Objective: to study the specific features of the mechanisms responsible for the development of acute respiratory distress syndrome (ARDS) induced by direct and indirect damaging factors and to reveal its differential diagnostic signs. Materials and methods. Lung morphological changes were studied creating experimental models of ARDS of various genesis in 75 outbred male albino rats weighing 300—400 g, which included the direct damaging factor acidine-pepsin aspiration (Group 1, n=25) and the indirect damaging factor blood loss (Group 2, n=50). Prospective examinations were made in 73 patients (43 men and 30 women, whose age was 21 to 69 years) with ARDS caused by direct damaging factors, such as aspiration pneumonitis, pneumonia, blunt chest injury, and pulmonary contusion (37 patients, including 21 men and 16 women) and in those with ARDS caused by indirect damaging factors, such as abdominal sepsis, severe concomitant injury, and hemorrhagic shock (36 patients, including 22 men and 14 women). Results. The study has shown that ARDS caused by direct and indirect damaging factors is characterized by different developmental mechanisms and lung morphological changes that underlie the specific features of functional impairments. Conclusion. The findings made it possible to substantiate and propose new approaches to the differential diagnosis and treatment of ARDS caused by direct and indirect damaging factors. Key words: acute respiratory distress syndrome, direct and indirect damaging factors, thoracic and pulmonary compliance, lung extravascular fluid, positive end-expiratory pressure, respiratory support, intensive care unit.

The relationships between drug affinity constant (Kag) for the particles of perfluorane nanoemulsion and physicochemical properties of ligands were studied by correlation and multiple regression analyses. The following parameters were applied: lipophilicity (LogP), molecular weight (MW), topological polar surface area (TPSA), the number of hydrogen donors (Don) and acceptors (Acc) in the formation of a hydrogen bonds, the number of rotating bonds (Rot), and drug molecule ionization constant (pKa). The Kaf — physicochemical properties relationships were found to be mainly nonlinear and to mostly show up in the lipophilicility parameter LogP of ligands. During the multiple regression analysis, a number of regression equations were derived, which described the relationship of the perfluorane affinity Kaf to the physicochemical properties of drugs and could predict this interaction for both existing and newly synthesized compounds.

Objective: to reduce the number of perioperative cardiovascular events in elderly patients during traditional cholecystectomy, by using anesthesia based on sevoflurane (SF) and fentanyl (FL). Subjects and methods. Forty-eight patients aged 60 to 75 years, who were divided into 2 groups, operated on by a classical surgical technique for chronic calculous cholecystitis in the presence of concomitant coronary heart disease and essential hypertension, and had grade 3 surgical risk according to the classification of the Moscow Research Society of Anesthesiologists and Reanimatologists, were examined. Premedicaton was routine. The induction of anesthesia was as follows: intravenous propofol (PF) (1.8±0.2 mg/kg) and FL (2.2±0.4 mg/kg) in Groups 1 and 2. General anesthesia (GA) was maintained by SF (1.1±0.2 MAC) and FL (2.4±0.4 jBg/kg/hr) in Group 1 (n=25) and by PF (2.0—4.0 mg/kg/hr) and FL (3.5±0.7 ^Bg/kg/hr) in Group 2 (n=23). In both groups, mechanical ventilation was as follows: N2O:O2 = 2:1; air flow, 6 l/min. Myoplegia was rocuronium bromide (RB) (0.075—0.1 mg/kg) in Group 1 and RB (0.15 mg/kg) in Group 2. Hemodynamics was studied during 5 stages of surgery. Results. Central hemodynamics (CH) was rather stable in patients after GA with SF. Significant CH changes were noted only during the traumatic stage of surgery, which were less pronounced than those in patients following GA with PF. CH parameters returned gradually to the baseline values at the end of surgery and virtually to the background values after tracheal extubation. The patients under GA with PF showed significant CH changes at all stages of the study. Conclusion. Analysis of the systemic hemodynamic changes induced by the use of SF and PF suggests that GA with SF in elderly patients is more preferable than that in those with PF. Key words: sevoflurane, hemodynamics, elderly.

Objective: to optimize procedures to maintain minute circulation volume at different stages of orthotopic liver transplantation. Subjects and methods. In the period 2005—2010, Sverdlovsk Regional Clinical Hospital One performed 32 orthotopic liver transplantations, including one retransplantation. The patients’ ASA class was (4—5). The operations were carried out under general anesthesia. The mean duration of surgery was 8.1 (range 5.8—10.5) hours. The investigators applied anesthesia based on iso-fluorane 0.6—0.9 MAC (by monitoring the anesthesia depth index with cerebral state index (CSI-40-60)), as well as extended central hemodynamic monitoring (prepulmonary hemodilution). All the operations were made via portofemoroaxillary bypass, by using a centrifugal Biopump. Eight surgical stages were identified: 1) run-in (after tracheal intubation); 2) liver mobilization; 3) partial bypass; 4) complete bypass (hepatectomy, a liver-free period); 5) reperfusion; 6) a postreperfusion period (bypass end); 7) biliary repair; 8) the end of an operation. The concentrations of blood parameters, electrolytes, acid-base balance, and the levels of lactate and glucose were examined. The data were processed statistically. Central hemodynamics was monitored by prepulmonary thermodilution, by calculating cardiac index (CI), stroke index, and total peripheral vascular resistance index (TPVRI) at the stages: liver mobilization, postreperfusion period (bypass end), and the end of surgery. Results. Even during partial bypass, there was a significant drop in mean blood pressure (MBP) as compared to the baseline levels (p<0.05). Reperfusion was also accompanied by a significant decrease in MBP and an increase in heart rate. At the end of reperfusion and in the postreperfusion period, TPVRI was halved (689.2±68.0) as compared to the baseline levels. In the postreperfusion period, central venous and pulmonary artery pressures were significantly increased by 32 and 21%, respectively. That period was marked by a significant rise in CI. Serum lactate and glucose elevations starting from the complete bypass stage were associated with the liver being excluded from the circulation and cannot be a marker of inadequate tissue perfusion. Conclusion. The decrease in MBP during portofemoroaxillary bypass is associated with hypovolemia and mainly with vasoplegia during reperfusion. Approaches to maintaining the adequate minute circulation volume depend on the surgical stage: sufficient preload is needed during complete bypass and it is expedient to combine an infused load with vasopressors for the correction of the reperfusion syndrome with low TPVR. Key words: liver transplantation, minute circulation volume, general anesthesia, central hemodynamics.

Objective: to study the specific features of systemic hemodynamics and stress markers in young (1—5-year-old) and old (6—12-year-old) children during orthopedic surgery under intra- and postoperative epidural analgesia. Subjects and methods. Seventy-six children aged 1 to 12 years, who had undergone orthopedic surgery, were examined. According to their age and the type of intraoperative analgesia, the patients were divided into 4 groups. Groups 1 and 2 included children aged 1—5 years and Groups 3 and 4 did those aged 6-12 years. Total intravenous anesthesia with diprivan and fentanyl was used in Groups 1 and 3. Combination epidural anesthesia was performed in Groups 2 and 4. Central hemodynamic parameters and biochemical stress markers (adrenaline, cortisol, glucose, and interleukin-6) were estimated in the intra- and postoperative periods. Results. Slight reductions in peripheral vascular resistance and blood pressure without a considerable change in cardiac output were found to be typical hemodynamic responses in 1—5-year-old children during epidural anesthesia. In 6—12-year-old children under epidural anesthesia, the hemodynamic responses showed a similar trend, but they were more marked than those in young children. Adequate infusion therapy can prevent the reduced minute volume of circulation during epidural block. In the young and old children, epidural anesthesia exerts a more marked stress-protective effect than does total intravenous anesthesia, which manifests itself as a less significant rise in the level of stress markers intra- and postoperatively. Key words: epidural anesthesia, children, hemodynamics, surgical stress.

Objective: to comparatively study the efficiency of postoperative analgesia in patients with lung cancers, by using patient-controlled intravenous analgesia (PCIA), continuous epidural analgesia (EA) + PCIA, and intrapleural analgesia (IPA) + PCIA. Subjects and methods. Forty-six patients who had undergone thoracotomy and lung resection were examined. According to the mode of analgesia, the patients were divided into 3 groups: A (n=16) PCIA with 0.1% morphine, by applying programmed syringe pumps; B (n=14) continuous epidural infusion of 0.2% ropivacaine solution + PCIA with morphine; C (n=16) intrapleural bolus infusion of 0.5% ropivacaine + PCIA. The degree of sedation and the incidence and degree of side paranarcotic effects were estimated. Results. The use of mono-PCIA in patients who have undergone high-traumatic surgery is characterized by its low efficiency and a high rate of adverse reactions as compared with the other methods. Group A showed excess sedation in 12.5%, skin itching in 18.7%, urine retention in 6.3%, and nausea/vomiting in 18.8%. There was only one case of vomiting and one case of skin itching in both Group B and Group C. This was due to the significantly lower amount of morphine used during continuous EA and IPA. The daily amount of morphine averaged 0.63, 0.19, and 0.2 mg/kg/day in Groups A, B, and C, respectively (p<0.01). Conclusion. The postoperative employment of continuous EA and IPA increased patient mobility and improved external respiratory and cardiohemodynamic parameters, causing a reduction in the number of pyoseptic complications and convalescence time. In patients who have undergone lung resection, IPA fully meets the patient needs for pain relief and may be recommended for postoperative analgesia along with EA. Key words: thoracotomy, patient-controlled intravenous analgesia, continuous epidural analgesia, intrapleural analgesia.

Objective: to develop an algorithm in order to choose a method for anesthesia and its components that minimally affect heart rhythm and the cardiac conduction system (CCS) for patients at high risk for perioperative arrhythmias. Subjects and methods. Seventy-five patients aged 62.2±9.63 years, who received cardiotropic therapy for the compensation of cardiovascular diseases and had undergone surgery for abdominal malignancies, were examined. According to the anesthesia technique, the patients were randomized into 4 groups: 1) (n=16) multimodal intravenous general analgesia (IGA); 2) (n=17) sevoflurane inhalation anesthesia (IA); 3) (n=19) combination epidural anesthesia (EA) and IGA; 4) (n=20) a combination of EA and IA. The effects of anesthesia components on heart rhythm and CCS were evaluated from the results of Holter continuous ECG monitoring. Results. A change in the heart rhythm pattern was recorded in all the study group patients. Group 1 had increased ectopic activity: a rise in the number of supraventricular and ventricular premature beats (SPB and VPB) by 67.2 and 29.9%, respectively (p<0.05), which required correction in 4 of the 16 patients. The other groups showed a reverse tendency: a decrease in the number of SPB and VPB (by 10.3 and 9.37% in Group 2, by 53.6 and 29.5% in Group 3, and by 49.3 and 37.8% in Group 4, respectively), and the development of cardiac impulse conduction disturbances (pauses, > 2000 msec), which required special correction in 8 of the 19 patients in Group 3 and in 5 of the 20 patients in Group 4, respectively. There were no postoperative complications associated with cardiac rhythm or conduction disturbances. Conclusion. The choice of an anesthesia technique at high risk for perioperative arrhythmias is determined by the baseline cardiological status of a patient and by the nature of the arrhythmogenic effect of anesthetics. Multimodal IGA is preferred for baseline conduction disturbances. Sympathetic epidural blocks in combination with IGA and IA are indicated for patients with tachysystoles. Sevoflurane has no considerable effect on rhythm and CCS. Key words: peri-operative arrhythmias, anesthesia for high vascular risk patients, operation, cardiotropic therapy.

Anteriomedial-access regional sciatic nerve block has been devised and applied. Thirty-five anteriomedial-access regional sciatic nerve blocks were performed in the supine position, by using ultrasound imaging and electrostimulation of the peripheral nerves. The anteriomedial approach to the sciatic nerve permits anesthesia to be made without changing the body position in patients with multiple lower limb fractures and traumatic upper limb injury. More potent premedication was used during manipulation, by achieving a Ramsay sedation scale score of 3—5. The anesthesia was effective in all cases. There were no complications. Key words: regional anesthesia, sciatic nerve, anteriomedial access, ultrasound imaging.

Objective: to estimate bispectral (BIS) index and electroencephalographic (EEG) changes during anesthesia with halothane, sevoflurane, and a successive combination of sevoflurane and isoflurane, by taking into account age. Subjects and methods. Sixty children aged 3 to 17 years, who had undergone elective surgery, were randomized to 3 groups of 20 children each: 1) halothane anesthesia; 2) sevoflurane anesthesia; and 3) a successive combination of sevoflurane and isoflurane. A 1:1 oxygen-nitrous oxide mixture was used for anesthesia in all the groups. EEG (using a 6-channel computer-assisted encephalograph) and bispectral index (XP version) was continuously recorded throughout the anesthesia, except the transition to isoflurane in Group 3. Results. In the halothane group, EEG displayed a gradual reduction in basic rhythm, an increase in slow activity with the rhythm being recovered on emergence. The BIS index changed from 96—99 to 19—36 with a spike of up to 80—87 on emergence. In Groups 2 and 3 where the induction of anesthesia used sevoflurane, EEG recorded a pointed а-rhythm, increased amplitude, and rhythm synchronization. The BIS value changed from 96—99 to 19—37. In Group 2, it was 30 to 40 on anesthesia maintenance and up to 82—87 on emergence. In Group 3, the isofluorane anesthesia stage changed EEC patterns towards rhythm synchronization and gave rise to slow fluctuations in all leads. The BIS index was 30—39 on anesthesia maintenance and 80—86 on emergence. Conclusion. EEC and BIS index monitoring values corresponded to the clinical course and depth of anesthesia. The comparison of the clinical data of the course of anesthesia and the values of EEG and BIS monitoring could lead to the conclusion that BIS technology might be of informative value in children. Key words: inhalation anesthesia, electroencephalography, BIS monitoring, isoflurane, sevoflurane, halothane.

Objective: to provide a rationale for a need to introduce the new constant — the minimum alveolar concentration for respiratory depression (MACrespiratory depression) and to determine its value. Subjects and methods. Forty-three patients aged 20— 45 years, who had normal weight and ASA physical status I—II, were examined. All the patients underwent induction of sevorane anesthesia without narcotic analgesics, nitrous oxide, and myorelaxants. A laryngeal mask was installed after MAClm was achieved. Sevorane concentrations were increased on a vaporizer, by changing Etanesth at a rate of 0.2 vol% per min until Etanesthresp;ratory depression was achieved. Results. A rationale was provided for a need to introduce the new inhalation anesthesia constant MACrespiratory depression that is, in accordance with the MAC conception, regarded as the inhalation anesthetic concentration that necessitates assisted ventilation in 50% of the patients. MACrespiratory depression was 1.8 MAC. This is essentially more than both MAC and 1.3 MAC, the anesthetic concentration at which any operation can be performed in 90% of patients. At the same time, the derived value of 3.7 vol% is somewhat below MACbarr (4.07 vol%), which means that anesthesia with sevorane only under spontaneous respiration will be inadequate in few patients or its performance will be associated with the risk of hypoxia. Conclusion. The authors’ successively developed concept of anesthesia with preserved spontaneous respiration necessitates the introduction of the new inhalation anesthesia constant MACrespiratory depression. Its value is 3.7% vol% for sevoflurane. Key words: induction of anesthesia, minimum alveolar concentration, spontaneous respiration, inhalation anesthesia.

Objective: to study the hemodynamic effects of sevoflurane during the induction of anesthesia in elderly patients at high risk for cardiac events. Subjects and methods. This study enrolled 32 patients who had a left ventricular ejection fraction of <30% during preoperative examination. According to the presumptive type of anesthesia, the patients were randomized to one of the study groups: In the sevoflurane group receiving infusion of fentanyl (1 ig^kg”‘^hr”‘), anesthesia was induced by sevoflurane at the maximum concentration of 8 vol% at first inspiration, without the respiratory circuit being prefilled. After loss of consciousness, further saturation was carried out using Fianesth, 5 vol%. Combination anesthesia (CA) was that which was induced by successive administration of dormicum, ketamine, propo-fol, and fentanyl. The trachea was intubated during total myoplegia under the control of TOF (TOF-Watch, Organon, the Netherlands). Results. In all the patients under CA, its induction was made during infusion of dopamine (5 lg^kg”‘^min”‘), the dose of which had to be increased up to 10 ig • kg-1 • min-1 in 6 (75%) patients. Nevertheless, there were decreases in mean blood pressure (BPmean) to 46±6 mm Hg and in cardiac index (CI) to 1.5±0.3 fig • kg-1 • min-1 (by 32% of the outcome value). In the sevoflurane inhalation induction group, only 3 (12.5%) patients needed dopamine. Its dose producing a cardiotonic effect was near-minimal; its average maintenance infusion rate was 5.3±0.3 ig^kg”‘^min”‘. The reduction in CI was statistically insignificant; despite a 9% decrease in BPmean, this indicator in the sevoflurane group remained within acceptable ranges. Conclusion. The use of a sevoflurane-based inhalation induction technique permits higher hemodynamic stability in patients at high risk for cardiac events. Key words: inhalation induction, sevoflurane, ketamine, elderly patients.

Objective: to study the cardioprotective effect of remote ischemic preconditioning (RIP) in cardiosurgical patients operated on under extracorporeal circulation (EC). Subjects and methods. Fifty-two patients with coronary heart disease (mean left ventricular ejection fraction 58.9±7.4%) operated on under EC and inhaled isofluorane anesthesia were examined. All the patients were randomized into two groups: 1) RIP; 2) without RIP. Central hemodynamic parameters and the plasma levels of troponin I, creatinine phosphokinase (CPK), and CPK-MB were estimated in the intraoperative and early postoperative period. Results. Before EC, cardiac index was significantly higher in the study group than that in the control one [2.31 (1.99; 2.5) and 2.05 (1.91; 2.25) bmin/m2, respectively; p<0.05]. Before EC, there was a significant increase in stroke index in the study group as compared with the control one [41.4 (34.73; 51.25) and 36 (28.87; 41.28) ml/m2, respectively; p<0.05]. In the study group, the significant excess was retained immediately after EC [40.89 (36.53; 42.15) and 35.14 (32.2; 37.24) ml/m2, respectively; p<0.05]. There were no statistically significant intergroup differences in the concentration of serum markers of injury. Conclusion. A positive hemodynamic effect is observed when a procedure for RIP is used in patients with coronary heart disease during direct myocardial revascularization under EC at the preperfusion stage. Key words: remote ischemic preconditioning, troponin I, extracorpo-real circulation, myocardial protection.

The innate immune system plays a key role in triggering a systemic inflammatory response (SIR). The triggering receptor expressed on myeloid cells (TREM-1), which is located on neutrophils and monocytes, is involved in SIR, by regulating the effector mechanisms of innate immunity. Hyperproduction of proinflammatory cytokines is a pathogenetic component of the hyperergic phase of acute systemic inflammation. The simultaneous activation of Toll-like receptors and TREM-1 increases the production of cytokines manifold. This is compensatory and adaptive, however, resulting in damage to organs and tissues during excessive production of cytokines. Key words: triggering receptor expressed on myeloid cells, Toll-like receptors, cytokines, inflammation.

The review gives information on the specific features of a perioperative period in HIV-infected patients receiving anti-retroviral therapy. The possible complications resulting from the use of antiretroviral drugs and their correction modes are described.