Objective: to study the time course of immunological changes in patients with acute severe brain injury (SBI) and their use along with the integrated indices of evaluation of its severity to define criteria for predicting the development of pyoseptic complications. Subjects and methods. Immunological parameters were studied in 53 SBI patients aged 17—65 years on days 1, 7, and 14 days after injury. There were 2 groups: 1) 16 patients without complications; 2) 37 patients with pyoseptic complications in the acute period of the disease. The integral scales SIRS, CPIS, Glasgow coma scale (GCS), APACHE II, laboratory parameters (immunograms, platelets, soluble fibrin-monomer complexes, and medium molecular weight peptides) in the prediction of pyoseptic complications were analyzed in patients with SBI. A control group consisted of 23 apparently healthy individuals. Results. The found immunological parameters lead to the conclusion that patients with SBI had significant immunodeficiency of mixed genesis by the cellular and humoral types in the acute period of the disease, immune system activation at week 2 of the disease in the development of pyoseptic complications. The decrease in the immunoregulatory index or less than 1.17 or its increase or more than 2.55 on day 1 after SBI was associated with the higher risk of pyoseptic complications. Some indices of an immunogram and the integral scales APACHE II, SIRS, CPIS, and GCS were found to be of low importance in the prediction of pyoseptic complications in SBI. Multivariate regression analysis showed that indices, such as the relative blood count of CD3+, CD95+ lymphocytes, platelets, the serum levels of immunoglobulin M and medium molecular weight peptides (at 262 nm), as well as GCS scores and the maximum temperature on the day of the investigation, were of the greatest value in the construction of prognostic models. Conclusion. The proposed models for the prediction of pyoseptic complications in the acute period of SBI may be useful in optimizing the use of antibiotics and immunomodulating therapy. Key words: severe brain injury, prediction of pyoseptic complications, cellular and humoral immunological parameters.

Objective: to study stepwise differences in the severity and pattern of severe traumatic injuries due to road traffic accidents in patients during the qualified and specialized stages of medical care in the age groups of 1 month to 18 years in the Rostov Region. Material and methods. The 2004—2009 case reports were used to make a retrospective comparative assessment of the condition of victims with severe road traffic injury at care stages in 2 groups: 1) one-month- to 18-year-old children who had been primarily admitted to the qualified-stage intensive care units (n=61); 2) one-month-to 18-year-old patients from the intensive care unit of the Regional Children’s Hospital, referred from the qualified-stage intensive care units (n=133). Results. The number of specialized-stage children in grave and extremely extensive grave condition at the specialized stage was 14.7% more than that at the qualified stage (100 and 85.3%, espectively). Concomitant injury was encountered more frequently (by 13%) in the specialized-stage patients (73.7 and 60.7%, respectively). The severity of road traffic injury was determined mainly by brain injuries at the qualified irnd specialized stages (96.7 and 96.1%), by skeletal injuries (11.6% more frequently) and thoracic ones (9.8% more frequently) at the specialized stage. The prevalence of abdominal injuries at the qualified stage was 9.8% higher. The pattern of brain injury in the specialized-stage patients showed a preponderance of brain contusion and epidural hematomas by 18.5 and 6.5%, respectively. Conclusion. Severe thoracic and brain injuries (craniocerebral injuries, brain contusion, and intracranial hematomas) are an indication for patient referral to the specialized care stage in order to perform high-technological diagnostic and therapeutic methods. Key words: children, road traffic accidents, severe injury, medical care stages.

Objective: to perform an experimental study of the effect of sterofundin isotonic on the biochemical parameters characterizing the degree of organ injury after acute massive blood loss (AMBL). Material and methods. Experiments were carried out on 36 male Wistar rats weighing 230—250 g. Hemorrhagic stroke was simulated via AMBL in a volume of 2.5 ml/100 g at a rate of 2 ml/min. An hour after AMBL, there was hypovolemia compensation within 60 minutes in a volume of 200% of the blood loss: by Ringer’s solution in a control group and by sterofundin isotonic in an experimental group. Then blood reinfu-sion was made in a volume of 70% of blood loss. The biochemical parameters of multiple organ dysfunction (glucose, lactate, urea, creatinine, bilirubin, total protein, albumin), enzymemia (aspartate aminotransferase, alanine aminotransferase, creatine phosphokinase, lactate dehydrogenase, amylase), endotoxemia (low- and medium-molecular-weight substances in the plasma and erythrocytes), acid-base condition, electrolytes of venous blood, and animal survival were determined on days 1 and 3 following AMBL. Results. There was a reduction in the time and degree of posthemorrhagic metabolic, biochemical, and electrolyte disorders, enzymemia, and endotoxemia in the experimental animals. Conclusion. The experimental studies suggest that Ringer’s solution is inadequately effective in preventing multiple organ dysfunction due to AMBL. The malate-containing blood substitute sterofundin isotonic that is used during early therapy for AMBL exerts a marked preventive effect on the development of visceral organ injuries when multiple organ dysfunction occurs in the early and late posthemorrhagic period. The experimental findings make it possible to recommend that sterofundin isotonic should be used in intensive care of hypovolemic shock arising from AMBL. Key words: acute massive blood loss, malate, sterofun dinisotonic, lactate, endotoxemia, multiple organ dysfunction.

Objective: to introduce blood saving technologies and to develop algorithms for management of patients with pelvic fractures. Subjects and methods. Sixty patients aged 40.6±2.3 years with pelvic fractures were examined. The banking of packed autoerythrocytes and auto freshly frozen plasma (AutoFFP), intraoperative acute hypervolemic hemodilution (AHH), and instrumental reinfusion of washed autoerythrocytes were made in all the patients. Blood loss volume averaged 32.1±1.7 ml/kg. The parameters of central hemodynamics (CH), blood oxygen-transport function, the blood system (red blood cells, hemoglobin, packed cell volume, and platelets) were studied. AutoFFP was transfused in the most traumatic period of surgery, autoblood was on completion of surgical hemostasis, and washed autoerythrocytes were within 3—4 hours after surgery. Postoperative reductions in hemoglobin to below 80 g/l and packed cell volume below 25% are indications for packed autoerythrocyte transfusion. Results. During preoperative autoblood banking, the parameters of CH and the blood system underwent no changes, all variations in the parameters were within the normal range and compensatory. When AHH and instrumental washed erythrocyte reinfusion were conducted, there was a significant increase in cardiac index (CI), stroke index by 37 and 30%, respectively; reductions in total peripheral vascular resistance index by 38%, mean blood pressure by 18%, moderate hypercoagulation, and significant decreases in hemoglobin, packed cell volume, red blood cells by 17, 15, and 18%, respectively. The values of acid-base condition and homeostasis underwent no considerable changes. Arterial blood O2 content was significantly lowered by 16%; however, global O2 uptake remained unchanged at the baseline levels due to the increase of CI by 30% of the baseline level. Conclusion. The application of blood saving technologies, preoperative autoblood banking in particular, AHH, and instrumental washed autoerythrocyte reinfusion allowed a refusal to use allo-geneic blood components during pelvic repair, by preventing the development of hemotransfusion complications. Key words: blood loss, blood saving, packed autoerythrocytes, auto freshly frozen plasma, acute hypervolemic  hemodilution, autohemotransfusion, instrumental washed autoerythrocyte reinfusion, spinal epidural anesthesia.

Examining the hemostatic system in 436 patients with injury and acute blood loss by an instrumental low-frequency piezoelectric hemocoagulation technique permits one to assess the likelihood of thrombohemorrhagic complications and multiple organ dysfunction syndrome in early stages of disease. Key words: acute blood loss, hemorrhagic shock, APACHE, disseminated intravascular coagulation, multiple organ dysfunction syndrome.

Objective: to reveal the mechanisms of development of hemostatic disorders after liver resection. Material and methods. One hundred and twenty cases of liver resections for primary hepatic cancer were retrospectively analyzed. Patients with an uncomplicated postoperative period (Group 1.1), isolated hepatic coagulopathy (Group 1.2), and developed multiple organ dysfunction (MOD) (Group 1.3) were analyzed. The values of hemostasis, hemodynamics, and oxygen status (oxygen delivery, uptake, and utilization) and biochemical and acid-base homeostatic parameters were monitored in these patients twice daily. Results. A significant reduction in Factor VII levels within the immediate hours after surgery was an early hemostasiological marker of the development of hepatic coagulopathy (isolated or as part of MOD). In patients with further evolved MOD, the level of hemostatic system activation markers (fibrin degradation products and D-dimer) was increased from the first 24 postoperative hours, which suggested the development of disseminated intravascular coagulation (DIC) concurrent with hepatic coagulopathy. The development of energy deficiency was at least 24 hours ahead of the clinical manifestation of hepatic coagulopathy and DIC in the patients undergoing liver resection. Hypoxic energy deficiency (the decreased delivery and uptake of oxygen and its higher utilization coefficient, and elevated blood lactate values) was a predictor of the development of isolated hepatic coagulopathy. Further worsening of hypoxic energy deficiency (an increase in blood lactate values and a reduction in venous oxygen saturation) or its transformation to enzyme energy deficiency (lowered oxygen uptake and utilization) was a predictor of DIC development. Conclusion. In the patients undergoing liver resection, the development of energy deficiency is at least 24 hours ahead of the clinical manifestation of hepatic coagulopathy (which evolves in the presence of hypoxic – energy deficiency) and DIC (which manifests in the presence of enzyme energy deficiency). To correct the existing Адрес для к°рреспонденции (Correspondence to): energy deficiency is the key condition to determine the effectiveness of performed hemostasis-modulating therapy. Key words: liver resection, hepatic coagulopathy, disseminated intravascular coagulation, energy deficiency.

Objective: to choose an artificial ventilation (AV) mode in premature neonates with respiratory distress syndrome (RDS) after administration of exogenous surfactants and to compare the duration of AV and the development of complications in relation to the type of an exogenous surfactant. Subjects and methods. The paper presents the results of choosing an AV mode in 122 premature neonates with severe RDS. The choice of an AV mode, the duration of respiratory therapy, and the development of complications after administration of exogenous surfactants were studied. The neonatal infants were divided into 2 groups: 1) 55 neonates who were given Surfactant BL in the complex therapy of RDS; 2) 67 neonates who received Curosurf. Results. The study has demonstrated that the initial mode of ventilation (completely controlled assisted or positive end expiratory pressure) may be chosen after administration of Curosurf depending on the clinical picture of remaining respiratory failure. This policy makes it possible to preserve spontaneous breath in 29.3% of cases and to considerably reduce the duration of respiratory therapy. When Surfactant BL is used, only one initial AV mode (completely controlled ventilation) may be chosen according to the manufacturer’s guidelines as drug-induced cessation of spontaneous breathing is required. Nevertheless, the administration of Surfactant BL also facilitates recovery of effective spontaneous breathing in most neonates with RDS. Conclusion. The use of the exogenous surfactants enables the AV modes with preserved spontaneous breathing to be employed, which reduces the duration of AV and the number of complications. Key words: respiratory distress syndrome, premature neonates, Curosurf, Surfactant BL, artificial ventilation modes.

Objective: to optimize artificial ventilation on the basis of studies of lung mechanical properties in neonatal infants with visceroabdominal disproportion in the perioperative period. Subjects and methods. The investigation enrolled 57 neonates, including 42 (73.7%) with gastroschisis and 15 (26.3%) with omphalocele. All the patients received intensive care, artificial ventilation using a Bear Cub apparatus in the control modes by the volume (A/C, SIMV/PSV) with continuous monitoring of hemodynamics and respiratory mechanics (dynamic compliance, resistance, pressure-volume loop, and flow-volume) by applying a graphics monitor. Intraabdominal pressure (IAP) was measured by the Crohn method. Results. The investigation showed an association between the changes in IAP in different stages of the study and those in respiratory parameters in newborns. Preoperative adaptation of the respiratory system was noted in all the neonates. Within the first 24 hours of the first-stage correction of visceroabdominal disproportion, both groups showed a gradual reduction in dynamic compliance by 3.4 times, a rise in resistance by 2.42 times with PIP being increased up to high figures — 20—22 cm H2O, as well as maximum value changes on the graphics monitor. The mechanical properties of the lung returned to relatively normal values at 72 hours of extension. Conclusion. Elevation of IAP to high values causes changes in respiratory mechanics and is a rather informative criterion for correction of ventilation parameters. Furthermore, a marked perioperative IAP increase (more than 10—11 mm Hg) maximally affects the mechanical properties of the lung in neonatal infants with visceroab-dominal disproportion. Key words: visceroabdominal disproportion, intraabdominal pressure, compliance, respiratory mechanics, resistance.

Objective: to reveal possible causes of postoperative multiple organ dysfunction syndrome (MODS) in patients after surgery under extracorporeal circulation (EC), by measuring the level and balance of pro- and anti-inflammatory cytokines. Subjects and methods. The investigation enrolled 162 patients who had undergone operations on the heart and thoracic aorta. The levels of interleukins (IL)-6, IL-8, and IL-10 were determined by ELISA. Results. At surgery under EC, MODS was encountered in 5.7%, mortality was 55.6%. The principal causes of MODS were prolonged EC concurrent with bleeding (23%), massive hemorrhage (16%), perioperative myocardial infarction and cardiogenic shock (15%), prolonged EC (12%), acute lung injury (12%), disseminated intravascular coagulation (10%), allergic and anaphylactic reactions (9%), and intravascular hemolysis (6%). The levels of pro- and anti-inflammatory cytokines were substantially increased in all the patients after surgery under EC irrespective of the presence of MODS in the postoperative period. The patients with MODS displayed pro- and anti-inflammatory cytokine imbalance due to a preponderance of the proinflammatory activity of a systemic response. During massive hemorrhage (more than 20 ml/kg), the patients with MODS exhibited a reduction in the two pools of cytokines. In the absence of MODS, there was a parallel increase in both pro- and anti-inflammatory cytokines. The magnitude of a change in the level of cytokines is related to the volume of blood loss. During prolonged EC (more than 170 min), the patients with MODS had a higher pro- and anti-inflammatory cytokine ratio due to the elevated levels of both pools, but the elevation of anti-inflammatory cytokines was more pronounced. In the patients without MODS, the values of both groups of interleukins were sigmficantly unchanged with longer duration of EC. Key words: multiple organ dysfunction syndrome, systemic inflammatory reaction, interleukins 6, 8, 10, extracorporeal circulation, operations on the heart and thoracic aorta.

Objective: to study the efficacy of third- versus secondary-generation fatty emulsions as part of parenteral nutrition in patients operated on for gastric cancer. Subjects and methods. Envelope randomization was used to make up two groups, each comprising 10 patients, operated on for gastric cancer in the scope of gastrectomy. A control group received parenteral nutrition having the following components: Lipofundin MST/LST 20%, (500 ml daily) + Nutriflex 48/150 (B. Braun) (1000 ml daily, 1744 kcal/day). The study group patients were given Lipoplus 20% (500 ml daily) + Nutriflex 48/150 (1000 ml daily, 1745 kcal/day). Parenteral nutrition was used on postoperative days 1 to 5. Results. Nutritional status evaluation revealed a significant increase in the concentration of total protein and albumin in the control and study group patients on postoperative day 6. The use of both second- and third-generation fatty emulsions caused a significant increase in the concentration of triglycerides on day 6 after surgery; no differences were found between the groups. On day 6 following surgery, there was a significant decrease in IL-4 in both groups (p<0.05). At the same time the Lipofundin MST/LST group showed a significantly lower concentration of IL-4 than did the study group (p<0.05). After termination of a parenteral nutrition course, the study and control groups showed a significant decrease in one of the major pro-inflammatory cytokines — IL-6. Conclusion. In the study group, the serum anti-inflammatory activity of IL-4 was more evident than that in the control group and the proinflammatory activity (IL-6 concentration) decreased, which can support that as compared with the second-generation fatty emulsions, third-generation ones with a balanced omega 3 to omega-6 fatty acid ratio (1:2.7) had a normalizing effect on systemic inflammatory processes and cytokine balance with increased anti-inflammatory and reduced proinflammatory activities. Key words: third-generation fatty emulsions, omega-3/omega-6 fatty acids, pro and anti-inflammatory cytokines.

Endotracheal intubation used as a method of cardiopulmonal resuscitation and advanced life support in a field condition frequently represents a problem even to very experienced resuscitatiors because of its extremly complex circumstances. The author’s aim of this work is to suggest his own way of the patient’s intubation in a field condition by the application of the method which has not been described in the literature yet. A several dozen of patients have been intubated by this method in such conditions which did not represent even the minimum for intubation done in a conventional way, but they were enough to prove our method. Maximum performing time for the sample was 15 seconds. We consider that, using this method, the endo-tracheal intubation can be realized in all conditions up to now thought untouchable. This method requires only 30 to 35 cm wider space than patient’s shoulders occupate and 20 to 30 cm extra of his height. The only noted inadequacy is the risk in spine injury intubation, but with more careful treatment it can be avoided. Key words: Endotracheal intubation, cardiopul-monal resuscitation, field condition, restrained space.

Objective: to reveal the clinical and morphological features of acute community-acquired and nosocomial pneumonia (NP). Materials and methods. The results of treatment were retrospectively assessed and those of autoptic studies were analyzed in 43 dead patients with pneumonia. There were two groups: 1) 13 subjects with community-acquired pneumonia; 2) 30 subjects with NP. Results. A clinicomorphological study revealed different stages of acute respiratory distress syndrome (ARDS) in both groups. The probability of its development increases if microbial associations are identified as an etiological factor. In community-acquired pneumonia, ARDS was detected in 6 of the 13 cases in which 5 (83.3%) cases were in the presence of progressive pulmonary inflammation. In Group 2, ARDS was recorded in 21 of the 30 cases and it followed the occurrence of pneumonic infiltration. On days 2 and 3 of ARDS, there were hyaline membranes and a preponderance of interstitial edema. Five days later, inflammatory changes were prevalent, severe alveolar edema (subtotal and total) and multiple hemorrhages were noted, and the number of hyaline membranes increased. Conclusion: The analysis has indicated that ARDS, including acute pulmonary lesion, as the first stage of respiratory distress syndrome in patients with pneumonia of varying genesis is more frequently detectable than traditionally thought. Acute respiratory failure in 27 (62.8%) of the 43 patients was caused by different stages of ARDS, which alone or in combination with other complications was as a cause of death. Key words: acute community-acquired pneumonia, nosocomial pneumonia, respiratory distress syndrome.

Objective: to study the clinical and morphological features of viral А (НШ1) pneumonia with the development of severe respiratory failure and acute respiratory distress syndrome (ARDS). Materials and methods. Data were collected on 11 deaths in patients with severe influenza A (H1N1) who had been treated at the intensive care units of various city hospitals. Results. The clinical features and major X-ray manifestations of the pneumonia and respiratory mechanical changes were described and the results of postmortem studies in patients whose disease course had been complicated by significant respiratory failure and ARDS were presented. Conclusion. Rapid development of severe respiratory failure and ARDS, which determine high mortality rates, also in patients without evident comorbidity is one of the specific features of the course of primary viral A (H1N1) pneumonia. The study of X-ray diagnostic and postmortem findings seems to enhance the understanding of the mechanisms of lung lesion in viral pneumonia. The specificity of acute lung pneumonia lesion in California influenza makes certain corrections into the tactics of respiratory support. Key words: intensive care, influenza A (H1N1), acute respiratory distress syndrome, respiratory support, histology, computed tomography.

Twenty-five autopsy cases of influenza А (НШ1) in Moscow were analyzed. Primary pathological changes were found in the trachea and lung. The lung showed a pattern of the exudative and proliferative stages of diffuse alveolar damage. In addition, there were signs of infectious-toxic shock associated with viremia. Bacterial bronchopneumonia with confluent foci was detected in only 20% of the dead cases. Key words: influenza А (НШ1), diffuse alveolar damage.

Objective: to reveal pulmonary morphological changes in acute lung injury (ALI) of varying etiology. Material and methods. An experiment was carried out on 4 groups of albino non-inbred male rats weighing 300—400 g. The following ALI models were 1) acidin-pepsin solution (PH-1.2) aspiration; 2) blood aspiration; 3) blood loss (50% circulating blood volume) concurrent with vascular thrombosis in the microcirculatory bed; 4) artificial ventilation-induced ALI. The duration of the study was 1 hour to 3 days. Histological lung slices were stained with hematoxylin and eosin; a Schiff reaction was conducted. Results. All the animals developed interstitial edema, exhibited desquamation of the bronchial epithelium; damage to the capillary endothelium and basement membranes; segmental leukocyte, macrophage, and lymphocyte infiltration of intraalveolar septa, atelectases, hemorrhages, and sludges. Conclusion. Morphological signs in ALI are nonspecific and they do not depend on an etiological factor. Morphological changes in ALI result in damage to the endothelium of lung capillaries and their basement membranes, higher capillary permeability, extravascular fluid accumulation, and protein exudation with the development of noncardiogenic pulmonary edema. Key words: acute lung injury, blood loss, artificial ventilation, aspiration.