Objective: to perform a complex study of typical plasma sex hormone changes and their functional significance in males with severe concomitant injury (SCI). Subjects and methods. Fifty-nine males aged 18—49 years who had SCI were enrolled in the study. The admission severity was an APACHE II score of 18.6±2.4. According to the outcome of the disease, all the patients were divided into 2 groups: A) survivors; B) deceased persons. A control comprised 12 healthy male donors aged 19-36 years, in whom the levels of 8 sex steroids were measured. The standard procedures were used to comparatively analyze the concentrations of pituitary reproductive hormones and aldosterone. Hormonal concentrations were studied over time on posttraumatic days 1, 3, 5, 7, 10, and 15. The plasma hormone profile was examined by test kits (BSL, USA) on a Stat Fax 2100 device (Awareness Technology Inc., USA) for enzyme immunoassay. Prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), progesterone (P), 17-hydroxyprogesterone (17-OH-P), dehydroepiandrosterone sulfate (DHEA-S), androstendione (A), testosterone (T), dihydrotestosterone (DHT), estrone (E1), estradiol (E2), and aldosterone were determined. Results. The complex study of phasic changes in the profile of 11 plasma sex hormones was first conducted in males in the posttraumatic period. Moreover, the typical plasma hormonal changes were elevated prolactin levels and their phasic variations, normal LH and FSH levels with a tendency for further phasic LH changes and FSH reduction. After the injury, the plasma concentration of P was increased and that of 17-OH-P was decreased. The levels of A and DHEA-S varied in the normal range with a tendency for DHEA-S to be lower during the process. In the posttraumatic period, the plasma content of T and DHT was substantially reduced and that of E1 and E2 was increased. The deceased patients generally showed higher levels of A, DHEA-S, and estrogens as a reflection of dysregulatory pathology and complications. The changes revealed in hormonal levels are of significance in understanding the pathogenesis of SCT and its sequels. This may serve as a basis for the development of new therapy methods using sex hormones as adaptogens in the postresuscitative period. Key words: severe concomitant injury, sex hormones, prolactin, luteinizing hormone, follicle-stimulating hormone, progesterone, 17-hydroxyprogesterone, androgens, estrogens.

Objective: to determine the time and development rate of acute lung injury (ALI) in severe brain injury (SBI) complicated by aspiration of gastric contents or blood. Subjects and methods. Twenty-nine patients aged 19 to 70 years, who had isolated SBI, of whom there were 24 males and 5 females), were examined. The patients were divided into 2 groups: those with aspiration of gastric contents (n=9) or blood (n=10). A control group included 10 patients with SBI without aspiration. A PiCCO plus device was used to determine pulmonary extravascular fluid. ALI was diagnosed in accordance with the recommendations of the Research Institute of General Reanimatology, Russian Academy of Medical Sciences. Results. SBI patients with aspiration of gastric contents or blood were found to have significantly increased pulmonary extravascular water (p<0.01) and a lower oxygenation index (<300), which correlated with each other. ALI was recorded in the first hours after injury in about 50% of cases in both patients with gastric contents aspiration and those with blood aspiration. Conclusion. In patients with SBI complicated by aspiration of gastric contents or blood, pulmonary extravascular fluid accumulation concurrent with other signs of injury may be regarded as a criterion for acute lung injury. Key words: severe brain injury, aspiration, acute lung lesion.

Objective: to reveal the specific features and major mechanisms of development of calcium metabolic disturbances in severe mechanical injury in the presence of steroid-induced osteoporosis. Materials and methods. Experimental studies were performed on 197 albino outbred male rats weighing 250—300 g. The studies used physiological, pathophysiological, X-ray, biochemical studies, enzyme immunoassay, and statistical methods. Results. Calcium metabolic changes in standard mechanical injury depend on the specific features of the body’s individual responsiveness that modulates the course of a posttraumatic reaction and makes up 3 types: non-shock; shock non-fatal, and shock fatal. Osteoporosis aggravates the course of all types of a posttraumatic reaction and reduces the rats’ survival. The new mechanisms responsible for calcium metabolic disturbances, which specify the diagnosis and evaluation of the severity of injury running in the presence of glucocorticoid osteoporosis, are established. Conclusion. The osteoporosis-deteriorated course of a posttraumatic reaction is caused by the mechanism of inadequate bone formation, by relevant parathyroid hormone, thyroid-stimulating hormone, T4, and T3 changes, and hypercytokinemic indices. Key words: severe mechanical injury, glucocorticoid-induced osteoporosis, calcium metabolism, cytokines.

Objective: to determine the optimum alveolar opening parameters for the improvement of postoperative pulmonary oxygenizing function in patients with a left ventricular ejection fraction (LVEF) of less or more than 40% after aortocoronary bypass surgery (ACBS). Subjects and methods. Twenty patients with a LVEF of less than 40% after ACBS and with postoperative pulmonary oxygenizing dysfunction (PaO2/FiO2 less than 250) (Group 1) were examined. A control group consisted of 20 patients with a LVEF of more than 40% (Group 2). Gas exchange, respiration biomechanics, and central hemodynamic (CH) parameters were monitored (a Vigilance monitor (Edvard LifeScience)). Alveolar mobilization was carried out on Drager Evita-2 apparatuses in the BIPAP mode, by taking into account the previous artificial ventilation (AV) parameters. The low pressure phase corresponded to the positive end-expiratory pressure (PEEP) with volume AV, the high pressure phase was Pplato; the duration of both phases — that of inspiration and expiration (the high pressure phase was inspiration time; the low pressure phase was expiration time). Then the values of Pplato and PEEP were simultaneously increased by 2 cm H2O with a duration of 10 breathing cycles, by continuously monitoring Vt and SaO2 over this interval. By continuously monitoring Vt, a stepwise increase in PEEP and Pplato was continued until there was a Vt reduction or a negative impact of AV on CH. All alveoli were considered to be open when the maximum Vt and SaO2 were achieved. Conclusion. In Group 1 patients with Pinsp of 27—30 cm H2O, PEEP of 10—12 cm H2O, there are increases in PaO2/FiO2 and Cst. In Group 2, the increase of PaO2/FiO2 and Cst is observed with Pinsp of 30—35 cm H2O and PEEP 12—14 cm H2O. With these AV indices, there is an allowable hemodynamic reduction that results in no negative consequences and development of cardiovascular events. After switching to AV in an individually chosen mode, all hemodynamic parameters return to the baseline level. Consequently, the proposed AV mode and ventilation parameters are safe and effective for the prevention of early postoperative respiratory failure in cardiosurgical patients. Key words: recruiting ventilation, positive end-expiratory pressure, alveolar opening.

Objective: to study the plasma content of B-type natriuretic peptides in coronary heart disease patients prepared for surgery under extracorporeal circulation and to assess the association of the level of these biomarkers with the data of clinical and functional studies. Material and methods. The levels of active B-type natriuretic peptide were determined by immunofluoresence assay in the blood of 52 patients aged 57.8±1 years. The patients’ baseline clinical condition was in New York Heart Association (NYHA) Functional Class I—IV. The left ventricular ejection fraction was 59.6±1.2%. The plasma concentration of the inactive N-terminal fragment of the BNP prohormone (NT-proBNP) was estimated by electric chemiluminescence technique in 61 patients aged 54.6±1.18 years. The patients’ clinical condition was in NYHA Functional Class II—IV. The left ventricular ejection fraction was 51.5±1.6%. Results. The plasma content of B-type natriuretic peptide in the examinees was 48.5±5.9 pg/ml. The level of the biomarker correlated with the NYHA functional class (r=0.4; p=0.005), the electrocardiographic signs of postinfarct cardiosclerosis (r=0.29; p=0.04), and left ventricular ejection fraction (r=-0.41; p=0.003), and end-systolic volume (r=0.32; p=0.03). The plasma concentration of inactive NT-proBNP was 659.4±91.6 pg/ml. The level of the biomarker correlated with the NYHA functional class (r=0.4; p=0.002), the stage of circulatory insufficiency as described by I. D. Strazhesko and V. Kh. Vasilenko (r=0.49; p=0.001), and left ventricular ejection fraction (r=-0.45; p=0.001), and end-diastolic (r=0.39; p=0.002) and end-systolic (r=0.42; p=0.001) volumes. In patients with the values of the biomarker of less than 1000 pg/ml, the latter was related to age (r=0.3; p=0.047). Conclusion. The study of the level of B-type natriuretic peptides in cardiosurgical patients with coronary heart disease, prepared for surgery under extracorporeal circulation, suggests that the content of both peptides is obviously correlated with the conventional clinicofunctional parameters. At the same time, the moderate or weak pattern of all correlations indicated the independent diagnostic value of biomarkers. Key words: B-type natriuretic peptides, brain nautri-uretic peptide (BNP), N-terminal fragment of the BNP prohormone (NT-proBNP), coronary heart disease, surgery under extracorporeal circulation.

Objective: to study the central hemodynamics (CH) and intracranial and cerebral perfusion pressures (ICP and CPP) in acute cerebral circulatory disorders (ACCD) and their possible relationships for further development of intensive differential therapy for the detected disorders. Material and methods. Hemodynamic studies using the transpulmonary thermodilu-tion technique, measurements of ICP, calculations of CPP, and currently available X-ray studies were conducted in 18 patients on days 1, 3, 5, and 7 of ACCD. All the patients were found to have essential hypertension and coronary heart disease. Results. In the first 5 days of ACCD, there was a normodynamic type of circulation in hemorrhagic stroke (HS) and a hypodynamic type in ischemic stroke (IS). ICP remained at the baseline elevated level in the IS group and increased over time in the HS group. CPP was significantly unchanged. Myocardial dysfunction was detected when there was a significant preload caused by a high postload. In IS, an inverse correlation was found between ICP and global ejection fraction (GEF), cardiac performance index (CPI) and on day 7, the correlation was direct. In HS, ICP had a direct correlation with CPI and an inverse correlation with GEF. These changes during treatment failed to progress and were revealed in the presence of brain dislocation, as evidenced by spiral computed tomography. Conclusion. Thus, the pattern of CH disorders depends on the type of ACCD. In the first 5 days of ACCD, a hypokinetic circulatory type is registered in IS and a normokinetic type is in HS. Evolving dislocation of the brain with impaired function of its stem structures due to ICP elevation is one of the causes of central hemodynamic changes. The value of ICP in ACCD is a crucial indicator in the diagnosis of secondary brain damages and determines treatment policy. Key words: acute ischemic attack, intracranial pressure, cerebral perfusion pressure, central hemodynamics, myocardial depression.

Objective: to evaluate the impact of the algorithm based on a combination of transpulmonary dilution and continuous venous blood oxygen saturation monitoring on perioperative infusion therapy and hemodynamic correction and on the length of postoperative stay in an intensive care unit and at hospital after aortocoronary bypass surgery without extracorporeal circulation. Subjects and methods. The patients were randomized to two hemodynamic monitoring groups: 1) routine monitoring (RM) (n=20) and 2) complex monitoring (CM) (n=20). In the RM group, therapy was based on the values of central venous pressure, mean blood pressure (BPmean), and heart rate (HR). In the CM group, it was founded on the values of intrathoracic blood volume index, BPmean, HR, central venous saturation (ScvO2), and cardiac index (CI). Measurements were made before, during, and 2, 4, and 6 hours after surgery. Results. In the CM group, colloidal solutions and dobutamine were significantly more frequently used, which was followed by increases in ScvO2 and CI as compared with the baseline values. The frequency of use of ephedrine was significantly higher in the RM group. The algorithm based on complex monitoring reduced the time of achieving the criteria for transferring from the intensive care unit and the length of postoperative hospital stay by 15 and 25%, respectively. Conclusion. Thus, the goal-oriented algorithm based on the complex monitoring of hemodynamics and oxygen transport makes it possible to reveal hemodynamic disturbances and correct them early, which can improve an early postoperative period during aortocoronary bypass surgery on the working heart. Key words: aortocoronary bypass surgery, goal-oriented therapy, central venous saturation.

Objective: to evaluate the severity of a cardiac lesion in pancreonecrosis and possible mechanisms of pancreatogenic heart failure. Materials and methods. Experiments were made on albino male Wistar rats. In 32 animals anesthetized with ether, pancreonecrosis was simulated by injecting autobile (0.15 ml/kg) into the pancreas with later ligation of the common bile duct. In 18 animals, immunosuppression was induced by triple hydrocortisone administrations and pancreonecrosis was then simulated. Thirty intact anesthetized rats served as a control. Cardiac contractility was studied using an isolated isovolumi-cally contracting heart preparation, by recording the force and velocity indices of contractility, glucose uptake, and enzymatic leakage into the coronary stream. The severity of endotoxemia, the rate of free radical processes, and the serum levels of cardiospecific and pancreatic enzymes were estimated. Results. Pancreonecrosis induces a cardiac lesion, followed by its contractile depression and increased glucose uptake per performed function unit. There is an enhanced susceptibility of isolated hearts to hypoxia, reoxygenation, and exogenous calcium. The hearts of immunosuppressed animals are damaged to a greater extent. Conclusion. Activation of free radical oxidative processes, inadequacy of the antioxidant defense system, impaired cardiac bioenergy, endotoxemia, and depressed phagocytosis have been established to be the leading pathogenetic factors of pancreatogenic myocardial depression. Key words: pancreonecrosis, pathogenesis of heart failure.

Any need for combining the effective antinociceptive defense of a patient during traumatic surgical interventions has give rise to multimodal combined anesthesia (MCA) comprising a combination of epidural analgesia with a small-dose local anesthetic (ropivacaine 2 mg/ml), an opioid (fentanyl 2 ^g/ml), and adrenaline (2 ^g/ml) with low-flow anesthesia with sevoflurane at low concentrations (Key words: multimodal anesthesia, traumatic operations, epidural analgesia, sevoflurane anesthesia, anesthetic safety, massive blood loss.

Objective: to study the course of spinal anesthesia in regular users of CAT (Catha edulis Forskal). Subjects and methods. The course of spinal anesthesia was studied in 75 patients in relation to the degree of drug dependence in patients with a national habit to chew systematically CAT, the herbal psychogenic stimulant (pseudoephedrine, amphetamine). According to the dependence and clinical manifestations, all the patients were divided into 3 groups. Results. During spinal anesthesia, arterial hypotension and tachycardia were more common in Group 1 and control patients. Groups 2 and 3 patients with baseline hypertonus of the sympathetic nervous system showed a more significant resistance of indices at this stage and virtually needed no ephedrine administration. The time course of changes in the Cardo autonomic index practically corroborated this regularity. However, in the immediate postoperative period, Group 3 patients’ condition is characterized by the signs of functionally exhausted tone of the sympathetic nervous system, as appear as the signs of discomfort, withdrawal syndrome, respiratory and circulatory disorders, urinary retention, enteroparesis, which require active therapy in an intensive care unit. Thus, Groups 2 and 3 patients have a false temporary intraoperative resistance of hemodynamic parameters and psychoemotional status, which are more dramatically observed in the postoperative period. Key words: spinal analgesia, CAT as a psychogenic stimulant, amphetamine, pseudoephedrine, withdrawal syndrome.

All-Russian Congress of Anesthesiologists-Resuscitators with the International Participation, Dedicated to the 100th Anniversary of Academician of the Academy of Medical Sciences V.A. Negovsky

The clinical course of sterile pancreonecrosis (SPN) (1992 Atlanta classification of acute pancreatitis) and intensive care measures were retrospectively analyzed in 496 patients with this condition. The diagnosis of SPN was established by a complex of clinical, biochemical, and instrumental studies (abdominal ultrasonography, gastroduodenoscopy, if needed, diagnostic laparoscopy). On admission, 5.6% of the patients underwent endoscopic papillosphincterotomy, 49.0% had Wirsung’s duct decompression via pancreatic juice aspiration. Endoscopic nasointensinal intubation was conducted in 75.8% of cases. When enzymatic peritonitis developed, laparoscopic abdominal drainage was carried out with 5 drains for _ peritoneal lavage (65.5%). The efficiency of medical measures was evaluated from the course and outcome of the disease. The authors analyzed 14-day mortality, the clinical and morphological regression of pancreonecrosis, the incidenceof local complications (acute fluid accumulations (AFA), and the incidence of infected pancreonecrosis (IPN). Results. According to the severity of the underlying condition, the patients were divided into two groups. Group 1 (SAPS < 9; mean score 7.4±0.8) included 338 (68.4%) of the 496 patients; Group 2 (SAPS > 9; mean score 12.5±1.8) comprised 158 (31.6%) patients. The baseline condition of patients was determined by the involvement extent of the pancreas and retroperitoneal fat. In Groups 1 and 2, mortality was 7.1 and 19.0%, respectively (p=0.000). Overall mortality was 10.9%. Cessation and regression of tissue necrotic changes in the pancreas and retroperitoneal fat were observed in 49.7% of cases in Group 1 and only in 12.7% in Group 2 (p=0.000). AFA was diagnosed in 43.2% of patients in Group 1 and in 68.4% in Group 2 (p=0.000). Adequate intestinal stimulation, nutritional support, and antibacterial therapy caused a mortality reduction in SPN irrespective of the SAPS severity. The abortive course of SPN was more frequently recorded in both groups when balanced multicomponent infusion therapy was performed in the first 24 hours of the disease. Regression of necrosis was also seen in the use of clinically effective gastrointestinal tract (GIT) stimulation, medical sedation, blockade of the secretory function of the gland, and antibacterial therapy in Group 1, and during adequate prolonged epidural anesthesia in Group 2. AFA was less frequently observed in the use of somatostatin analogues in Group 1 and complex infusion therapy and during adequate nutritional support only in Group 2. Fewer cases of infection in SPN were noted after effective GIT stimulation and antibiotic therapy in both groups, but during balanced (tube, parenteral) feeding in Group 1. Thus, adequate combined medical intensive therapy in Group 1 considerably improves the clinical course and outcomes of the disease. The results of intensive care were worse in extensive involvement of the pancreas and retroperitoneal fat (SAPS > 9). Key words: pancreonecrosis, intensive care.

The paper considers the basic principles of the pathophysiology, as well as the diagnosis and treatment of patients with severe acute pancreatitis. Key words: acute pancreatitis, pathophysiology, diagnosis, treatment.

Objective: to substantiate the choice of a gastrointestinal tract (GIT) function support regimen as a mode for correction of the abdominal compartment syndrome (ACS). Subjects and methods. Forty-three patients with different causes of inadequate GIT function of various origin and ACS (disseminated peritonitis (45%), pancreatitis (24%), and severe concomitant injury (31%)) were examined. Group 1 (control) received complete parenteral nutritional feeding (n=23; APACHE II scores, 21±4; calculated probability of fatal outcome, 33.5%). In Group II (study), complete parenteral feeding in the first 24 hours after stabilization was supplemented with GIT function support with Pepsisorb (Nutricia) in doses of 500, 1000, and 1500 ml on days 1, 2, and 3, respectively (n=20; APACHE II scores, 20±6; calculated probability of fatal outcome, 37.1%). During early enteral nutritional support, the SOFA score was significantly less than that in Group 1 on days 2—3; the oxygenation index significantly increased on day 3; the value of intra-abdominal hypertension decreased to the control values. The positive effect of the GIT function support regimen on regression of the multiple organ dysfunction syndrome (MODS) was confirmed by the lowered levels of biological markers (von Willebrand factor (WF) and endothelin-1 as markers of endothelial damage) of MODS. Correlation analysis showed a direct correlation between the markers of endothelial damage and the SOFA scores (r=0.34; p=0.05 for WF and r=0.49;p=0.03 for endothelin). Conclusion. The GIT function support regimen via early enteral alimentation with Peptisorb, which was initiated in the first 24 hours after admission, is able to level off the manifestations of the early stages of the abdominal compartment syndrome, with the acceptable values of oxygen balance and water-electrolyte and osmotic homeostasis being achieved. Key words: abdominal compartment syndrome, nutritional support, biological markers, oxygenation index, intra-abdominal pressure.

Whether gastrointestinal changes play an important role in the pathogenesis of infectious complications and sepsis and promote the occurrence of the multiple organ dysfunction syndrome is beyond question. A relationship is shown between the permeability of the intestinal wall and the incidence of complications, including the development of severe sepsis in critically ill patients. The present review shows the basic mechanisms contributing to intestinal barrier disintegration and a possibility of using exogenous glutamine to correct occurring disorders. Key words: bacterial translocation, sepsis, severe sepsis, glutamine, enteral feeding.