[MITOCHONDRIA-TARGETED ANTIOXIDANTS IN THE PREVENTION OF THE CORNEA EROSION WHEN PERFORMING SURGERY UNDER GENERAL ANESTHESIA.]

Despite the use of modern methods of prevention, at least 10% of patients operated on for ophthalmic indications not develop corneal erosion as the indirect complication of general anesthesia. OBJECTIVE: To reduce the number of ophthalmic complications of general anesthesia by prophylactic use of new mito- chondria-targeted antioxidants - Vizomitin (eye drops). MATERIALS AND METHODS: 70 patients, which was supposed to perform the average duration of operations under general anesthesia were randomized into 3 groups depending on the method specific (pharmacological) prevention of corneal erosions: (1) control (specic (pharmacological) prevention was not carried out), (2), using preparation "natural tear, and (3) "Vizomitin" preparation. Postoperative biomicroscopy was performed to assess the condition of the cornea, tear film stability was measured and the height of the tear meniscus. RESULTS: When using eye drops "Vizomitin" value is an indicator of stability of the tear film on the 3rd day after the operation more than in the control group of patients by 51% (p = 0.012) and patients groups, natural tear by 57% (p = 0.013). Surgical interventions performed under general anesthesia, leading to an increase in the number ofpatients with decreased tear meniscus height index of the control group with 4 to 7 patients (p = 0.30) in the group of natural tear from 3 to 11 patients (p = 0.008) . In the group with drug "Vizomitin" the number of such patients is reduced from 7 to 1 (p = 0.018). CONCLUSION: In the surgical procedures under general anesthesia eye drops "Vizomitin" effectively prevents the devel- opment of corneal erosion.

[INTENSIVE THERAPY OF THE PATIENT WITH VIRAL-BACTERIAL PNEUMONIA, PROLONGED VENTILATION (137 DAYS) AND TRACHEOESOPHAGEAL FISTULA].

A case of successful therapy of the patient with viral and bacterial pneumonia, prolonged ventilation (137 days) and tracheoesophagealfistula presented. The possibility of optimizing the gas exchange in the lungs by selecting appropriate modes of mechanical ventilation with the use ofproportional assist ventilation of the lungs (PVVL or PAV +), rather than suppressing patient's own attempts is shown.

[PERIOPERATIVE MANAGEMENT OF PATIENTS WITH DIABETES MELLITUS.]

The article is devoted to the existence of the problem of intraoperative provide patients with concomitant diabetes mellitus: a disease is not diagnosed in time, it increases the probability of death in the performance of surgery by 50%, where as the timely prevention and preparation reduces the chance of developing specific complications to the level of patients with the general population. The paper discusses the recommendations developed by the British Association ofEndocrinologists 2011 and Russia in 2015, as well as the Association ofAnaesthetists of Great Britain and Ireland (2015), provides practical recommendations for the preoperative preparation, anesthetic and resuscitation provide patients with concomitant diabetes mellitus.

PREVENTION OF HEART FAILURE PATIENTS WITH DECREASED EJECTION FRACTION IN NON-CARDIAC SURGERY: LEVOSIMENDAN OR ANESTHETIC CARDIOPROTECTION?.

BACKGROUND: Chronic heart failure (CHF) significantly worsens the prognosis of surgical treatment in noncardiac surgery, doubling mortality in compared with patients with coronary artery disease. Modern anesthesiology has at least two methods that potentially can improve the results in noncardiac surgery: anesthetic cardioprotection and the prevention of CHF decompensation with levosimendan. THE AIM: to study the efficacy of anesthetic cardioprotection andpreoperative preparation with levosimendan for the prevention of CHF decompensation in patients with reduced left ventricular ejectionfraction in noncardiac surgery. ENDPOINTS: the primary endpoint of the trial is the need and the maximum dose of inotropic drugs in the perioperative period; secondary point: the length of stay in the ICU, composite outcome, the dynamics of SI, FI, the content ofNT-proBNP and TnT Materials and methods: A randomized study was performed in three groups of patients during reconstructive operations on infrarenal part of aorta: control (traditional methodfor prevention of decompensation of CHF were used) - 31 patients; the group with the anesthetic cardioprotectivei - 31 patients; the group with a preoperative preparing with levosimendan - 30 patients. RESULTS: The incidence of heart failure (estimated by need to use inotropic drugs - IS) was 83% of control group patients and 75% of the patients of the group "VIMA" (p = 0,65). The number ofpatients needing the use of dobutamine in LS-group was significantly below, 50% (p = 0,02 relative to control group and p = 0,08 compared to the group VIMA). IS in the control group was 8 [6, 9] µg xkg⁻¹ - xmin⁻¹ ; group VIMA 8 [3; 9] mg xkg ⁻¹ xmin⁻¹ , whereas in the LS group only 2 [0; 7] mg ⁻¹ xkg⁻¹ xmin⁻¹ . Differences between groups credible, given the Bonferroni correction (p = 0,0015). In our study, was not identified significant differences in 30-day mortality: in the control group it was 3,4%; in the group VIMA of 3,1%; in the group of LS - 0% (p > 0,017); however, a composite outcome (number of adverse events (heart attack+stroke+mortality) were slightly better in the LS group - 17%, against 34% in the control group (p = 0,043). CONCLUSION: Preoperative preparation with levosimendan in patients with reduced fraction left ventricle ejection when performing reconstructive operations on the descending aorta reduces the incidence of episodes of decompensation of heart failure compared with the control group to 39,8% (p < 0,05). The use of this technique improves the composite outcome of operations on the infrarenal aorta. The study has not shown the influence of anesthetic cardioprotection in terms of hospitalization and composite outcome of surgical treatment.

[NONSPECIFIC DELIRIUM IN THE INTENSIVE CARE UNIT].

Delirium in the intensive care unit is a frequent and serious complication, significantly worsens the prognosis of the underlying disease. Diagnoses that assign patients with delirium include an acute encephalopathy toxic encephalopathy, resuscitation psychosis, and this is an incomplete list. Thus, delirium is apparently not a separate disease, is more likely that this is a symptom of central nervous system polyethiological inherently. Currently only two methods for the diagnosis of delirium are recommended: the assessment of confusion for the ICU (CAM-ICU) and a checklist for the assessment of delirium in the ICU (ICDSC). There are no specific methods for the prevention of delirium, but the observance of some simple rules can prevent its development. We should treat the disease, which has led to the appearance of delirium symptoms. For relief discussed the state recommended that a mild sedative non-benzodiazepine drugs (dexmedetomidine better) with a daily assessment of the level of consciousness.

[PERIOPERATIVE CARE FOR PATIENTS WITH UNDERLYING ARTERIAL HYPERTENSION (CLINICAL GUIDELINES)].

These clinical guidelines apply to the implementation of health care for all patients with concomitant hypertension in the perioperative period in a hospital. The guidelines specify the method of stratifying the risk of perioperative cardiac complications. We described methods for the treatment of urgent conditions with hypertension and hypertensive crises and identified the main features of the preoperative evaluation and preparation of patients with concomitant hypertension. The clinical guidelines contain recommendations on the management of intra- and postoperative period

[INDUCTION OF ANESTHESIA ON THE BASIS OF DESFLURANE AND FENTANYL--DANGER IN THE AMBULATORY SURGERY].

PURPOSE: To study the possibility of desflurane use for induction of anesthesia. MATERIALS AND METHODS: We analysed the intra- and immediate postoperative periods in 125 patients. Depending on the intended anesthesia method patients were randomised (the method of the envelopes) and included in one of two study groups: 1--volatile desflurane-based anesthesia (n = 62); 2--volatile sevoflurane-based anesthesia (n = 63). RESULTS: Desflurane based anesthesia led to apnea until the installation of laryngeal mask in 94.5% of patients (of 54), for whom a completion of inhalation induction was possible, whereas sevoflurane based anesthesia.led to apnea occurred only in one patient (1.6%). CONCLUSIONS: "Step up" desflurane-based inhalational induction and sevoflurane-based maximum concentration inhalational induction "without primaryfilling of the circuit" showed no significant in time necessary for achieving an anesthetic concentration essential for LMA installation. In both groups it was 3-5 min. desflurane-based volatile induction with addition of fentanyl led to apnea in 97% of patients and associates with a higher risk of bronchospasm.

[Comparison of pharmacological renal preconditioning with dalargin and lithium ions in the model of gentamycin-induced acute renal failure].

PURPOSE: To examine the efficacy of renal preconditioning effect of dalargin and lithium ions by observing the model of gentamycin-induced acute renalfailure. MATERIALS AND METHODS: The experiments were performed on white rats, male. The influence of dalargin and lithium ions on the development of gentamycin-induced acute renalfailure was studied in vivo. On the first 24 hours after dalargin injections were terminated, the rats were euthanized humanly. After this we took the blood for a biochemistry study and a renal culture for biochemical test and also for the test of gsk-3ß activity. Concentrations of creatinine and urea were studied in serum. The culture samples of renal tubular epithelium before insertion of gentamycin were incubated in dalargin or lithium ions in different concentrations. After that the substratum was immediately changed to gentamycin in different concentrations also and the incubated for 24 hours. After all the standards MTT-test was performed (based on the ability of living cells to reduce the unpainted form by 3-4,5-dimethylthiazol-2-yl-2,5-difenilterarazola to blue crystalline farmazan). RESULTS: Lithium precondition leads to the 250% increase of gsk-3ß concentration (p = 0.035). The same results were observed after injection of dalargin in 50 mcg/kg concentration. Concentration of creatinine was 44% lower in the dalargin group than in the control group (p = 0.022). Concentration of creatinine was 32% lower in the lithium group than in the control group (p = 0.030). Concentration of urea was 27% lower in the lithium group than in the control group (p = 0.049). Morphological inflammatory changes in the control group were more significant also. In vitro studies showed the maximum efficacy in the lithium group. The most effective dalargin concentration was 5 mg/ml. CONCLUSION: Lithium and dalargine preconditioning lowers the signs of gentamycine induced acute renal failure and damage rate of renal parenchyma in vivo and in vitro.

[Molecular mechanisms of ischemic-reperfusion syndrome and its personalized therapy].

Cardiovascular pathologies are the major causes of morbidity and mortality in the world. Cessation of the blood flow in large vessels, supplying tissues with oxygen and substrates, leads to ischemic conditions accompanied by unwanted shifts of oxidative metabolism and rise of the reactive oxygen species (ROS) generation. Small amounts of ROS are essential elements of the cell metabolism, however pathological elevation of ROS jeopardizes the survival of cells, organs and even organisms. Paradoxically, blood flow restoration during prolonged ischemia leads to oxidative stress that is often fatal for a live system. Oxygen paradox appears to be a limiting factor in clinical practice that intuitively seeks for immediate and complete restoration of a damaged blood flow. Mitochondrion is a major ROS source and a key element of pro-apoptotic signaling, however it is clear, that mitochondria are the main target for anti-ischemic treatment. In the present review we consider two ways of such anti-ischemic strategy, bringing ischemic tolerance to the organ through mitochondrial involvement, such as intrinsic, biological, or artificial, pharmacological adaptive systems (preconditioning). The latter is aimed to simulate elements and high efficiency of intrinsic protective system. The role of antioxidants in anti-ischemic therapy and their effects on preconditioning signaling are discussed in the review.

[Successful implementation of shortened postoperative period program after ten hours of general anaesthesia in patient with morbid obesity].

Early patient's activation is the best method of prophylaxis of many complications of the postoperative period. Patients with obesity are at high risk of developing complications in respiratory system. The following clinical report is about the successful implementation of the shortened postoperative period program in patient with morbid obesity after general desflurane maintained anesthesia and, at the same time, epidural ropivacaine-based anesthesia. Anesthesia lasted for 10 hours. The intraoperative period was well controlled and characterized with stable hemodynamic indexes. On the fourth minute after desflurane intake was terminated and recovery of consciousness and spontaneous breathing of the patient were registered, patient was extubated. This clinical experience and also an information than can be found in the earlier publications allow us to consider a desflurane maintained anesthesia as one of the safest and comfortable methods of anesthesia for patients with a morbid obesity.

[Inhalation induction anesthesia: special indications or a routine procedure?].

The efficacy, safety and expediency of various types of the induction anesthesia before the long-lasting major surgery were analyzed. The combination of inhalation of sevoflurane in maximal concentration with phentanil allowed the effective and safe induction and trachea intubation on the 3-4th minute on the background of the nimbex myoplegia. The monoinduction with sevoflurane provides the sufficient analgesia not earlier then after 7-9th minute, which allows the safe intubation at a time. Therefore, the study proved, that the inhalation induction with sevoflurane in various modifications, could be the standard method of inductive anesthesia.

Nephroprotective effect of GSK-3ß inhibition by lithium ions and δ-opioid receptor agonist dalargin on gentamicin-induced nephrotoxicity.

Nephrotoxicity and ototoxicity are the most considerable side effects of aminoglycoside antibiotics, such as gentamicin that seriously limits its application in medicine. The major mechanism of negative effect of gentamicin on kidney cells involves damage of mitochondria and induction of an oxidative stress that causes cell death resulting in kidney dysfunction. In this work we compared effects of the lithium ions and δ-opioid receptors agonist, dalargin on gentamicin-induced kidney injury. It was revealed that LiCl and dalargin treatment reduced renal tubular cell death and diminished kidney injury caused by gentamicin. Both LiCl and dalargin were found to enhance phosphorylation of glycogen synthase kinase 3ß in the kidney which points to induction of nephroprotective signaling pathways. Thus, we conclude that lithium ions and dalargin might be considered as novel promising agents for future use to prevent negative consequences of therapy with aminoglycoside antibiotics.

[Anesthesia during diagnostic endoscopic interventions in the outpatient setting].

The review of the literature is devoted to the urgent problem of today--anesthetic maintenance of diagnostic endoscopic studies. The authors of the review have attempted to systematize the results of numerous publications to provide a deeper insight into the existing problems and perspectives in this field of anesthesiology, which can facilitate an anesthesiologist in his/her decision on anesthesia to be performed in diagnostic endoscopy.

[Analysis of fatal cases and irreversible CNS injuries as complications of anesthetic maintenance].

The authors made a retrospective analysis of the 1988-2007 forensic medical examinations. They selected 45 fatal cases and 9 cases of severe irreversible CNS injuries occurring within 30 days after surgery as absolute complications due to anesthetic maintenance and postoperative management. Among the victims there were 7 children and 47 adults. In each case concerned, an attempt was made to reveal all critical incidents and factors associated with an evolving fatal outcome and it was suggested that a poor outcome could be prevented. It was noted that the most critical incidents resulting in death or severe irreversible CNS injuries were associated with respiratory disorders. These incidents were most frequently observed in the induction of anesthesia when tracheal intubation was attempted and in the early period (within 2 hours) after surgery. The most common associated factors should include inadequate preparation of a patient for surgery, improper medical care in the early postoperative period, and unavailability of automatic monitoring systems. It was ascertained that there was a potential for the prevention of death in most cases (53/54).

[Epidemiology of postoperative cognitive disorders].

The literature review concisely considers a relatively new problem of postoperative cognitive disorders occurring in surgical patients. The paper considers the present views of the etiology of postoperative cognitive disorders and their contributing and aggravating factors. Particular emphasis is laid on a factor, such as a surface anesthetic level and sudden intraoperative consciousness recovery, as well as on the prevention of this complication through the monitoring of anesthesia depth.