[Optimization of anesthetic maintenance using two-channel laryngeal masks Proseal during endovascular correction of congenital defects in infants and young children].

The paper analyzes the efficiency of the authors' procedure for anesthetic maintenance based on a combination of inhalational (sevoflurane) and intravenous (1% propofol) anesthesia on spontaneous breathing through a ProSeal laryngeal mask airway in the X-ray endovascular correction of congenital heart diseases in infants and young children. The study included 118 children aged 2 to 7 years with secondary atrial septal defect, who had undergone endovascular defect correction, by applying an Amplazer septal occluder. The key points of the anesthetic maintenance proposed by the authors are: (1) substitution of routine pharmacological premedication for psychological (the presence of parents); (2) inhalational (sevoflurane) anesthesia in the induction of anesthesia; (3) replacement of an endotracheal tube by a ProSeal laryngeal mask; (4) refusal of myorelaxants and respiratory support without artificial ventilation. The authors' anesthesia protocol during these operations provides a safe perioperative period.

[Use of sevoflurane during cardiosurgical and endovascular operations in children].

The good tolerability of sevoflurane, the mild and prompt onset of a hypnotic state, the absence of airway irritation, and the safe use of the agent make the anesthetic of choice for introductory anesthesia in pediatric cardiosurgery. The purpose of the study was to develop and assess the procedure of sevoflurane anesthesia during cardiosurgical and endovascular operations in children with congenital heart diseases. Twenty-five children aged 2-9 years (of them 15 children with congenital heart disease) operated on under extracorporeal circulation (EC) were examined. Ten children underwent X-ray surgical endovascular interventions: closure of the patent arterial duct with an "Amplatzer ductus occluder" system. The duration of operations under EC was 116 to 289 min; that of EC was 60-20 (49 +/- 8) min. Endovascular operations lasted 60-80 min. Premedication was made with ketamine, midazolam, and methacin during cardiosurgical operations. The children were referred without premedication, escorted by their parents for endovascular surgical interventions where in the parents' presence the children were given inhalational sevoflurane at a concentration of 5-6% through the mask of an anesthetic apparatus until they fell asleep. This made it possible to avoid the child's weeping and resistance and to puncture the peripheral vein without pain. Steady-state hemodynamics and metabolism suggest that combined anesthesia using sevoflurane at a concentration of 1.3-22% of the minimal alveolar one is adequate in correcting congenital heart disease in children. The application of this anesthetic procedure permitted extubation of 73% of children within 1-2 hours when their condition met the criteria for early activation and extubation.

[Implementation of modern principles of blood saving methods at cardiac surgery under extracorporeal circulation]. / Realizatsiia sovremennykh printsipov beskrovnoi khirurgii pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

The introduction of principles of bloodless surgery into different areas of practical medicine is favoured by not only risks from donor blood transfusion, but also by the results of the researches dealing with the body's adaptation to acute anemia, with the determination of its allowable limits, and with much experience with bloodless operations used in Jehovah's Witnesses. The present study was undertaken to make a scientific-and-practical assessment of actual own blood funds and their introduction in order to decrease or refuse to use donor blood at cardiac surgery under extracorporeal circulation (EC). A retrospective analysis of hemotransfusion policy in 1993-2001 was conducted in over 2000 patients operated on under EC for coronary heart disease, acquired and congenital cardiac diseases at the Open Cardiac Surgery Department, Russian Surgery Research Center, Russian Academy of Medical Sciences. Own blood saving methods, such as intraoperative autohemotransfusion as two modalities, washed autoerythrocytic reinfusion, autoplasma reinfusion, as well as the use of different pharmaceuticals effective in reducing hemorrhage after EC were evaluated. The introduction of the above own blood saving methods may decrease the use of donor erythrocytes and freshly frozen plasma by 2.6 and 1.8 times, respectively, may completely refuse transfusing thromboplasma, assure adequate hemostasis, reduce the incidence of adverse reactions associated with donor blood transfusion in cardiac surgical patients. A complex use of the developed saving donor blood methods and pharmaceuticals aimed at improving hemostasis allowed donor blood transfusion to be completely refused in more than 70% of patients at aortocoronary bypass surgery under EC.

[Cerebral oximetry during cardiac surgery under extracorporeal circulation]. / Opyt ispol'zovaniia tserebral'noi oksimetrii pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

The time course of changes in rSO2 were studied in 58 patients during the uncomplicated course of cardiac operations under extracorporeal circulation (EC) and moderate hypothermia. rSO2 was also compared with central hemodynamic parameters, bioelectrical cerebral activity, and hemoglobin oxygen saturation of the bulb of the internal jugular vein (jbSO2). In the pre- and postperfusion period there was a significant correlation of rSO2 and jbSO2 (p = 0.01), yet with a low correlation coefficient (r = 0.348). During EC, no correlation was found between rSO2 and jbSO2 (p = 0.09, r = 0.386). Changes in rSO2, blood pressure, EEC, body temperature were analyzed in 2 groups of patients at the stages of an operation under EC. Group 1 comprised patients with cardiac valvular apparatus lesions and Group 2 included those with coronary heart disease who differed not only in age, but also in the history of mainly cerebrovascular atherosclerotic lesions, hypertensive disease, myocardial infarction, etc. In patients from both groups, a reduction in rSO2 occurred at the beginning of EC and at the maximum of cooling. But if in Group 1 patients, the significant reductions in rSO2 at the beginning of EC coincided both with that in mean blood pressure (BPmean), as compared to the baseline values (from 75.55 +/- 10.68 to 66.5 +/- 11.73 mm Hg, p = 0.01), and with the change in the frequency spectrum of EEC (a decrease in the frequency of the right edge, as compared to the baseline values, from 20.77 +/- 1.44 to 19.58 +/- 1.14 Hz, p = 0.01), in Group 2 patients, all significant decreases in rSO2 were accompanied only by a significant reduction in BPmean, but without changes in the frequency spectrum of EEG. It should be noted that over the uncomplicated course of an operation all changes in rSO2 were in the normal range of age-related values.

[Epidemiology and prevention of anaphylactoid reactions in heart surgery patients]. / Epidemiologiia i profilaktika anafilaktoidnykh reaktsii u kardiokhirurgicheskikh bol'nykh.

A retrospective analysis of the incidence, severity, and causes of anaphylactoid reactions (AR) in 1504 cardiosurgical patients operated on at Research Center of Surgery in 1995-1999 showed that AR occurred in 109 (7.4%) patients: 60% during aortocoronary bypass operations, 27.2% during correction of acquired heart diseases, and 12.8% during correction of congenital heart diseases. Skin symptoms predominated in the structure of AR (59.7%); cardiovascular episodes ranked second (38.5%), and the incidence of pulmonary reactions was lowest (1.8%). The causes of AR during anesthesia and surgery were platelet-rich plasma and fresh-frozen plasma (35.3%), antibiotics (12.1%), protamine (12.1%), myorelaxants (9.9%), colloid plasma substitutes (8.8%), dioxidine (3.3%), heparin (2.2%), aprotinin (1.1%), diazepam (2.2%), and other agents (7.6%). A history of AR and repeated interventions are risk factors of AR. The protocol of AR prevention in cardiosurgical patients includes determination of risk factors, selection of the least hazardous agents, strict adherence to the rate of infusion of histamine-releasing drugs, minimum utilization of donor blood components (platelets and plasma), use of H1 and H2 blockers, corticosteroids (celestone) during premedication and operation. Such treatment helped decrease the severity and incidence of AR in cardiosurgical patients to 4.7%.

[The anesthesiological support of liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

The choice of anesthesia for a high risk operation, orthotopic transplantation of the liver (OTL), is discussed. The authors propose a protocol of anesthesia for OTL. For induction anesthesia, intravenous drugs should be preferred; the liver-free stage of the operation is carried out under anesthesia with a closed isoflurane contour, and the initial metabolic disorders of patients are corrected. When the bloodflow is let in the transplanted organ, intravenous drugs (ketamine, phentanyl, and benzodiazepines) should be administered in order to reduce the vasodilating effect of isoflurane and vasopressors for preventing relative hypovolemia. At the final stage of anesthesia, isoflurane is used. Before transporting the patient into intensive care ward, phentanyl in a dose of 1.5-3 micrograms/kg was injected, because of rapid elimination of isoflurane and awakening of the patient. This protocol maintained the hemodynamics and the major metabolic parameters at the optimal level.

[Use of corticosteroids betamethasone and prednisolone in the prevention of allergic reactions in patients undergoing heart surgery with artificial blood circulation]. / Primenenie kortikosteroidov--betametazona i prednizolona dlia profilaktiki allergicheskikh reaktsii u kardiokhirurgicheskikh bol'nykh pri operatsiiakh s iskusstvennym krovoobrashcheniem.

The authors discuss measures preventing intraoperative allergic reactions in patients subjected to cardiopulmonary bypass surgery. A retrospective analysis of the incidence of allergic reactions in 1330 patients operated on the heart showed that cardiosurgical patients are liable to anaphylaxis because of intraoperative administrations of numerous drugs (besides anesthetics), specifically, antibiotics, protamine, etc., blood components, solutions. Comparison of the incidence of anaphylactic and anaphylactoid reactions allowed the authors to recommend corticosteroids to be added to anesthesiological protocols with prophylactic purpose. A new corticosteroid betamethasone is more effective than traditional prednisolone in equivalent doses as regards prevention and alleviation of allergic reactions in cardiosurgical patients.

[Treatment of phlegmonous and necrotic forms of erysipelas]. / Lechenie flegmonoznoi i nekroticheskoi form rozhi.

Clinical observations, bacteriological examinations in 220 patients operated upon for phlegmonous and necrotic erysipelas and investigation of the immunological background (in 48 of them) have shown that phlegmono-necrotic erysipelas develops due to the displacement of streptococci from the inflammatory center of the secondary infection against the background of the venous and lymphostasis with reduced local immunity.