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The purpose of this study--a comparative evaluation of the treatment of postoperative acute respiratory insufficiency in cardio surgical patients with lung opening maneuver and conventional mechanical ventilation. The study included 81 patients operated on the heart and magistral vessels in which the immediate postoperative period was complicated by the development of acute lung injury. Patients were divided into 2 groups: 1 (main) group (48 patients), on which the open lung technique was used, 2 (control) group (33 patients) who underwent a standard respiratory support. The initial values of the partial oxygen pressure in arterial blood and the oxygenation index in patients of both groups were significantly reduced, and the fraction of intrapulmonary shunting - significantly increased. Starting with 1 day sharp increase in PaO2 and IE in patients with the first group was noticed, which coincides with the beginning of the opening of the alveoli. At the same time, the dynamics of these indicators in the second group had the reverse tendency. After the recruiting maneuver in all patients significant improvements in the mechanics of breathing were noticed. As a result of the recruiting maneuver in the first group sustained improvement of arterial oxygenation was achieved in 35 patients. In patients with acute postoperative respiratory failure recruiting maneuver led to a significant increase in arterial oxygenation and reduce the fraction of intrapulmonary shunt. Application of "open lung" maneuver leads to the resolution of respiratory failure, which greatly reduces the timing of mechanical ventilation and length of stay of patients in intensive care units in comparison with traditional methods of respiratory therapy.

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A prospective randomized study was conducted to compare the antiarrhythmic activity of amiodarone and propafenone used to prevent atrial fibrillation (AF) after aortocoronary bypass surgery (ACBS). The study included 100 patients who had undergone myocardial revascularization. The patients were divided into 2 groups that did not significantly differ in their baseline condition, history data, the type of a surgical intervention, and the incidence of postoperative complications. Antiarrhythmic therapy was initiated within the first 24 hours after surgery. Group 1 (n=50) was given intravenous amiodarone in a dose of 6 mg/kg/day. Rhythm disturbances occurred in 13 (26%) patients. Group 2 (n=50) received oral propaferone in a dose of 6.6 mg/kg/day. AF occurred in 5 (10%) patients. The difference between Groups 1 and 2 was statistically significant (p = 0.047). The preventive use of propafenone recovered sinus rhythm in earlier periods (4602 +/- 71 min) than that of amiodarone (760 +/- 82 min); p = 0.049. Thus, propafenone was found to be a more effective drug used to prevent AF after ACBS, which is attributable to different pharmacodynamic behavior of the agents.

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OBJECTIVE: to evaluate the efficiency of pharmacological correction of a systemic inflammatory response in patients after coronary bypass surgery, by using mexidol. SUBJECTS AND METHODS: 40 patients with coronary heart disease, who had undergone myocardial revascularization were examined. A study group (n = 20) received mexidol within 5 days before, during, and 5 days after surgery. A control group (n = 20) were given 0.9% NaCl solution. The degree of a systemic inflammatory response was estimated from the levels of C-reactive protein (CRP), the cytokines IL-6, IL-8, and TNF-alpha. The activities of serum enzymes and myoglobin were determined. RESULTS: after surgery, both groups showed the elevated concentrations of IL-6, IL-8, TNF-alpha, and CRP, but their elevation was statistically significant less in the study group than in the control one (p < 0.05). In both groups, there were increases in the levels of alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, lactate dehydrogenase, creatinine phosphokinase, and myoglobin, which was statistically significant more apparent in the control group (p < 0.05). CONCLUSIONS: mexidol diminishes the magnitude of a systemic response after aortocoronary bypass surgery under extracorporeal circulation and has an organ-protective effect.

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The study deals with infusion therapies in children with thermal injury and with its impact of its qualitative composition at the local (tissue) and systemic levels. The investigations have indicated that the best qualities' in replenishing the volume of circulating blood and in eliminating hypovolemia are shown by hydroxyethylated starch (the study used voluvene) that offers advantages in the rate of correction of blood concentrations and in the maintenance of a volumic effects and that increases oxygen delivery, resulting in a rapider emergency from shock and improving the trophism of a burn wound.

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The possibility of performing the recruiting artificial ventilation technique with a high plateau and positive end-expiratory pressure was studied in 32 cardiosurgical patients, including those with cardiovascular insufficiency. The lung opening maneuver, by using the artificial ventilation adjustable by pressure and the monitoring peak pressure, PDKV, tidal volume, and dynamic compliance, by accurately determining the points of opening and closure is the method of choice in alveolar recruitment. This method permits a significant improvement of arterial oxygenation and dynamic compliance of the lung in patients with acute respiratory failure. This maneuver using the high airway pressures adversely affects hemodynamics particularly in patients with lowered reserves of the cardiovascular system. In this connection, a careful monitoring of hemodynamic parameters is required for the timely provision of cardiotonic and vasopressor support.

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Twenty patients aged 33 to 71 (54 +/- 6) years (male - 13, female - 7) operated on the heart and main vessels were included in the case study. I.e. those patient were investigated, whose immediate postoperative results were complicated by the syndrome of multiple organ failure (SMOF) that developed due to different-etiology shock, huge blood loss and hemotransfusion or to the syndrome of acute postperfusion lung damage. NIMLV was made at the resolution stage of SMOF and ARDS after artificial pulmonary ventilation (APL) for as long as 5-7 days. The indications for extubation of patients were as follows: PaO2/FiO2 of 200 and more mm Hg, respiratory rate (RR) of less than 30 per min, respiratory volume of more than 6 ml/kg with pressure support at inspiration of less than 5 cm H2O and with the total pressure at the exhalation end of no more than 3 cm H2O. Mask ventilation sessions were started in a growing dyspnea of more than 26 per min, a decreased content of oxyhemoglobin in arterial blood (below 95% at oxygen inhalation of 10-15 l/min), involvement of auxiliary muscles in breathing and at subjective complaints of patients related with complicated breathing and with being short of air. The mask SIMV ventilation with a preset apparatus-aided rate of inhales of 2-6/min, with Bi-PAP and PSV inhale pressure of 15 cm/ H2O and with PEEP of 3-5 cm/ H2O was made by 40-120 min sessions; the number of IFMLV sessions ranged from 6 to 22/patient, mean - 11 +/- 1.1 h. The total IFMLV duration was 10.7 +/- 1.1 h. The need for respiratory support persisted for 4-6 days after extubation. In 18 (90%) of 20 patients, the mask pulmonary ventilation resolved the respiratory insufficiency. Two (10%) patients were reintubated because of progressing multiorgan failure and because of obturation of the left main bronchus. A questioning of patients on the comfort degree of mask ventilation denoted the Flow-by triggering to be by far better tolerated by patients versus the pressure triggering.

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An efficiency and safety of continuous infusion of naropin in the epidural analgesia of 38 patients after coronary artery bypass grafting were demonstrated. A variation of combined anesthesia, which was elaborated at the Russian Research Center of Surgery of the Russian Academy of Medical Sciences and which comprises (as a basic component of anesthetic management) a high thoracal epidural block (T2-T4) by continuous infusion of a 2% solution of naropin at a velocity of 5 +/- 2 ml/h. Anesthesia was supported by isoflurane (0.5 +/- 0.9%). The patients were extubated in the operated theater and taken to the resuscitation unit with continuous infusion of 0.2% naropin solution. All studied parameters were registered after discharge from the operating theater and 1, 3, 6, and 16-18 hours after surgery. The pain-syndrome intensity was measured at the verbal scale with 0 to 3 points. The mean duration of continuous naropin infusion was 16.7 +/- 0.5 h, mean dose--2.2 +/- 0.2 ml/h. Naropin was administered at a dose of 1-3 ml/h in 89.7% of cases and at a dose of 6 ml/h only in 2.9% of cases. The drug, when used in small doses, ensured a high anesthetic efficiency. A total lack of pain or a mild pain of 0.1 points was observed in 86.5% of patients at stage 5 of examinations and in 100% of patients at stage 3. Naropin infusion did not entail any impairment in ventilation or gaseous metabolism. A reliable decrease of arterial pressure (AP) and of central venous pressure (CVP), (p < 0.05) were registered beginning from stage 2. CVP decrease versus stage 1 was ensured in 38.% of patients by stage 4 and the number of patients with a decreased CVP (less than 60 mm H) went up, versus stage 1, by 3 times. APsyst of less than 90-80 mm Hg was registered in 15 (39.8%) of patients at different examination stages, which necessitated the use of noradrenalin at mean dose of 174 +/- 21 ng/kg.min. The infusion of naropin at dose of 1-6 ml/h did not entail any impairment in the central nervous system (hallucinations, convulsions, and headache).

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The activity of a regional reanimation-and-consultation center (RCC) related with transportation of 3219 children (79.5% of them were newborns) is summarized in the paper. The share of children assigned for artificial lung ventilation (ALV) increased from 50.8% to 82.6%, while the lethality rate dropped from 12.8% to 6.9%. The above results were enabled by a maximally early re-hospitalization of patients from therapeutic-and-prevention facilities (TPF) with limited medical care abilities and by early preparations (for transportation) by using the DINAR-2 expert system. The children were transported only after the main vitally important systems had been compensated for and with support of an adequate intensive care therapy. Should the above principles be met, the specialized therapy could be started at he earliest possible time; it promoted the therapy quality and cut the patients' stay in intensive care units.

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An assessment of the key pathogenesis chains involved in triggering the vital complications was based on a prospective randomized controllable retrospective study of a burn-disease clinical course in 473 children. As a result of it, a standardized system was worked out, within a large industrial region, designed to render the medical care to children with severe thermal lesion; such system cut the therapy time by 12 days in the intensive care unit and by 2.6 time--in hospital; it also contributed to reducing the purulent-and-septic complications from 73.9% to 21% and the lethality rate--from 3% to 0.8%.

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Infectious complications after combustion represent the leading cause of lethal outcomes and attract an increasing attention of specialized services (anesthesiologists-resuscitators, combustiologists, infectionists, immunologists, clinical pharmacologists etc.). The increased incidence of the pyo-septic pathology in the whole world resulted first of all in the growing number of complications of burn disease in children. At the same time there appeared new pathological states which are thought to be outside the frame of traditional notions (e.g. the development of toxic shock syndrome). Many causes depending on the functional peculiarities of the children organism are responsible for the specific course of burn disease in children, the process itself having a number of peculiar features.

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Clinical observations show that intubation continuing as long as 7 days are followed by complications in 37% of cases at an average. A longer intubation results in complications twice more often. Placing tracheostoma is an alternative of prolonged intubation of the trachea. In spite of the wide introduction of this method into practice, it has both the supporters and active opponents. The indications, specific features and consequences of placing tracheostoma were studied in 69 children. The assessment of the efficiency of treatment of children in critical states with the method of placing tracheostoma is given.

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Basic principles of feeding of the patients (adult and children) with a serious thermal trauma, which cause considerable disturbances of a homeostasis of organism: hypermetabolic inverse of a metabolism, decrease of immune resistance, losses of water and electrolytes masses. Early use of quality and valuable nutrition for such patients (under observation was 56 patient--adult and children of different age) is a method of treatment reliably improving outcome of an intensive therapy reducing number of complications of a burn disease and contributing to the prompt convalescence of the patients.

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Visual perception is disordered in children aged 10-15 years subjected to surgery under ketamine and brietal anesthesia in an outpatient setting. Psychological testing was carried out during 24 h after intervention. Results of the Rorschach's test indicate that ketamine impairs the quality of visual perception (inadequate evaluation of the size, shape, velocity, etc.). Brietal disorders mainly the integrity of visual image. Visual perception did not normalize 24 h after both anesthesias. Disorders typical of each drug persisted.

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A model of regional network of pediatric resuscitation has been created in the Sverdlovsk region. The model is based on evaluation of hazards, is staged, standard, and makes use of a universal information space. The unifying structure is a pediatric resuscitation consultation center. Its main tasks are therapy and counseling in the region and introduction of overall training in reanimation and intensive care of children, with improvement of the level of urgent care at therapeutic institutions of the region. The activities of the resuscitation care network promoted a significant decrease in neonatal mortality by 29.5% and of infant mortality by 28.7%.

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Search for effective method for decreasing the mortality of children with severe thermal injuries and approaches to preventing and treating multiorgan dysfunction in severe thermal injury is a pressing problem of reanimatology. The majority of scientists consider disorders in the ventilation-perfusion function of the lungs the main factor in the pathogenesis of burn shock. Lung injury is most often the first manifestation of multiple organ dysfunction. The depth of disorders in the gas exchange function of the lungs clearly correlates with the severity of burn injury and the terms of the beginning of respiratory support. The severity of burn shock, preclinical diagnosis of acute respiratory distress syndrome and disseminated intravascular blood coagulation, depth of hemodynamic disorders and disorders in the oxygen transporting system can serve as a criterion of the compensatory stress and be an indication for active respiratory therapy. Comparison of the main and control groups demonstrated the efficiency of early respiratory therapy in children with severe burns, because such therapy normalizes the blood oxygen transporting function and hemodynamic parameters sooner and with less strain for the compensatory potential of the organism.

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Prone position ventilation (PPV) became an effective method of management of ARDS since 1974. Its positive effects on arterial oxygenation have been amply described, but its impact on the results of treatment and hospital mortality remains a disputable point. We observed 2 groups of patients, 36 pts. each, with ARDS after cardiovascular surgery. The main causes of ARDS were shock syndrome, massive blood loss and transfusion, previous COPD, and postcardiopulmonary bypass ALI. Because of impaired lung function (PaO2/FiO2 < 200), all patients were supported by special methods of ventilation including PEEP, high FiO2, and PCV with inverse I:E ratio. In the main group, PPV was started on days 3.6 +/- 1.2 postoperation. Daily duration of PPV was 4-12 h, after which the patients were turned into a supine position. Controls were treated in a supine position. The groups were identical by age, sex, types of surgery, severity of ARF, and manifestations of MOSF. PPV improved lung function and arterial oxygenation. Clinical outcomes were better in the PPV group than in the controls: a lower frequency of threatening arrhythmia, better results of MOSF treatment, and lower mortality (69 and 33.4%, respectively). Prone position is an effective measure improving arterial oxygenation in patients with ARDS after cardiovascular surgery. The main results of PPV are decrease in complications induced by hypoxia and higher survival rate.

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Effect of ventilation in the face-down position (VFDP) on the oxygenation function of the lungs and hemodynamics is studied in 32 patients (aged 22-64 years) subjected to open-heart surgery complicated by development of acute respiratory failure (RF). In 23 patients with grave respiratory distress syndrome, VFDP was performed with forced ventilation of the lungs (FVL) and in 9 with less grave RF, with noninvasive mask ventilation of the lung (NIMVL). Body position of patients on FVL was changed every 4-12 h, of nonintubated patients, 45-60 min. The oxygenation function of the lungs improved in the intubated patients as early as during the first hour of FVL in the face-down position: PaO2/FiO2 notably increased and a tendency to decrease of A-aDO2 and Qs/Qt was observed. The positive effect was maximal after at least 4-hour FVP in the face-down position: PaO2/FiO2 increased by 76.6%, intrapulmonary shunting fraction decreased by 43%, and the O2 alveolar-arterial difference decreased by 27% in comparison with the initial values. After body position of patients was changed, the above improvements did not disappear, despite a slight decrease of the effect attained. VFDP with NIMVL led to similar results: O2 alveolar-arterial gradient decreased, PaO2/FiO2 decreased by 24.2%, the mean values of this ratio approaching the norm. Positive effect somewhat decreased after catecholamines were discontinued, but the oxygenation function of the lungs remained better than initially.

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The severity of acute respiratory failure (ARF) in patients with purulent meningitis (PM) depends on the severity of consciousness disorders. ARF is most expressed in comatose patients, whereas in PM involving no consciousness disorders there were no changes of the gaseous composition of the blood or acid-base status. After forced ventilation of the lungs is started, gaseous composition of the blood normalizes. Timely active respiratory care decreased by half the mortality in this patient population, this indicating that such patients are to be treated in intensive care wards for timely correction of disordered vital functions.

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The authors analyze the respiratory complications in patients with acute respiratory failure (ARF) developing as a result of poisoning with organophosphorous (OPC). Twenty-two percent of 470 patients had to be maintained on forced ventilation because of ARF. The indications for forced ventilation of the lungs are as follows: paralysis of respiratory muscles, 90% drop of vital capacity of the lungs, and disorders of the gaseous composition of the blood (PaCO2 over 56 +/- 3 mm Hg and PaO2 below 67 +/- 5 mm Hg). The incidence of respiratory complications among patients on forced ventilation was as high as 92%, which is due to the pathogenesis of the chemical disease developing after OPC poisoning. The complications are the most incident among men aged 30 to 60. The respiratory distress syndrome of adults ranks first among the respiratory complications. It was diagnosed in 70.6% of dead subjects in 34.4% of convalescents. This syndrome is one main cause of high mortality, particularly so in subjects dying in three or more days of intensive care. The duration of forced ventilation of the lungs does not depend on the time when the patient was transferred on ventilation or on the poison. Analysis of mortality indicates that it is lower among patients administered forced ventilation at the prehospital stage.

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