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ФИБРИЛЛЯЦИЯ ПРЕДСЕРДИЙ ПОСЛЕ КАРДИОХИРУРГИЧЕСКИХ ОПЕРАЦИЙ: ПАТОФИЗИОЛОГИЯ И МЕТОДЫ ПРОФИЛАКТИКИ
Get PDFAtrial fibrillation is one of the most frequent complications occurring after cardiac surgery. Post-operative atrial fibrillation confidently increases the risk of mortality and associated complications. Pathogenesis of this disorder is frequently based on combination of several promoting factors. A major number of studies has been performed among cardiac surgery patients in order to search for effective drug therapy or other surgical techniques aimed at post-operative atrial fibrillation prevention. At present none of the suggested prevention treatment can assure secure protection from post-operative atrial fibrillations and associated complications. Therefore new studies are needed aimed at the detail investigation of pathophysiology of this disorder and development of effective prevention and treatment methods. Фибрилляция предсердий является одним из наиболее частых осложнений, встречающихся после кардиохирургических вмешательств. Послеоперационная фибрилляция предсердий достоверно увеличивает риск развития летального исхода и ассоциированных осложнений. Патогенез развития данного заболевания зачастую обусловлен сочетанием нескольких провоцирующих факторов. В ходе поиска эффективной лекарственной терапии или других хирургических методов для профилактики послеоперационной фибрилляции предсердий проведено большое количество исследований среди пациентов кардиохирургического профиля. В настоящее время ни одна из предложенных схем профилактической терапии не гарантирует надежной защиты пациента от развития послеоперационной фибрилляции предсердий и ассоциированных осложнений. Поэтому весьма актуальным представляется проведение новых исследований, направленных на детальное изучение патофизиологии данного заболевания, и разработки эффективных способов профилактики и лечения.
ДИАГНОСТИКА БЕССИМПТОМНОЙ ИШЕМИЧЕСКОЙ БОЛЕЗНИ СЕРДЦА У БОЛЬНЫХ, КОТОРЫМ ПРЕДСТОЯТ РЕКОНСТРУКТИВНЫЕ ОПЕРАЦИИ НА АОРТЕ И МАГИСТРАЛЬНЫХ АРТЕРИЯХ НИЖНИХ КОНЕЧНОСТЕЙ
Get PDFGoal of the study: working out procedure aimed at the diagnostics of painless myocardial ischemia in the patients expecting surgery on aorta and main arteries of lower limbs. Materials and methods. 72 patients with disorders of aorta and main arteries of lower limbs were enrolled into the study. Depending on factors of risk to develop cardiac vascular disorders as per Lee score they were divided into two groups. Group 1 (n = 38) included patients who had 2 and more risk factors in the pre-operative period, Group 2 included patients (n = 34) who had less than 2 risk factors. All of the patients had holter monitoring, stress echocardiography and coronary arteriography during pre-operative period. Results. The study showed the high efficiency of Lee score of cardiac-vascular complication risks. The patients who had 2 risk factors and more had hemodynamically significant lesions of coronary bed in 97.4% which was detected by coronary arteriography. In Group 2 painless myocardial ischemia was detected almost in 1/3 of patients, which later provided certain impact in the choice of surgical treatment strategy. Conclusions. The results proved low efficiency of holter monitoring in the patients suffering from multi-focal atherosclerosis and high efficiency of stress echocardiography. The latter should be mandatory included into the examination procedure of such patients regardless of the results of Lee score; and coronary arteriography is to be performed in case of 2 risk scores and more. Detection of painless myocardial ischemia can change the plan of surgical treatment and requires amending anesthesia tactics.
ПОЛОЖИТЕЛЬНОЕ ВЛИЯНИЕ ИНФУЗИИ ЛЕВОСИМЕНДАНА ПОЖИЛЫМ ПАЦИЕНТАМ (60–75 ЛЕТ) СО СНИЖЕННОЙ ФРАКЦИЕЙ ИЗГНАНИЯ ЛЕВОГО ЖЕЛУДОЧКА (< 50%) НА ТЕЧЕНИЕ ПЕРИОПЕРАЦИОННОГО ПЕРИОДА В НЕКАРДИАЛЬНОЙ ХИРУРГИИ
Get PDFPre-surgery infusion with levosimendan with the rate of 0.05–0.1 mkg*kg-1 min-1 to the elder patients (60–75 years old) with lower ejection fraction of the left ventricle (less than 50%) results in its increase by 16.7% (p < 0.01), cardiac index – by 10.3% (p >< 0.01) and reduction of NT-proBNP level in blood by 24.1% (p >< 0.1) in 24 hours after the medication infusion start. The changes persist for at least 24 hours after the surgery. Key words: levosimendan, cardiac failure, peri-operative period, pre-surgery preparation, cardiac surgery, reduction of NT-proBNP level.>< 0.01), cardiac index – by 10.3% (p< 0.01) and reduction of NT-proBNP level in blood by 24.1% (p < 0.1) in 24 hours after the medication infusion start. The changes persist for at least 24 hours after the surgery. Key words: levosimendan, cardiac failure, peri-operative period, pre-surgery preparation, cardiac surgery, reduction of NT-proBNP level.>< 0.1) in 24 hours after the medication infusion start. The changes persist for at least 24 hours after the surgery. Предоперационная инфузия левосимендана со скоростью 0,05–0,1 мкг ∙ кг-1 ∙ мин-1 пожилым пациентам (60–75 лет) с низкой фракцией изгнания левого желудочка (менее 50%) приводит к ее увеличению на 16,7% (p< 0,01), сердечного индекса – на 10,3% (p < 0,01) и снижению содержания в крови NT-proBNP на 24,1% (p>< 0,01) через 24 ч после начала инфузии препарата. Изменения сохраняются как минимум 24 ч после операции.
СРАВНИТЕЛЬНАЯ ОЦЕНКА БОЛИ И КАЧЕСТВА ЖИЗНИ У ПАЦИЕНТОВ ПОСЛЕ ОТКРЫТОЙ И ВИДЕОАССИСТИРОВАННОЙ ЛОБЭКТОМИИ ПО ПОВОДУ РАКА ЛЕГКОГО
Get PDFThe pain and pain syndrome remain to be serious problems of clinical medicine and surgery as one of its aspects. The positive correlation was found out between the type of surgery and post-operative pain in abdominal, thoracic and orthopedic surgeries. Materials and methods. Results of a questionnaire survey in 130 patients were analyzed; from 2015 to 2017 all those patients had lobectomies for lung cancer using video-assisted thoracoscopic or open accesses in the Thoracic Department of Petrov National Medical Research Center of Oncology. The intensity of pain and life quality in the post-operative period were assessed using visual analogue scales, the Wong-Baker FACES pain rating scale, verbal rating scales, and McGill pain questionnaire. In order to assess life quality, the non-specific questionnaire of SF-36 was used in the cancer patients and those enrolled in the clinical studies of EORTC QLQ-C30 including the special module of QLQ-LC13 for lung cancer patients. The obtained results were analyzed and it was found out that intensity of pain was statistically significantly lower in video-assisted thoracoscopic access versus thoracotomy (U = 678.00; p < 0.05). When using the questionnaires of SF-36 (U = 8,742.50; p < 0.05) and EORTC QLQ-C30 (U = 3,759.00; p < 0.05) and the special module of QLQ-LC13 for lung cancer (U = 4,243.00; p < 0.05), the obtained data also indicated the better life quality and functions, reduction of pathologic manifestations versus open surgical access. Conclusion: Reduction in the pain intensity and higher life quality were typical of surgeries with use of video-assisted thoracoscopic technologies versus classical open access.
ИНВАЗИВНЫЙ МОНИТОРИНГ СЕРДЕЧНОГО ВЫБРОСА ПО ВРЕМЕНИ ТРАНЗИТА ПУЛЬСОВОЙ ВОЛНЫ ПОСЛЕ АОРТОКОРОНАРНОГО ШУНТИРОВАНИЯ НА РАБОТАЮЩЕМ СЕРДЦЕ
Get PDFGoal of the study: to evaluate the accuracy of invasive measurement of cardiac output (CO) by pulse wave transit time (PWTT) (esCCO, Japan) compared to transpulmonary thermodilution (TPTD) (PiCCO2 , Germany) after aortocoronary bypass (ACB) without cardiopulmonary bypass (ACB without CPB). Methods. 21 patients with ACB without CPB were enrolled into the study. During early post-operative period CO was simultaneously registered at eight stages basing on PWTT (COPWTT) and TPTD (COTPTD). Statistic analysis included evaluation of congruence of CO absolute values and capability to follow-up changes in CO. Results. In accordance with Bland-Altman analysis the average difference between two methods made 0.3 l/min. with consistency limits of ± 2.1 l/min. and percent error of 40%. Polar chart analysis showed the angular difference of 2.6°, radial consistency limits ± 53.3° and polar concordance of 69%. Conclusion: Lower repeatability of CO measurement by PWTT and insufficient capability to follow the changes in CO after ACB without CPB don not allow recommending this method in its invasive variant for routine practice as an alternative to thermodilution methods.
ИСПОЛЬЗОВАНИЕ ШКАЛЫ qSOFA В ПРОГНОЗЕ ИСХОДА У ПАЦИЕНТОВ С СЕПСИСОМ В ОРИТ (результаты российского многоцентрового исследования РИСЭС)
Get PDFThe objective of the study: to define the informative value of qSOFA score in the prediction of sepsis outcomes in the patients admitted to the intensive care wards of medical units in the Russian Federation.Subjects and methods. The multi-center, prospective, and observational trial was conducted. The following data were analyzed in the patients admitted to intensive care wards: number of qSOFA and SOFA scores, the presence of SIRS criteria, levels of lactate, and the outcome of the admission to the intensive care wards. The informative value of different scores and lactate level was analyzed using ROC-analysis.Results. The following areas under ROC-curves were defined for prediction of a lethal outcome in the patients with sepsis: qSOFA – 0.644 (95% CI 0.593–0.693); SOFA – 0.731 (95% CI 0.683–0.776); SIRS – 0.508 (95% CI 0.456–0.560); [qSOFA + lactate ≥ 4 mmol/L] – 0.713 (95% CI 0.646–0.774).Conclusion. To predict a lethal outcome in the patients with sepsis admitted to intensive care wards, qSOFA surpasses SIRS criteria, but it is not as good as SOFA score. The informative value of the prediction model [qSOFA+lactate ≥ 4 mmol/L] surpasses qSOFA score in the prediction of the outcome in sepsis patients, and it is as good as SOFA score.Цель исследования: определить информационную ценность шкалы qSOFA в прогнозе летального исхода у пациентов с сепсисом, госпитализированных в отделения реанимации и интенсивной терапии (ОРИТ) лечебных учреждений Российской Федерации.Материалы и методы. Многоцентровое, проспективное, обсервационное исследование. Проанализирована следующая информация о пациентах с сепсисом при поступлении в ОРИТ: количество баллов по шкалам qSOFA и SOFA, наличие критериев SIRS, уровень лактата крови, а также исход госпитализации при оказании помощи в ОРИТ. Проведен ROC-анализ информационной значимости различных шкал и уровня лактата крови.Результаты. В прогнозе летального исхода пациентов с сепсисом определены следующие площади под ROC-кривыми: qSOFA – 0,644 (95%-ный ДИ 0,593–0,693); SOFA – 0,731 (95%-ный ДИ 0,683–0,776); SIRS – 0,508 (95%-ный ДИ 0,456–0,560); [qSOFA + лактат ≥ 4 ммоль/л] – 0,713 (95%-ный ДИ 0,646–0,774).Заключение. В прогнозе летального исхода у пациентов с сепсисом при поступлении в ОРИТ шкала qSOFA превосходит критерии SIRS, но уступает шкале SOFA. Информационная ценность прогностической модели [qSOFA + лактат ≥ 4 ммоль/л] превосходит шкалу qSOFA в прогнозе исхода у пациентов с сепсисом и не уступает шкале SOFA
ВОЗМОЖНОСТИ МОНИТОРИНГА РАЗЛИЧНЫХ ВИДОВ НЕЙРОМЫШЕЧНОГО БЛОКА
Get PDFGoal of the review: to build up the current understanding of electrophysiological specific features of various neuromuscular blockades. Having analyzed the results of multiple studies devoted to investigation of the impact of various medications including inhalation anesthetics on the neuromuscular neurility, the authors summarized the current opportunities to monitor neuromuscular blockade. It has been noted that the data for blockade monitoring when using traditional neuromuscular blocking agents are studied much better compared to the drugs providing the other types of blockade. Цель обзора: сформировать современное представление об электрофизиологических особенностях различных видов нейромышечного блока. Проанализировав результаты многочисленных исследований, посвященных изучению влияния различных лекарственных средств, в том числе ингаляционных анестетиков, на нейромышечную проводимость, авторы систематизировали современные возможности мониторинга нейромышечного блока. Отмечено, что данные мониторинга блока при применении традиционных миорелаксантов изучены намного лучше, чем для препаратов, вызывающих другие виды блока.
ИСПОЛЬЗОВАНИЕ ШКАЛЫ QSOFA В ДИАГНОСТИКЕ СЕПСИСА. РЕЗУЛЬТАТЫ РОССИЙСКОГО МНОГОЦЕНТРОВОГО ИССЛЕДОВАНИЯ РИСЭС
Get PDFSubjects and methods. The multi-center, prospective, and observational trial was conducted. The following data were analyzed in the patients admitted to intensive care wards: number of qSOFAscores, the presence of SIRS criteria, levels of lactate, procalcitonin, C-reactive protein in blood, the presence of sepsis according to Sepsis-3 criteria. The value of qSOFA scores, SIRS criteria, and biomarkers for sepsis diagnostics was assessed by means of ROC-analysis.Results. The following areas under ROC-curves were defined during diagnostics of sepsis in the patients in intensive care wards: qSOFA – 0.679 (95%CI 0.646–0.712); SIRS – 0.714 (95% CI0.682–0.745), p = 0.099; when qSOFA exceeding 1 score: procalcitonin – 0.788 (95% CI 0.689–0.867), C-reactive protein – 0.787 (95% CI 0.688–0.866), p = 0.970.Conclusion. qSOFA score is compatible with SIRS criteria for diagnostics of sepsis among the patients in intensive care wards. qSOFA score is highly sensitive, but it is of low specificity for sepsis diagnostics. Should there be at least 1 score of qSOFA, it is recommended to test levels of procalcitonin or C-reactive protein in order to increase the specificity of this score for diagnostics of sepsis.Цель исследования: определить информационную ценность шкалы qSOFA в диагностике сепсиса у пациентов, госпитализированных в отделения реанимации и интенсивной терапии (ОРИТ) лечебных учреждений Российской Федерации.Материалы и методы. Многоцентровое, проспективное, обсервационное исследование. Проанализирована следующая информация о пациентах при поступлении в ОРИТ: количество баллов по шкале qSOFA, наличие критериев SIRS, уровень лактата, прокальцитонина, С-реактивного белка крови, наличие сепсиса согласно критериям «Сепсис-3». Проведен ROC-анализ информационной значимости шкалы qSOFA, критериев SIRS, биомаркеров в диагностике сепсиса.Результаты. В диагностике сепсиса у пациентов ОРИТ определены следующие площади под ROC-кривыми: qSOFA – 0,679 (95%-ный ДИ 0,646–0,712); SIRS – 0,714 (95%-ный ДИ0,682–0,745), p = 0,099; при qSOFA не менее 1 балла: прокальцитонин – 0,788 (95%-ный ДИ 0,689–0,867), С-реактивный белок – 0,787 (95%-ный ДИ 0,688–0,866), p = 0,970.Заключение. В популяции пациентов ОРИТ в диагностике сепсиса шкала qSOFA сравнима с критериями SIRS. Шкала qSOFA имеет высокую чувствительность, но низкую специфичность в диагностике сепсиса. При наличии по крайней мере 1 балла по шкале qSOFA целесообразно выполнить измерение уровня прокальцитонина или С-реактивного белка крови для повышения специфичности шкалы в диагностике сепсиса
АНЕСТЕЗИОЛОГИЧЕСКИЕ АСПЕКТЫ ПРОТОКОЛА УСКОРЕННОЙ РЕАБИЛИТАЦИИ В ХИРУРГИИ БРЮШНОГО ОТДЕЛА АОРТЫ
Get PDFОПЫТ ИСПОЛЬЗОВАНИЯ ДЕКСМЕДЕТОМИДИНА ДЛЯ ПРОВЕДЕНИЯ МЕДИКАМЕНТОЗНОЙ СЕДАЦИИ ПРИ ВНУТРИПРОСВЕТНЫХ ЭНДОСКОПИЧЕСКИХ ВМЕШАТЕЛЬСТВАХ
Get PDFGoal of the study: to evaluate the possibility of using dexmedetomidine for drug sedation when performing intraluminal endoscopic surgery (ILES). Materials and methods. 136 cases of dexmedetomidine used were analyzed in 100 patients at the age of 58.0 ± 1.5 years old (Me = 59, Min = 22, Max = 87) during the first and repeated video-assisted bronchoscopies, esophagogastroscopies, duodenoscopies and colonoscopies lasting for 73 ± 3 min. (Me = 65, Min = 15, Max = 330). Results. Sole use of dexmedetomidine was effective only in short-term ILES causing minimal trauma. If ILES lasts longer and causes bigger trauma dexmedetomidine is to be combined with nefopam, fentanyl, trimeperidin, propofol, and ketamine. Combined use of dexmedetomidine resulted in the reduction of doses of the drugs, provided opportunity to manage the depth of sedation without depression of spontaneous respiration, post-operative and post-procedure agitation, algidity, nausea and vomit. Conclusion. Dexmedetomidine can be considered as the drug of choice for sedation in ILES.