Objective: to analyze the causes of fatal outcomes in victims with severe concomitant injury (SCI) in an intensive care unit (ICU) of a multidisciplinary hospital. Subjects and methods. The data on 78 victims with SCI (65 men, 13 women) with SCI without the leading severe brain or spinal injury were retrospectivly analyzed. Results. Intrahospital mortality was 17.9%. The dead and surviving victims had an APACHE II score of 18.4±9.8 and 9.2±7.9, respectively (p=0.0008). According to the ISS scale, injury severity was 41±11.8 scores in the dead and 34.8±10.7 scores in the survivors (p=0.07). The APACHE II and ISS scores were of little prognostic use — AUC (the area under the ROC curve) was 0.19 and 0.35, respectively. Gender and the estimated blood loss volume had no statistically significant impact on mortality. In the structure of mortality, 21.4 and 78.6% fell on early (in the first 5 days after injury) and late (on day 12 or later post-injury), respectively. Late mortality was associated with septic complications in 90.9%. To predict the risk of septic complications, we developed a model including the APACHE II condition severity on admission, chest, limb, and pelvis injury severities. The sensitivity and specificity of the obtained criterion were 87.5 and 84.5%, respectively (AUC 0.88). Conclusion. In SCI, mortality at a present-day multidisciplinary hospital remains high, largely due to late mortality associated with pyoseptic complications. Our developed model may be used in the assessment of fatal septic complications for differentiated prophylaxis.

Objective: to study a relationship of the parameters of the cytokine status to the biochemical markers of oxidative stress and antioxidant defense (AOD) as the links of a systemic inflammatory reaction in victims with severe isolated and concomitant brain injury (BI). Subjects and methods. The study was conducted in 12 victims with severe isolated BI and in 14 with severe concomitant BI, aged 18 to 69 years, who were treated at the Unit of Anesthesiology and Reanimatology, Rostov-on-Don City Emergency Medical Care Hospital Two. Results. A direct average correlation was found between the level of IL-4 and the concentration of malondialdehyde (MDA) in the red blood cells on days 1—3 and 5—7 after the onset of injury in the patients with severe isolated BI. Those with concomitant BI showed a direct average correlation between the plasma level of MDA and the concentration of IL-10 on days 1—3 after the onset of injury. In patients with concomitant BI, there was a relationship between the imbalance in the cytokine status and the destruction of cell biomembranes, which is evidenced by dissociation in the presence of an inverse average correlation between the content of IL-6 and the level of MDA in the red blood cells and a direct strong correlation between the content of IL-6 and the level of MDA in the plasma. Conclusion. The findings suggest that in traumatic brain injury, imbalance in the cytokine system is associated with oxidative stress and AOD activation, which permits these processes to be regarded as components of a common mechanism of brain injury. This regularity is particularly evident in victims with concomitant BI. Key words: brain injury, lipid peroxidation system, antiox-idant defense, cytokine status.

Objective: to study the time course of changes and relationship of the serum indicators of apoptotic processes in neurore-suscitation patients. Subjects and methods. Thirty-eight neuroresuscitation patients, including 14 patients with severe brain injury (SBI) (mean age 41.4±4.3 years) and 24 patients with strokes (mean age 53.8±2.5 years), were examined. The group of patients with strokes was divided into 2 subroups: 1) 11 patients with ischemic strokes (IS) and 2) 13 with hemorrhagic strokes (HS). The Glasgow coma scores for admission consciousness loss were 7.6±0.8 in the SBI group and 9.5±0.7 in the stroke group; mortality was 28.6 and 37.5%, respectively. A control group included 16 subjects (mean age 47.9±3.8 years). The investigators measured the serum levels of FAS antigen and its ligand (sAPO-I/FAS and sFAS-L), cas-pase-1/ICE, sCD40 (Bender MedSystem, Austria) and hTRAIL (Biosource, Belgium) by solid-phase immunoassay in neuroresuscitation patients on days 1, 7, and 14 of the acute period of diseases. They used statistical methods, such as Wilcoxon-Mann-Whitney U-test, Spearman’s rank correlation test. Results. A reduction in hTRAIL was observed in all the groups. There was a decrease in serum sCD40 in strokes on days 1 to 14 and in SBI on days 7 to 14. An increase in caspase 1/ICE was seen in HS in the first 24 hours, in IS on days 1 to 7, and in SBI on days 1 to 14. The most pronounced rise in caspase-1/ICE was induced by ischemic brain lesion within the first week of disease. A prolonged increase up to 2 weeks was noted in SBI. No rise in serum FAS-L was found in the examinees. The time course of changes in sAPO-I/FAS was different in all the groups. The most marked, moderate, and none reductions were revealed in HS, IS, and SBI, respectively. There was a pronounced serum sAPO-I/FAS increase in SBI within the first 24 hours. Assessment of correlations between the serum indicators of apoptosis revealed that there were differences in the association between the indices under study in all the patient groups and in the control group. Conclusion. There are general features and differences in the time course of changes in serum apoptotic markers and their association in the acute period of SBI, IS, and HS. Key words: severe brain injury, stroke, apoptosis, APO-I/FAS, FAS-L, caspase-1/ICE, CD40, hTRAIL.

Objective: to reveal gender differences in brain structural changes after clinical death and to assess the neuroprotective properties of the hormonal agent Gynodian Depot. Materials and methods. The brain neuronal populations were morphometrical-ly studied in adult albino rats of both sexes which had sustained 10-minute cardiac arrest. At minute 30 after resuscitation, oil solution of estradiol with dehydroepiandrosterone was intramuscularly injected into the study group animals in doses of 0.1 and 5 mg/100 g. The comparison group of animals received the equivalent volumes of saline. Gender- and age-matched intact rats served as a control. An image analysis system of cresyl violet-stained paraffin brain sections was used to determine the density and composition of highly ischemia-perfusion-sensitive populations of pyramidal neurons of Layer V of the sensomo-tor cortex, the CA1 and CA4 hippocampal sectors, and Purkinje cells in the lateral cerebellum. Results. It has been established that there are gender differences in brain morphology in health, which are detectable in the postresuscitative period. The site of lesions has been found to be different in resuscitated rats of different gender. At the same time, male brain lesions are more extensive, i.e. these involve to this or that extent all the examined regions: the cerebellum and CA4 hippocamplal sector exhibit neuronal death; the cortex and CA1 hippocampal sector show dystrophic changes in the nerve cells. In the females, neuronal shedding processes were observed in the CA1 hippocampal sector only. Estradiol + dehydroepiandrosterone treatment has been ascertained to prevent nerve cell death only in the males and to fail to affect the density and composition of the neuronal populations under study in the females. Conclusion. The findings suggest that it is important to identify the structural bases of sexual dimorphism in the body’s reaction to ischemic exposure and that it is necessary to take them into account when developing effective therapy and choosing the optimal treatment policy to correct posthypoxic encephalopathies. Key words: gender differences, postresuscitative neuronal changes, hormonal therapy, morphometry.

Objective: to define the informative value of the parameters of gas exchange, lung volumetry, and central hemodynamics in the diagnosis of acute respiratory distress syndrome (ARDS) in nosocomial pneumonia (NP). Subjects and methods. The study included 38 patients with cancer and severe injury who were divided into 3 groups in accordance with the diagnostic criteria of ARDS and NP: 1) patients with ARDS + NP; 2) those with NP; 3) those with non-ARDS, non-PN. ARDS was diagnosed in 2 steps. At Step 1, the investigators took into account risk factors for ARDS and used the lung injury scale developed by J. Murray et al. and the ARDS diagnostic criteria defined by the American-European Consensus Conference on ARDS. At Step 2, after obtaining the data of lung volume-try (1—2 hours after Step 1), they assessed the compliance of the above criteria for ARDS with those developed by the V. A. Negovsky Research Institute of General Reanimatology, Russian Academy of Medical Sciences, and redistributed the patients between the groups. The stage of ARDS was determined in accordance with the classification of the above Institute. All the patients underwent a comprehensive examination the key element of which was to estimate gas exchange parameters and to monitor lung volumetry and central hemodynamics by the transpulmonary thermodilution methods, by using a Pulsion PiCCO Plus monitor (Pulsion Medical Systems, Germany). The findings were statistically analyzed using a Statistica 7.0 package (arithmetic mean, error of the mean, _ Student’s test, Newman-Keuls test, correlation analysis). The difference was considered to be significant if p-value was Results. The patients with ARDS + NP were observed to have a significantly lower oxygenation index (10 ml/kg) and Murray scale scores (>2) than those in patients with NP without ARDS. The reference values of the pulmonary vascular permeability index due to its inadequate informative value call for further investigation. The volumetric parameters of central hemodynamics are required to confirm the non-cardiogenic nature of pulmonary edema. Conclusion. Oxygenation index, ELWI, static lung compliance, and Murray scale scores are of informative value in the diagnosis of ARDS in NP. The use of the criteria developed by the V. A. Negovsky Research Institute of General Reanimatology allows the false-positive results of the diagnosis of ARDS in NP to be ruled out in 21.7% of cases. Only the integrated assessment of these parameters enables the diagnosis of ARDS in NP. Isolated analysis may lead to diagnostic errors. No increase in ELWI was found in NP without ARDS. Key words: acute respiratory distress syndrome, nosocomial pneumonia, diagnosis.

Objective: to study the specific features of oxygen transport function in patients with various oxygen delivery changes caused by alveolar opening maneuver (mobilization) performed early after extracorporeal circulation. Subjects and methods. Alveolar opening maneuver was made in the presence of relative arterial hypoxemia under the control of dynamic thora-copulmonary compliance. The maximum airway pressure was as high as 31.1±0.3 cm H2O; the positive end-expiratory pressure was 16.0±0.3 cm H2O. According to the changes in oxygen delivery after alveolar opening maneuver, the investigators retrospectively identified the following groups: 1) (n=14) with a lower and 2) (n=15) higher values. The groups did not differ in age (53.6±2.8 and 56.4±1.8 years), extracorporeal circulation duration (106.4±11.2 and 86.8±4 min), and inotropic support intensity (4.7±0.5 and 4.6±0.6 ^g/kh/min for dopamine and/or dobutamine) (p>0.05). The mode of alveolar opening maneuver and its impact on thoracopulmonary compliance and pulmonary oxygenizing function were identical in the groups (p>0.05). Results. 48.3% of the patients with relative arterial hypoxemia show a linear relationship between the oxygen delivery and consumption indices (r=0.73; p=0.003), and there was a close inverse correlation between the oxygen utilization coefficient and intrapulmonary shunting (r=-0.77; p=0.001). After alveolar opening maneuver, the oxygen delivery index decreased in these cases from 440.7±31.7 to 376.9±20.4 ml/min/m2 (p<0.05). The time course °f changes oxygen delivery influenced mixed venous hemoglobin oxygen saturation (r=-0.71; p=0.005), which was related to lactatemia before (r=0.71; p=0.004) and after (r=0.7; p=0.005) alveolar opening maneuver. Conclusion. After extracorporeal circulation, relative arterial hypoxemia may be concurrent with the signs of oxygen transport system tension in patients with impaired pulmonary oxygenizing function. Moreover, regional blood flow impairments in the peripheral tissues and those in the lung are closely related. After alveolar opening maneuver that improves pulmonary oxygenizing function, oxygen delivery decreases, affecting mixed venous hemoglobin oxygen saturation. The findings give grounds to recommend close monitoring and timely correction during alveolar mobilization in the early period after cardiosurgery. The specific features of oxygen transport and utilization during standard interventions into the heart under extracorporeal circulation call for further in-depth studies. Key words: oxygen transport, oxygen delivery and consumption, alveolar opening maneuver (mobilization), arterial hypoxemia in cardiosurgical patients.

Objective: to study a role of proinflammatory and anti-inflammatory cytokines in the pathogenesis of acute respiratory distress syndrome (ARDS) in preterm neonates. Subjects and methods. The examination program included the determination of production of IL-1/J, IL-4, IL-6, and TNF-a in various biological fluids of mothers and their preterm neonates. Blood cytokines were measured in 57 preterm neonates. The study comprised infants at 27 to 36 weeks postconception who had birth weights of 1040 to 2980 g. Results. The study has revealed the specific features of postnatal immune adaptation in premature neonates. The most changes are characteristic of proinflammatory IL-6. Expression of this cytokine in biological fluids is variable and it depends on the factors that influence the intrauterine fetal status: threats of pregnancy interruption, maternal somatic diseases, and development of severe gestosis. Conclusion. The findings support that premature neonates have a balance between proinflammatory and anti-inflammatory interleukins, and a rather mature immune system that prevents the development of an inflammatory process in the presence of ARDS during artificial ventilation. In ARDS, there was no suppressed function of the monocyte-macrophageal cells that produced proinflammatory cytokines. The changes in proinflammatory and anti-inflammatory interleukins promoted postnatal adaptation of the immune system in a premature neonate. The performed treatment ensured anti-infectious defense and the maintenance of homeostatis and vital functions in preterm newborn infants. Key words: preterm neonates, acute respiratory distress syndrome, proinflammatory and anti-inflammatory cytokines.

Objective: to comparatively assess the intensity of oxidative stress (OS) in acute poisonings by various toxic chemicals. Subjects and methods. Two hundred and eighty-seven patients with acute poisoning by psychopharmacological agents, ethanol, and cauterants were examined. Results. A correlation was found between the manifestations of OS and the severity of poisoning. The investigators revealed the impacts of exposure to toxic chemicals and complications of the toxicogenic phase of acute poisoning by the above toxicants on the intensity of OS. Conclusion. The intensity of OS in the poisonings under study increases in proportion to the severity of intoxication, toxicant exposure in the body. The presence of hemolysis, upper airway burn, and chronic alcoholism deteriorate OS. Key words: oxidative stress, acute poisonings, chemical burn, chronic alcoholism.

Objective: to examine changes in the autonomic nervous system (ANS) function in patients with carbon monoxide poisoning in relation to the condition severity. Subjects and methods. The ANS was studied in 114 patients aged 15 to 82 years with carbon monohydrate poisoning who were treated at the N. V. Sklifosovsky Research Institute of Emergency Care, Moscow, in 2004—2008. Cardiointervalographic readings were analyzed in relation to the condition severity, the presence of thermal damages to the skin and upper airway, and that of blood alcohol. Results. Within the first hours after poisoning, the function of the ANS was found to be impaired, which was associated with the development of hypersympathicotonia caused by the increased activity of its sympathetic part and the decreased tone of the parasympathetic one. The magnitude of hypersympathicotonia depends on the severity of poisoning, on the presence of thermal damages to the upper respiratory tract and that of blood alcohol. The preponderance of the tone of the ANS parasympathetic part suggests the disturbance of adaptive and compensatory mechanisms and the likely poor prognosis of the poisoning. Conclusion. Cardiointervalography is recommended for the objective evaluation of the severity of carbon monoxide poisoning. Key words: carbon monoxide, autonomic nervous system, cardiointervalog-raphy, adaptive and compensatory mechanisms.

Objective: to study the mechanisms of redistribution of toxins between biological media (blood and lymph) during enhanced lymph circulation after thoracic duct cannulation. Materials and methods. Experimental studies were performed on 12 mongrel dogs with reproduced general purulent peritonitis, which were divided into 3 groups and which differed in various times of thoracic duct cannula functioning. The redistribution of toxins was based on the study of medium-weight molecular fractions in different development periods of endotoxicosis. Results. Clinical observations have ascertained and confirmed that the potentiated draining effect of the lymphatic system in surgical endotoxicosis depends on the completeness of lymph circulation rearrangement after thoracic duct cannulation and external lymph drainage restoration. Conclusion. It is expedient to carry out thoracic duct cannulation as soon as possible if the course of surgical endotoxico-sis is supposed to be severe. This will accelerate lymph circulation rearrangement and ensure a prompter elimination of toxins, which can enhance the efficiency of extracorporeal lymph detoxification. Key words: lymph circulation, endotoxicosis, thoracic duct cannulation, medium-weight molecules.

Sepsis remains to be one of the most urgent problems of modern medicine, which are associated with a steadily high mortality (as high as 70%). The central point of the pathogenesis of abdominal pathogenesis is the translocation of the gram-negative flora and the elevated blood concentrations of lipopolysaccharide in the bacterial cell wall (endotoxin), which induces a systemic inflammatory reaction and has direct and indirect cell damaging actions. The technologies that have recently emerged in the clinic for the selective hemosorption of endotoxin in combination with dynamic monitoring of its blood level (LAL test) open up wide prospects for the treatment of abdominal sepsis. The paper gives a clinical example of successful therapy for septic shock, by using the sorbent LPS adsorber (Alteco, Switzerland) in a patient with abdominal sepsis in the presence of blood cancer. Selective hemosorption of endotoxin could substantially reduce its blood concentration, which attenuated a systemic inflammatory reaction, stabilized hemodynamics, and improved lung microcirculation with resolution of respiratory failure. Key words: abdominal sepsis, endotoxin, selective hemosorption.

Objective: to substantiate an algorithm for early respiratory-kinesiological rehabilitation used in the multimodality treatment of cardiosurgical patients developing multiple organ dysfunction syndrome (MODS). Subjects and methods. A randomized study was performed in 90 cardiosurgical patients with postoperatively evolving MOD, who were mechanically ventilated. In addition to conventional intensive therapy, these patients received an original complex of early respiratory-kinesiological rehabilitation. Results and Conclusion. The study has demonstrated the impact of respiratory and kinesiological rehabilitation on the course of a postoperative period: normalization of autonomic status-evaluating tests (from Д13±1.7 to Д7.5±4.9), endurance coefficient (21.8±9.9 to 16.5±7.2) in the study group versus 20.5±10.2 to 18.3±6.5 in the control group), adaptation potential (from the poor values 3.3±2.7 to the tension ones 2.9±2.2 scores since day 2; this trend was observed in the control group since postoperative day 5); improvement of gas transport parameters during exercises and within at least 6 hours after this, without changing artificial ventilation (AV) modes (improvement of the values of DO2I (by 12.3±4.5% of the baseline value), VO2I (by 8.8±5.3% of the baseline value), O2ER (by 16.5±8.5% of the baseline value); accelerated switching to assisted ventilation modes (78.6±18.3 hours (the start of assisted AV modes) in the study group versus 92.1±22.7 hours in the control one); a shorter length of stay in an intensive care unit (9.55±4.3 versus 14.2±5.5 days). The positive result from a primary pharmacoeconomic analysis for surviving patients is shown. Key words: rehabilitation, multiple organ dysfunction, cardiac surgery.

Objective: to evaluate the impact of experience on the quality of anesthesia in ambulatory surgery. Materials and methods. The authors undertook a study of the role of experience and specialization on the occurrence of complications in ambulatory anesthesia care. By using the internal audit and calculating the frequency of critical cases, they examined the results of the work of two groups of anesthetists: 1) medical beginners after 2-year adjunct practice and 2) one-day hospital specialists having an at least 7-year practice length. Results. In the beginner group, the number of critical cases per operation was twice higher than that in the experienced specialists. The paper shows the detrimental pattern of the residual principle in selecting anesthetists for work at a one-day hospital and provides evidence that specialization is required in the area under discussion. Key words: ambulatory anesthesiology, role of an anesthetist’s experience, critical cases.

Objective: to evaluate the impact of intermittent plasmapheresis in combination with 10% HES (Refortan® HES 10%, Berlin-Chemie AG) on hemostatic parameters in pregnant women with hypercoagulation syndrome. Subjects and methods. One hundred and forty pregnant women at 25-to-34 weeks gestational age with significant hypercoagulation as shown by hemostasiograms, who received a course of intermittent plasmapheresis for correction of hemostasis, were followed up. Plasma exchange using 10% HES (Refortan®) 500 ml was performed in 80 pregnant women. That with 0.9% NaCl 800 ml was carried out in 60 pregnant women. Results. There were substantial shifts towards a reduced coagulation potential in both groups. When a control hemostasiogram was recorded after 14 days, no negative changes were found in the former group whereas in the latter group all the study indices returned to the values obtained before a course of intermittent plasma-pheresis with plasma exchange using 0.9% NaCl. Conclusion. The performed analysis of hemostatic changes in pregnant women from the study and control groups leads to the conclusion that the use of HES (Refortan® 10%) as a plasma-substituting solution during intermittent plasmapheresis results in a more considerable and longer stabilization of the blood coagulation potential at the expense of the plasma and platelet links of hemostasis and the increased blood fibrinolytic potential, as suggested by the indicators of decreased intravascular coagulation processes. Furthermore, these positive effects persist for at least two weeks, which promotes a more effective prevention of placental insufficiency and gives grounds to substantially reduce a medical burden in pregnant women with hypercoagulation syndrome and to prolong pregnancy in these women. Key words: pregnancy, miscarriage, hypercoagulation, plasmapheresis, hydroxyethyl starch.

Objective: to evaluate the efficiency of cytokine sorption with carbon with a locally aminocaproic acid-modified surface from the plasma of patients with general purulent peritonitis. Materials and methods. The material of the investigation was the plasma obtained during plasmapheresis in 10 patients with acute pancreatitis complicated by pancreonecrosis and general purulent peritonitis, which was used to estimate before and after sorption the content of the cytokines: interleukin (IL)-1/8, IL-4, and IL-8 by enzyme immunoassay. The sorption properties of carbon hemosor-bent and aminocaproic acid-modified sorbent were comparatively evaluated. Results. Aminocaproic acid-induced modification of the carbon adsorbent surface with its further polycondensation results in the higher content of superficial functional groups (oxygen- and nitrogen-containing) that enhance the hydrophility of the surface and the specific pattern of sorption, thus acting as a means for controlling and regulating the plasma concentration of regulatory proteins, primarily the proinflammatory cytokine IL-1^3, the chemokine IL-8 and the T-helper cell clone cytokine IL-4.