[Anesthesia during liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

Different methods and components of anesthesia during operations in donors and recipients were studied by using the experience in maintaining anesthesia during 39 relative and 7 cadaveric hepatic transplantations. The experience in using epidural anesthesia and total intravenous anesthesia at the donor stage of hepatic lobar transplantation was comparatively analyzed. Combined epidural anesthesia (CEA) may be used during long-term and traumatic operations dealing with hepatic lobectomy in a relative donor since it is noted for low hepatotoxicity and no drastic hemodynamic exposures. CEA can substantially reduce pharmacological loading with opioids or myorelaxants, which is particularly important in taking the lobe of the liver. This reduces the recovery period of adequate own respiration, activates a patient more rapidly, substantially reduces the risk for postoperative iatrogenic complications. Balanced general anesthesia whose major component is inhalational anesthesia with isoflurane is the method of choice in performing an operation in the recipient. The use of isoflurane in the minimal-flow mode is cost-effective and safe. When anesthesia is performed in the recipient, it is necessary to take in account drastic hemodynamic pattern changes at the liverless stage during vein-venous bypass surgery, including the liver into systemic circulation, and the likelihood of development of significant reperfusion and concomitant metabolic and coagulative disorders.

[Experience in the clinical use of intravenous hypnotic pofol (propofol) in anesthesias of different duration]. / Opyt klinicheskogo ispol'zovaniia vnutrivennogo gipnotika pofol (propofol) pri anesteziiakh razlichnoi prodolzhitel'nosti.

A new anesthetic pofol is characterized by predominantly hypnotic effect; it is a pharmacological analog of a well-known drug diprivan (propofol). The drug was used in 60 anesthesias for bronchoscopic manipulations and cardiosurgical operations. Its effects on hemodynamics, gas exchange, and reactions during induction and after anesthesia were evaluated. The present findings and results of previous clinical trials of diprivan indicate identity of pofol and diprivan. Clinical course of induction and anesthesia and hemodynamic reactions and effects on the respiratory system of patients were virtually the same. Pofol is well tolerated by the patients, its allergenic activity is low, it is rapidly metabolized and causes virtually no side effects. Positive results of clinical trials of pofol recommend it for clinical use.

[Functional state of the right and left heart at different stages of anesthesia in patients with ischemic heart disease during myocardial revascularization surgery]. / Funktsional'noe sostoianie pravogo i levogo serdtsa na razlichnykh étapakh anestezii u bol'nykh IBS pri operatsiiakh revaskuliarizatsii miokarda.

57 ischemic heart disease (IHD) patients entered the study of right and left heart function at different stages of anesthesia and operation to reveal possible reasons of myocardial dysfunction and to propose effective prevention of this dysfunction. All the patients were operated on under multicomponent balanced anesthesia (relanium, fentanyl, arduan, nitric oxide with oxygen 1:1). Left ventricular function was assessed at Doppler echocardiography, right ventricular function--at catheterization of the lung artery with a Swan-Ganz catheter with low time constant. Hemodynamic monitoring was made with a domestic MX-04 monitor. It was found that in the preperfusion period diastolic function of the right and left ventricles is impaired much more than the systolic one. The conditions of anesthesia and operation affect right ventricular function more than the left one. Diastolic and systolic right ventricular dysfunctions were observed at all stages and three stages of the operation, respectively. Diastolic and systolic left ventricular dysfunction was observed at four and one stages, respectively. Basic causes of the above systolic and diastolic disorders in the preperfusion period may be tachycardia, arterial hypertension, reduction of the preloading and increased postloading (for the right ventricle) in artificial lung ventilation.

[Use of clofelin in the prevention of perioperative myocardial dysfunction in patients with ischemic heart disease]. / Ispol'zovanie klofelina dlia profilaktiki perioperatsionnoi disfunktsii miokarda u bol'nykh IBS.

The purpose of this study was to evaluate the possibility of using clofeline in anesthesiological protocol for myocardial revascularization as a drug preventing hemodynamic disorders and perioperative myocardial dysfunction. In group 1 (27 pts.) clofelin was used in premedication (150 micrograms at night on the eve of surgery and before the operation), group 2 (29 pts.) was control. Clofelin improved the stability of the cardiovascular system, decreased the incidence of hyperdynamic reactions, episodes of myocardial ischemia, and cardiac arrhythmia during surgery. Use of clofelin for premedication decreased the need in inotropic support during the postperfusion period from 49 to 37% and ensured a higher cardiac production during transfer from artificial to spontaneous circulation.

[Autonomic reactivity and intraoperative arterial hypertension in patients with ischemic heart disease]. / Vegetativnaia reaktivnost' i intraoperatsionnaia arterial'naia gipertenziia u bol'nykh IBS.

As patients with ischemic heart disease (IHD) may develop intraoperative hypertensive and hyperdynamic reactions provoking myocardial ischemia, the authors estimated reactivity of the autonomic nervous system before giving anesthesia. This was made for prediction of intraoperative hypertensive reactions and choice of an optimal anesthesia variant. Combination of spectral analysis of variability of the heart rhythm and active orthostatic test was employed for this purpose in 50 IHD patients undergoing myocardial revascularization.

[Prevention of negative hemodynamic effects of protamine sulfate by simultaneous infusion of microdoses of adrenaline]. / Profilaktika otritsatel'nykh gemodinamicheskikh éffektov protamina sul'fata s pomoshch'iu odnovremennoi infuzii mikrodoz adrenalina.

Two groups of coronary patients subjected to revascularization of the myocardium were examined in order to detect the negative hemodynamic effects of protamine sulfate (PS) and the possibility of their correction by simultaneous infusion of adrenaline microdoses. In group 1 (27 pts.) heparin was neutralized by infusion of PS alone (6 mg/kg) and in group 2 (27 pts.) by simultaneous infusion of PS and adrenaline (15 ng/kg/min). The functions of the right and left ventricles were evaluated by catheterization of the pulmonary artery by a Swan-Ganz catheter and transesophageal Doppler echocardiography. These methods provided volume and velocity characteristics of the right and left compartments of the heart. PS deteriorated the systolic function of the right ventricle, particularly in patients with initial dysfunction of the right heart. Infusion of adrenaline simultaneously with PS leveled its negative effects, thus preventing myocardial dysfunction.

[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.

[Practical aspects of cardioplegia]. / Nekotorye prakticheskie voprosy kardioplegii.

Concentrations of the ingredients have been analysed in a nonstandard cardioplegia solution (CS) and CS from St. Thomas Hospital at the outset before CS introduction into the coronary vessels of patients under cardioplegia. It has been shown that the use of nonstandard CS was accompanied by undesirable variability in ingredient concentration, which to some extent may be accounted for by the use of incompletely unfrozen CS. The use of CS from St. Thomas Hospital could be accompanied by moderate hypermagnesiumemia, which did not lead to the onset of vascular insufficiency. It is stressed that plasma magnesium content should be controlled when this CS is used.

[The contractility of the lower portion of the esophagus as a criterion of the adequacy of anesthesia]. / Sokratimost' nizhnego otdela pishchevoda kak kriterii adekvatnosti anestezii.

It has been found that narcotic analgesics (morphine, fentanyl and dipidolor), inhalation anesthetics (phthorothan and frilen) and an intravenous anesthetic calypsol suppress lower esophageal contractility. Comparison of lower esophageal contractility with hemodynamic parameters and ACTH and cortisol blood plasma content have revealed a direct correlation. It is concluded that the method of dynamic control over lower esophageal contractility may be an objective test controlling the adequacy of anesthesia during various surgical interventions.

[Endocrine response to extracorporeal circulation]. / Endokrinnyi otvet na iskusstvennoe krovoobrashchenie.

The authors analyze the results of measuring the content of vasopressin, renin, angiotensin II and aldosterone coupled with the results of studying hemodynamics, acid-base state, and lactate in the arterial blood during operations on the heart in 32 patients with different acquired heart diseases. The main attention was concentrated on studies into the nature of humoral changes during extracorporeal circulation in three types of anesthesia. In group I, anesthesia was maintained by fentanyl given in a dose of 5-6 micrograms/kg/h, diazepam (0.1 mg/kg/h), and arduan (0.02 mg/kg/h). In the second observation group, at the beginning of perfusion the patients were administered trimetotan (artonad) (0.2 mg/kg), and in group III, the dose of fentanyl was raised during perfusion to 10-12 micrograms/kg/h. It is concluded that during extracorporeal circulation, it is desirable that the dose of fentanyl be increased to attain more adequate anesthesia in that period of heart surgery. The magnitude of humoral changes occurring in the body during extracorporeal circulation served as a criterion for anesthesia adequacy.

[Heart transplantation conducted at the All-Union Research Center of Surgery (the first clinical experience)]. / Transplantatsiia serdtsa v VNTsKh (pervyi klinicheskii opyt).

The authors analyse experience in the first eight operations for orthotopic transplantation of the heart. Six patients were discharged from the clinic with good immediate results. Comparison of their own data with summarized results gained in other countries allowed the authors to define some specific problems which are of practical interest for clinics embarking on the clinical realization of the problem of heart transplantation.

[Lipid peroxidation in open-heart operations]. / Perekisnoe okislenie lipidov pri operatsiiakh na otkrytom serdtse.

The intensity of lipid peroxidation (LPO) and antioxidant system activity (ASA) have been studied using chemiluminescent technique in 15 patients with ischemic heart disease subjected to surgery under moderate hypothermia. Two types of responses to surgical intervention and cardiopulmonary bypass have been demonstrated depending on baseline LPO intensity. Low baseline intensity of free-radical reactions at the beginning of perfusion is first enhanced and then attenuated by the end of perfusion, which is accompanied by ASA activation. This indicates adequate protective and adaptation body reactions. The same group of patients was characterized by a significant correlation between the parameters studied in venous blood and blood outflowing from the myocardium prior to and following the aorta clamping. With high LPO intensity that remained unchanged in the course of the intervention no correlation between LPO and ASA parameters has been observed in venous and coronary sinus blood. These patients develop various cardiovascular complications in the postperfusion period. It has been concluded that high baseline LPO level is prognostically unfavourable, with no correlations between the parameters under study observed in venous blood and blood outflowing from the myocardium.

[Impairment of glucose metabolism and changes in insulin activity during open heart surgery]. / Narushenie metabolizma gliukozy i izmenenie aktivnosti insulina pri operatsiiakh na otkrytom serdtse.

The examination of 147 surgical patients with cardiac diseases revealed that the onset of an operative intervention (skin incision) was accompanied with a substantial rise in endogenous insulin antibody titers in the blood of the operated patients, which is likely to trigger glucose metabolic disturbances. Insulin, 0.8-1.0 U/(kg/hour), and glucose, 0.4-0.5 g/(kg/hour), therapy (IGT) initiated prior to the skin incision and continued up to the application of forceps to the aorta was found to prevent the increase in insulin antibody titers both during the surgery and within 16-18 hours of the nearest postoperative period. IGT was demonstrated to improve myocardial contractility of patients in the preperfusion period and to provide an additional protection of the heart during its temporary anoxia. Insulin synthetic processes were activated in the nearest postoperative period in patients receiving IGT, unlike patients from the control group, the latter showing signs of diminished functional activity of B cells in the pancreas along with a moderate enhancement in the titer of antibodies to endogenous insulin. It was concluded that intraoperative IGT is a pathogenetically substantiated therapeutic modality in the complex of anesthetic supply during open heart surgeries.