (5.8 days); that of IACP was 9 days. In the first 24 hours, there were no ECMO-related complications apart from mild bleeding from the site of cannula insertion. The patient stayed in the intensive care unit 12 days. Results. IACP is used to treat cardiogenic shock, but it is ineffective in severe cardiogenic shock. ECMO is one of the possible options for maintaining life and for stabilizing the condition. Current ECMO systems may be employed for urgent peripheral connection and coronary artery intervention. ECMO may be used for resuscitation and temporary life support, which permits as high as 50—75% of patients with refractory cardiogenic shock to be saved. Conclusion: emergency coronary stenting with ECMO support is the technique of choice for the treatment of acute myocardial infarction complicated by severe cardiogenic shock. Key words: extracorporeal membrane oxygenation, cardiogenic shock, coronary artery stenting.

Objective: to determine quantitative changes in procalcitonin (PCT) and S100β protein in serum from newborn infants under the long-term intensive care in an intensive care unit in order to optimize managing the care. Subjects and methods. A study group prospectively included 69 critically ill neonates of more than 2 days of birth admitted to the neonatal intensive care unit. The levels of PCT (normal values Results. In critically ill neonates, both biomarkers were shown to be increased in most cases. The level of PCT varied from the normal values up to 72 ng/ml [mean 1.03 (range 0.36—3.92 ng)]. Mean level of S100β protein was 0.339 (range 0.234—0.481) ^g/l. Levels of PCT and S100β positively correlated (r=0.47; p<0.05). The infants with the increased baseline levels of PCT demonstrated significant reduction of the biomarker over time that was considered as the adequacy of performed antibiotic therapy. The highest S100β levels were recorded in premature babies with sepsis including those without significant perinatal lesion of the central nervous system (CNS). Unidirectional reduction was typical for both S100β and PCT levels. Combination of increased S100β serum concentration decreased PCT was a pattern of developing the periventricular leukomalacia. There was evidence for a direct relation of biomarker S100β? to the presence of convulsive syndrome (Kendal’s coefficient 0.36; p<0.05). Conclusion. Similarly to newborn infants with traumatic, hypoxic, and hemorrhagic CNS lesions, patients with infectious and septic pathology exhibited elevated S100β levels. Both biomarkers PCT and S100β are suggested to be included in a battery of clinical and monitoring tests to optimize treatment of high-risk neonates in the intensive care unit. Key words: newborn infants, premature infants, critical conditions, biomarkers, procalcitonin, S100β protein, laboratory monitoring, perinatal pathology, antibacterial therapy.