Objective: to evaluate the microcirculation system in critical conditions caused by abdominal sepsis for a further differentiated approach to intensive care. Subjects and methods. Twenty-four patients with abdominal sepsis (mean age 42.9±0.9 years) were examined; a control group consisted of 35 apparently healthy individuals (mean age 40.1±2.1 years). Over 11 days, the microcirculatory bed was evaluated by cutaneous laser Doppler flowmetry by means of a ЛАКК-02 laser capillary blood flow analyzer made in the Russian Federation (LAZMA Research-and-Production Association), by using a basic light guide for percutaneous microcirculation studies. Results. Throughout the study, tissue blood perfusion remained in the patients with sepsis due to the higher effect of mainly active components of vascular tone regulation on the microvascular bed. In a poor outcome, there was a reduction in both active and passive regulatory effects on tissue perfusion chiefly due to local (myogenic) factors. Conclusion. The findings suggest that the patients with sepsis have microcirculatory regulation changes aimed at maintaining tissue perfusion. A follow-up of the microcirculation may be useful in choosing intensive care tactics and predicting disease outcome. Key words: sepsis, microcirculation, microvascular bed, micro blood flow, tissue perfusion.

Objective: to analyze the incidence of infectious pulmonary complications depending on the duration of mechanical ventilation and to study a spectrum of pneumonia pathogens and their antibiotic resistance in intensive care unit (ICU) victims with severe concomitant injury. Subjects and methods. Forty-eight ICU victims with severe concomitant injury were examined. The incidence of purulent tracheobronchitis and pneumonia was analyzed depending on injury severity scores (ISS) and mechanical ventilation (MV) duration. Microorganisms were identified and their antibiotic susceptibility was determined. Results. The risk of infectious pulmonary complications was significantly higher and proportional to MV duration in victims with severe concomitant injury on traditional MV as compared those without MV (or on noninvasive ventilation). The pathogens of infectious pulmonary complications were chiefly gram-negative bacteria. Conclusion. There is evidence that there is an association between the ISS, the performance and duration of MV, the structure of pathogens, and their antibiotic resistance. Key words: infectious pulmonary complications, pneumonia, concomitant injury, mortality.

Objective: to study the efficiency of respiratory, non-respiratory, and pharmacological treatments in patients with acute respiratory distress syndrome (ARDS) induced by direct (aspiration pneumonitis, bilateral pneumonia, or lung contusion) and indirect (abdominal sepsis, polytrauma, or hemorrhagic shock) damaging factors. Subjects and methods. The results of treatment were retrospectively analyzed in 185 patients (122 men and 63 women whose age varied 18 to 69 years) with ARDS resulting from aspiration pneumonitis, bilateral pneumonia, or lung contusion (84 patients, including 53 men and 31 women) or from abdominal sepsis, polytrauma, or hemorrhagic shock (101 patients, including 69 men and 32 women). The efficiency of a lung opening maneuver, mechanical ventilation in the prone position, Surfactant BL, perftoran, and their combination use in ARDS developing due to direct and indirect damaging factors was studied. Results. The study treatment modalities were ascertained to show varying clinical efficiency in patients with ARDS caused by direct and indirect damaging factors. Conclusion. The findings made it possible to substantiate the necessity of setting off ARDS induced by direct and indirect damaging factors, to develop and propose new approaches to the differentiated treatment of different forms of ARDS. Key words: acute respiratory distress syndrome, direct damaging factors, indirect damaging factors, thoracopul-monary compliance, lung extravascular fluid, respiratory support, mechanical ventilation, positive end-expiratory pressure, lung opening maneuver, prone position, perftoran, surfactant.

Objective: to study the role of a tissue factor pathway inhibitor (TFPI), the metalloproteinase ADAMTS-13, and its inhibitor in the pathogenesis of acute respiratory distress syndrome (ARDS) in A/H1N1 influenza. Subjects and methods. The study enrolled 52 patients of both sexes aged 19 to 40 years with different clinical forms of A/H1N1 influenza, of whom 14 patients developed Stages I-II ARDS in the presence of pneumonia. An enzyme immunoassay was used to estimate the concentrations of TFPI, ADAMTS-13, and its inhibitor, the antibodies of the IgG class. Results. The level of TFPI increased in parallel with the progression of the disease, its highest concentration was found in patients with ARDS-complicated influenza pneumonia. There was a higher relative activity of ADAMTS-13 in patients with moderate pneumonia while this enzyme was relatively deficient in those with ARDS-complicated pneumonia. Conclusion. Relative ADAMTS-13 deficiency is one of the triggers of ARDS in severe forms of pneumonia in the presence of A/H1N1 influenza. The high level of TFPI may predict the development of respiratory distress syndrome in pneumonia in the presence of influenza infection. Key words: A/H1N1 influenza, respiratory distress syndrome, tissue factor pathway inhibitor, ADAMTS-13.

Objective: to estimate changes in respiratory and circulatory functions in the acutest period in patients with pulmonary artery thromboembolism (PATE) without arterial hypotension during their first visit. Subjects and methods. The authors analyzed 28 cases of PATE without lowered blood pressure (BP) on primary examination in the prehospital stage (systolic BP (SBP) was less than 100 mm Hg). The study enrolled 17 men and 11 women; their mean age was 67.5±14.5 years. The clinical and ECG pattern was compared on primary examination and over time (following an average of 87±29.7 min). Results. With emergency team care, the rate of tachypnea decreased from 75% on primary examination to 64% over time (p=0.07). Mean respiration rate (RR) fell from 24.0±5.7 to 21.0±5.6 per min (p=0.02). The manifestations of cyanosis were also reduced from 39 to 32% (p=0.4). On primary examination, mean RR, SBP, and diastolic BP were 100.0±19.1 per min, 140.0±21.9 and 80.0±11.5 mm Hg, respectively; after prehospital therapy, these were 100.0±28.2 per min, 130.0±36.8 and 80.0±21.9 mm Hg, respectively (p>0.5). Tachycardia was observed in 60% of the patients both on primary examination and following therapy. One (4%) patient, over time, developed hypotension. ECG analysis revealed an increase in the signs of right cardiac cavity overload. Conclusion. A prehospital fatal outcome was recorded in 1 (4%) patient of those having PATE without arterial hypotension; _ total mortality was 18%. There was progressive deterioration in 32% of the patients due to the progression of both respiratory and cardiovascular failures correctable in the prehospital stage in more than 32 and 39% of cases, respectively. Key words: pulmonary artery thromboembolism, prehospital stage, mortality.

Objective: to define the optimal tranexamic acid dosage regimen to reduce perioperative blood loss during total endo-prosthetic hip joint replacement (TEHJR). Subjects and methods. A randomized controlled trial enrolled 90 patients admitted for elective primary cementless TEHJR. Prior to surgery, all the patients were given an intravenous bolus injection of tranexamic acid in a dose of 1 g. A day before surgery, the patients were divided into 3 groups of 30 subjects each. In Group 1, tranexamic acid was administered only before incision of the skin. In Group 2, a second bolus of tranexamic acid 1 g was injected 3 hours after start of surgery. In Group 3, 1 g of tranexamic acid was readminis-tered 6 hours following surgery if drainage blood loss volume exceeded 200 ml. Results. No statistically significant differences were found between the study patient groups in terms of the amount of blood loss, the blood levels of hemoglobin, needs for hemotransfusion therapy, and the frequency of postoperative complications. Conclusion. A second bolus of tranexamic acid 1 g does not reduce the amount of blood loss as compared to a single preoperative bolus dose of tranexamic acid 1 g during elective primary cementless TEHJP. Key words: tranexamic acid, endoprosthetic hip joint replacement, blood loss.

Objective: to evaluate the efficiency of cardiotropic therapy in neonates with severe posthypoxic myocardial ischemia and to improve severity rating criteria that would allow a differentiated approach to therapy for this condition. Subjects and methods. The efficiency of cardiotropic therapy was evaluated in 53 newborn infants with posthypoxic myocardial ischemia. Thirty (56.6%) neonates received phosphocreatinine in a dose of 30 mg/kg/day for 3 days as cardiotropic support; 23 (43.4%) babies had riboxine in a dose of 15—20 mg/kg. Results. The use of phosphocreatinine was found to be more effective than that of riboxine and to favor better blood biochemical composition parameters and lower ECG and intracardiac hemodynamic changes, which in turn reduced the time of mechanical ventilation from 11 to 8.25 days and that of administration of dopamine from 8 to 6 days, and its dose from 2 to 5 mg/kg/min. Conclusion. This investigation has led to the conclusion that there is a need for a comprehensive approach to diagnosing postischemic myocardial damages, including not only their clinical picture, but also a set of biochemical markers for ischemia and ECG and EchoCG changes on the 1st, 3rd, and then every 5—7 days and for the concomitant use of cardiotonic (dopamine) and cardiotrophic (phosphocreatinine) therapy; the administration of phosphocreatinine on intensive care unit admission (after prior hypoxia) as early as possible improves neonatal heart performance values. There are positive changes in both ECG and EchoCG and biochemical parameters (LDH, ALT, AST, De Ritis ratio). Key words: posthypoxic myocar-dial ischemia, neonates, phosphocreatinine.

Objective: to evaluate the impact of ultrasound-guided nerve imaging on the efficiency and safety of supraclavicular brachial plexus block. Subjects and methods. Sixty-five patients underwent supraclavicular brachial plexus block. According to the method of nerve identification, all the patients were allocated to one of two groups: 1) Kulenkampff’s block, by identifying the nerves by a nerve stimulator (n=30); 2) supraclavicular block, by identifying the nerves by ultrasound scanning (n=35). Anesthesia was carried out with a local anesthetic solution containing 20 ml of 2% lidocaine and 10 ml of 0.5% bupivacaine (a total of 30 ml). Results. There is evidence for the high efficiency (97.1%) of ultrasound-guided nerve imaging and its safety (no multiple attempts to verify nerves and complications) as compared to the Kulenkampff supraclavicular block using neurostimulation to identify the plexus (p<0.05). Conclusion. The authors’ modified ultrasound-guided imaging in performing the brachial plexus block helps define nerve localization and observe the placement of a needle against the anatomic structures as it is advanced. Local anesthetic spread observed by ultrasound scanning confirms the precise location of the needle tip. Key words: ultrasound-guided nerve imaging, brachial plexus, efficiency of anesthesia, complication, supra-clavicular approach.

Objective: to improve the results of treatment in victims with acute heart failure complicating severe concomitant injury, by optimizing inotropic support and to evaluate the efficiency and safety of combined use of drugs with a different mechanism of positive inotropic action. Subjects and methods. In a prospective randomized clinical trial, 26 victims with polytrauma and coronary heart disease-compromized myocardial contractility received inotropic support as a combination of dobuta-mine and levosimendan (Group 1; n=12) or that of dobutamine and epinephrine (Group 2; n=14). Invasive hemodynamic monitoring (Swan-Ganz) was made every 6 hours for 72 hours. The levels of lactate, troponin I, and brain natriuretic peptide (BNP) were measured. Holter ECG monitoring was also made. The end points of the study were cardiac index (CI), duration of inotropic therapy, length of stay in an intensive care unit (ICU), and development of complications. The differences in the indicators were considered statistically significant atpResults. By the use of combination inotropic therapy, hemodynamic instability was thought to be predominantly manifestations of acute heart failure (ejection fraction, 41±7%; CI, 2.1±0.15 l/min/m2; BNP, 1130±280 ng/dl) in compensated normovolemia (central venous pressure, 12±2 Hg mm; pulmonary artery wedge pressure, 14±1 Hg mm). Mean CI was 3.5±0.14 l/min/m2 in Group 1 patients receiving therapy and 2.6±0.33 l/min/m2 in Group 2 (95% confidence interval (CI), 0.49—0.91;p=0.03). The mean duration of inotropic therapy was 71±10.5 and 102±13.5 hours in Groups 1 and 2, respectively (95% CI, 99—161; p=0.001). In Group 2, cardiac arrhythmias (defined as Lown-Wolf class 3-5), an elevation of serum lactate levels (mean, 3.8±0.8 mmol/l; p<0.05), and a clinically significant increase in troponin-I concentrations (mean, 0.85±0.17 ng/ml; p<0.05) were more frequently recorded than those in Group 1. The victims showed no statistically significant differences in the length of ICU stay. Conclusion. The investigation has yielded clinically significant results suggesting that a combination of dobutamine and levosimendan makes it possible to effectively control hemodynamics in victims with polytrauma and diminished myocardial systolic function and to reduce the duration of inotropic support and the negative effects of catecholamines. Key words: combination inotropic therapy, adrenomimetics, levosimendan, polytrauma, heart failure.

The authors consider the main aspects of the rational use of the novel inotropic drug levosimendan in cardiosurgical patients on the basis of the results of the trials described in the literature and on their own findings in this review. The purpose of the analysis made was to provide a rationale for the effective use of this drug. The review shows the role of the ultrasound indicator left ventricular ejection fraction, the prognostic scale EuroSCORE, and the natriuretic peptides NT-proBNP and BNP in defining indications for levosimendan administration for preoperative preparation. There are original data on the lower level of the natriuretic peptides due to levosimendan therapy. The target hemodynamic monitoring values indicating that it is essential to use levosimendan in postperfusion heart failure are discussed. It is shown that it is expedient to use levosimendan simultaneously with traditional medical measures, by taking into account the pharmacokinetic features of a calcium sensitizer. The problem of levosimendan readministration in patients operated on the heart as well is stated. That there are no clear algorithms for repeated use of the drug is shown. At the same time, possible options of this therapy in different clinical situations are given. Key words: levosimendan, cardiosurgery, heart failure.

The paper describes the theory of a medical service and medical delict in the supplement to forensic medical examination on medical controversies. Key words: medical delict, forensic medical examination, medical controversies.