Objective: to optimize the diagnosis of a systemic inflammatory reaction (SIR) after aortocoronary bypass surgery (ACBS) under extracorporeal circulation (EC), by examining the reaction of the peripheral blood lymphocytic plasma membrane to surgery. Subjects and methods. Eighty-three patients with coronary heart disease (CHD) who had undergone ACBS were examined. The lymphocytic plasma membrane was studied before and 1, 2, 3, and 7 days after surgery. Lymphocytes were derived on the ficoll-verografin (Pharmacia Chemical, Uppsala, Sweden) density gradient (p=1.077). The isolated cells were investigated by phase contrast microscopy (900X). Results. The patients with CHD were found to have perioperative peripheral lymphocytic plasma membrane changes (blebbing), the genesis of which was determined by impaired membrane-cytoskeleton interactions. More plasma membrane changes occurred throughout the postoperative period, with their maximum being recorded on day 1, which corresponded to the increase peak in the concentrations of interleukin-6 and tumor necrosis factor-а. Conclusion. The follow-up cell membrane changes appearing as peripheral lymphocytic blebbing reflect the development of SIR during ACBS under EC. In patients with CHD, the lymphocytic plasma membrane blebbing is of varying degrees: from early to terminal. The determination of peripheral lymphocytic blebbing allows one not only to record SIR, but also to assess its time course of changes. Key words: lymphocytic blebbing, systemic inflammatory reaction, aortocoronary bypass surgery, extracorporeal circulation.

Objective: to analyze DNA polymorphism in inpatients with pneumonia. Subjects and methods. Group 1 consisted of 99 patients with acute community-acquired pneumonia (CAP). Group 2 included 95 patients with severe concomitant injury, including wounds (n=63) and generalized peritonitis (n=32). Among Group 2 patients, the authors singled out two subgroups: 2A comprising 57 patients with nosocomial pneumonia (NP) and 2B including 38 patients without NP. A control group was composed of 160 apparently healthy individuals. Polymerase chain reaction genotyping was carried out for the polymorphic genes controlling xenobiotic detoxification (such as GSTM1, GSTT1, GSTP1, and CYP1A1) and the MTHFR gene that is responsible for DNA synthesis and methylation. Results. Predisposition to acute CAP has been shown for the carriers of a minor allele (4889G) at the CYP1A1 locus: 12.7% versus 5.4% in the controls (p=0.034; OR=2.6); In Group 1 patients, the development of complications (toxic myocarditis, pleuritis, pleural empyema, toxic nephropathy) is most probable for a combination of GSTT1 + GSTM1 0/0 genotypes (OR=3.2; p=0.010 versus the control group). It has been established that in severe injury, peritonitis (2B), NP does not develop statistically significantly in 61.1% of cases with the GSTM1 + GSTT1 + genotype versus 38.8% in the controls (p=0.022) or versus 37.5% in subgroup 2A (p=0.045; OR=2.6). Key words: acute community-acquired pneumonia, nosocomial pneumonia, gene polymorphism.

Objective: to reveal a relationship between the impaired oxygen transport and the sectoral distribution of fluids in severe concomitant injury (SCI). Subjects and methods: A follow-up covered 29 patients with SCI. The severity of the condition was evaluated using the traumatic shock scale (Dzhanelidze Research Institute of Emergency Care, Saint Petersburg). Differences were estimated between the groups of patients with varying traumatic shock and between the surviving and deceased victims. The victims were examined by the generally accepted standards of clinical and laboratory studies; noninvasive monitoring of hemodynamics and fluid distribution along the body’s aqueous sectors was made in all the patients, by applying integral tetrapolar rheovasography and two-frequency bioimpedance study (Diamant-M, Saint Petersburg). Results. The diagnostic and predictive values of determination of the cardiac index have been ascertained by the Tishchenko tetrapolar rheovasography in patients with SCI. The cardiac index of less than 3.2 l/min^m2 in the first 24 hours after referral to an intensive care unit (ICU) is a predictor of mortality. The above cardiac index is consistent with the presence of evident oxygen debt along with the respective oxygen extraction coefficient of greater than 42%. With lower cardiac index, there may be associated dyshidria: hyperosmolar hyperhydration of the intravascular sector and interstice with a tendency for intracellular sector dehydration. On the basis of determination of a low cardiac index (less than 3.2 l/min^m2 in the first 24 hours after referral to the ICU), intensive care tactics aimed at preventing and correcting the above-mentioned homeostatic disorders should be chosen. Key words: severe injury, cardiac index, oxygen transport, water electrolyte disorders.

Objective: to evaluate the efficacy and safety of tranexamic acid in knee joint replacement. Subjects and methods: the prospective open-label study of the efficacy of tranexamic acid as an agent for blood loss reduction in knee joint replacement included 41 patients who were randomly randomized in two groups. Tranexamic acid (Tranexam, ZAO «Mir-Pharm») was injected intravenously in a dose of 15 mg/kg in Group 1 patients just before tourniquet removal, which caused a significant (p=0.003) reduction in drainage losses (from 556 (200; 800) ml to 234 (100; 300) ml) and in the calculated (from the changed concentration on days 3—4 postoperative days) values of overall blood loss (from 1821 (1348; 2156) ml to 1269 (924; 1580) ml (p=0.001) in the immediate postoperative period. There were no tranexamic acid-associated complications. Conclusion: Tranexamic acid is an effective agent in reducing blood loss when the knee joint is replaced. Key words: knee joint replacement, blood loss, tranexamic acid.

Objective: to reveal the major regularities and mechanisms of morphological changes in the rat pulmonary circulation arteries in the late posthemorrhagic period and to compare them with age-related features of the vessels. Materials and methods: experiments to generate graduated hemorrhagic hypotension with the blood pressure being maintained at 40 mm Hg were carried out on young (5—6-month) albino male Wistar rats. Throughout hypotension and 60 days after blood loss, the blood was tested to determine low and average molecular-weight substances by spectrophotometry and the pro- and antioxidative systems by chemiluminescence. Pulmonary circulation arteries were morphologically studied in young animals, rats in the late posthemorrhagic period and old (24—25-month) rats. Results. Sixty-minute hemorrhagic hypotension leads to the development of endotoxemia and imbalance of the pro- and antioxidative systems, the signs of which are observed in the late periods (2 months) after hypotension. At the same time, the posthemorrhagic period is marked by the significant pulmonary circulation arterial morphological changes comparable with their age-related alterations in old rat. This shows up mainly in the reorganization of a connective tissue component in the vascular wall: the elevated levels of individual collagen fibers, their structural changes, elastic medial membrane destruction and deformity. At the same time, there is a change in the morphometric parameters of vessels at all study stages while their lowered flow capacity is only characteristic for intraorgan arteries. Conclusion: The increased activity of free radical oxidation and endotoxemia may be believed to be one of the causes of morphological changes in pulmonary circulation arteries in the late posthemorrhagic period, which is similar to age-related vascular alterations. Key words: hemorrhagic hypotension, pulmonary circulation arteries, free radical oxidation, endotoxemia, remodeling, late posthemorrhagic period, age-related vascular changes.

Objective: to establish how the protective properties of HSP70 family proteins are realized in the postresuscitative period depending on the organism’s individual typological features. Materials and methods. Neuronal populations of the CA1 and CA4 region of the hippocampus, cerebral sensorimotor cortex V and Purkinje’s cells of the cerebellum were comparatively morpho-metrically and immunohistochemically studied in the rats who had sustained 12-minute clinical death and differed in the results of active avoidance conditioning (AAC). Immunological responsivness to heat-shock proteins was determined by peroxidase-antiperoxidase assay using polyclonal antibodies to HSP70. The density and composition of the neuronal populations were ascertained by morphometric analysis. Results. The control animals having varying capacity for AAC were found to have differences in the composition of neuronal populations of hippocampal region CA4 and cerebellar Purkinje’s cells. Marked postresuscitative neuronal damages were only detected in the high-learned rats. In the controls, immunological responsivness to HSP70 in the CA1 and CA4 pyramidal cell populations of the hippocampus was found to be greater in the high-learned rats than that in the low-learned ones. There was only a postresuscitative increase in immunological responsivness to HSP70 in the CA1 and CA4 pyramidal cell populations of the hippocampus in the low-learned rats. Conclusion. By and large, the results of the present study suggest that the immunological responsivness of neuronal populations to HSP70 is linked to the individual typological features of the organism. There are differences in the immunological responsivness of neuronal populations to HSP70 between the animals having varying ability to learn in the controls and in the postresuscitative period. The specific features of exhibition of the neuroprotective properties of HSP70 depending on individual typological features of the organism are one of the important factors of different cerebral resistance to postresuscitative damages. Key words: cardiac arrest, individual typological features, HSP70, immunohistochemistry, neuronal populations.

Objective: to comparatively evaluate the analgesic activity and hemostatic effects of two nonsteroidal anti-inflammatory drugs (NSAID) that are most commonly used for postoperative analgesia — ketorolac and ketoprofen in patients operated on for diffuse nodular nontoxic goiter. Subjects and methods. At surgical treatment stages, the authors examined the degree of the pain syndrome by the visual analog scale and hemostatic parameters in 90 patients divided into three groups according to the postoperative analgesia mode (ketorol, ketonal, and promedol). Results. Postoperative analgesia in nontoxic goiter patients with ketorol and ketonal has been ascertained to be highly competitive with that with promedol and to give no rise to clinically significant complications inherent in NSAID. Ketorol provides a rapider, prolonged and effective postoperative analgesia than does ketonal. Ketorol affects the hemostatic system to a lesser extent than does ketonal. Conclusion. Ketorol analgesia may be considered to be the method of choice of postoperative analgesia in patients with nontoxic goiter. Key words: ketorol, ketonal, hemostasis, analgesia.

Objective: to develop a scheme for calculating the dose of a local anesthetic (LA) for spinal anesthesia (SA) during operative delivery, by taking into account the individual physical characteristics of a female patient. Subjects and methods. The course of SA was analyzed in 35 overweight women. In accordance with the body mass index (BMI), the patients were divided into 3 groups. In each group the authors identified subgroups with no arterial hypotension development (NAHD) and with arterial hypotension development (AHD) until a fetus was extracted. In each specific case, the used dose of a LA was compared with its dose calculated by the height of a patient and the difference between the BMI of a female patient and that taken as the normal value of 25 kg/m2. Results. When the doses of a LA, which were used for SA, were investigated, in all cases the doses of a LA were determined to be smaller than those calculated by the height of a patient. In the NAHD subgroups, the percentage reduction in LA doses was significantly greater than that in the AHD subgroups in all the three groups and the dose was increased as BMI rose from 13.6±1.6% in the NAHD subgroup in Group 1 to 34.7±1.2% in the same subgroup in Group 3. By comparing the percentage reduction in the LA dose and excess BMI, the authors established the correction coefficient for the LA dose calculated by height and derived a formula for calculating the dose of a LA, by taking into account the physical characteristics of a female patient. Conclusion. The LA dose calculation formula considering the individual physical characteristics of a female patient makes the determination of a LA dose more precise in order to optimize the course of anesthesia from the hemodynamic profile. Key words: spinal anesthesia, obesity, cesarean section.

Objective: to analyze the safety and clinical efficiency of early activation of patients operated on for coronary heart disease under extracorporeal circulation. Subjects and methods. The data available in the case histories of 673 patients aged 29—76 years, operated on in 1995, 2004, and 2006, were analyzed. The study excluded patients with severe intraoperative complications (acute myocardial infarction, a need for extracorporeal circulation, and surgical bleeding). Early activation was made on an operating table if there were no contraindications. Some sections of the study were performed in the matched patient groups. Results. With early activation, the dosages of fentanyl were reduced by 2.5-3 times as compared with the 1995 data; the use of ketamine and diazepam was stopped. Instead of the latter, the currently available inhalational agents are coming into use: midazolam has been introduced and the rate of propofol use has increased. The higher activation rate required the use of flumazenil, naloxone, and proserin. The goal-oriented study of central hemodynamics with emphasis on early activation has indicated that lower dosages of fentanyl have no negative impact on cardiac pump function or myocardial oxygen balance. When the trachea was extubated on the operating table, there was appropriate central hemodynamic stabilization. It was found that the incidence of postoperative myocardial infarctions did not depend on the rate of activation. The frequency of cardiovascular complications was 38.8±5.9% and 22.9±5.0% in the prolonged artificial ventilation (AV) and early activation groups, respectively (p<0.05); that of pulmonary complications was 16.4±4.5% and 5.7±2.8%, respectively (p<0.05). Early activation halved the length of stay at an intensive care unit (p<0.05) and reduced postoperative hospitalization at surgery units by 5 days (p< 0.05). Introduction of early activation caused a decrease in the duration of postoperative AV in the patients, inactivated in the operating-room, from 16±1 hours (in 1995) to 7±1.2 hours (in 2006). Conclusion. The results of the goal-oriented studies, as well as the analysis of an array of clinical data suggest that early activation after myocardial revascularization under extracorporeal circulation is a safe and clinically effective methodological approach to anesthetic and intensive care management in cardiac surgical patients with coronary heart disease. Key words: early activation, myocardial revascularization, operations under extracorporeal circulation, tracheal extubation in the operating-room.

During the Napoleonic wars, balloon evacuation of the wounded was the first to be made in the history when Paris was being defended. In the USA, casualty helicopters are being used in 20% of cases on evacuating the victims from the accident scene and in 80% during interhospital transportation. Russia also shows an ambiguous approach to employing air medical service — from the wide use of air transportation in the country’s regions that are difficult of access to its almost complete refusal in the regions with the well-developed transportation system. Long-distance transportation of critically ill patients by chartered or commercial planes is the reality of our time. In each region, continuing specialized teams of qualified medical workers who have a good knowledge of altitude pathophysiology and handle the obligatorily certified equipment should be created on the basis of large-scale medical centers.

Objective: to assess the time course of changes in the parameters of cerebral oxygenation and metabolism in the correction of intracranial hypertension with hyperosmolar solutions. Material and methods. 39 episodes of elevated intracranial pressure correction with 15% mannitol solution and HyperHAES solution were analyzed in 9 patients with intracranial hemorrhages. Changes in intracranial pressure and systemic hemodynamic, cerebral oxygenation, and metabolic parameters were studied. Results: A great difference was found in the effects of the test solutions on intracranial, cerebral perfusion pressure, and cerebral metabolism. Administration of 15% mannitol solution caused no cerebral metabolic changes. Infusion of HyperHAES solution induced a significant elevation in the concentrations of glucose and pyruvate in the interstitial fluid of both the arbitrarily intact and afflicted cerebral matter. Conclusion: The administration of 15% mannitol solution and HyperHAES solution is an effective method for correcting intracranial hypertension; however, the use of HyperHAES solution results in a more prolonged decrease in intracranial pressure, an increase in cerebral perfusion pressure, and an improvement of cerebral metabolism. Brain lesion due to intracranial hemorrhage may be accompanied by the development of mitochondrial dysfunction. Key words: intracranial hypertension, intracranial pressure, hyperosmolar solutions, tissue microdialysis.

Thyroid diseases are most common in endocrinology. Thyrotoxicosis induces dysfunction of virtually all organs and systems, the blood circulatory system being subjected to considerable changes. Cardiovascular diseases affect not only the quality of life in a patient, but significantly increase a risk from surgery that is the only radical treatment. For this reason, most authors consider thyrotoxicosis to be a contraindication to elective surgical intervention. At the same time it is known that drug compensation of thyrotoxicosis may be attained in not all patients. In this case, the results of treatment and a patient’s safety during surgery depend on the type and quality of anesthetic protection. The capabilities of anesthetic maintenance of thyroid surgery have recently expanded substantially. The paper deals with the preparation of patients with thyrotoxicosis for surgical intervention and the perioperative management of these patients. Key words: thyroid, toxic goiter, thyrotoxicosis, premedication, anesthetic mode, sevoflurane, xenon.

The paper reviews data on novel and combined maintenance/replacement therapies used to treat multiple organ failure/dysfunction, including those of septic origin. The basis of using these treatments is a new ideology of applying the earlier known and newly developed methods of efferent therapy that substantially improves the results of treatment in most seriously ill patients at intensive care units.

Analysis of the data available in the literature has made it possible to identify a range of the unsolved issues of theory and practice of cardiac contusion, which include no clear data on the prevalence of this pathology due to the use of various diagnostic standards; no rather specific lifetime diagnostic methods for cardiac contusion; no exact diagnostic criteria or contribution of cardiac lesions to the injury severity scale; no clarity in the understanding the nature of myocardial dysfunction that is responsible for cardiac events of heart contusion; difficulties in the diagnosis of the latter as a predictor of the development of complications and their prediction; no pathogenetically founded approaches to treating just cardiac lesions. Key words: cardiac contusion, epidemiology, clinical picture, diagnosis, complications, treatment, review of literature.

The paper describes the training system of anesthetists and resuscitators in Norway. The paper is based on the authors’ observations and review of the present references. The training of anesthetists and resuscitators in Norway is a long-term, rigidly controlled and well-planned process that comprises an university stage (6 years), internship (1.5 years), residency (5 years), authorization and licensing (up to 9 years). The authors believe that the training system of Russian anesthetists and resuscitators must be undoubtedly revised, by taking into account the European experience. Key words: professional training of anesthetists and resuscitators, postgraduate training of physicians.