[Safety criteria for blood refusion in military field surgery and trauma surgery].

Massive intracavitary hemorrhage in case if severe concomitant injury is the most frequent cause of death. Necessity of blood loss replacement requires effective and safe methods. One of them is blood reinfusion - technically less complicated method. The article shows advantages of using the hardware and filtration methods of blood sampling and reinfusion, developed scale rapid diagnosis of the level of hemolysis of autologous blood. Using of the method of filtration blood sampling provides 2X minimal amount of free hemoglobin than using an aspirator and reinfusion of blood with the contents therein to free hemoglobin 2.0g/ L prevents the risk of developing the syndrome and massive blood transfusion reduces the incidence of deaths at 11%. In patients with massive intracavitary hemorrhage it is advisable to use the method of semi-quantitative rapid analysis of free hemoglobin color scale.

[Pathogenesis and early diagnosis of deep vein thrombosis in case of polytrauma].

Pathogenesis and early diagnosis characteristics of acute deep vein thrombosis (advt) have been studied in 323 polytrauma patients (iss: 29.4 +/- 2.0 score). Acute vein thrombosis, confirmed by us examination, was determined in 22.3% of patients (in the case of severe craniocerebral trauma--scct--12.6%, extremity trauma--60.5%, spinal trauma 75%, severe sepsis--25%). Despite the complex diagnosis and prophylaxis (thrombus removal, thrombosed veins ligation, external iliac vein and inferior vena cava clipping, permanent and removable cava-filters positioning) pulmonary artery thromboembolism (pate) developed in 3.1%. ADVT in patients with polytrauma developed as a pathogenic basis of systemic inflammatory response syndrome (sirs), which was observed to be associated with endothelium damage and thrombophilia. Hence, thrombophilia values (high levels of crp, f.viiia, D-dimer, low levels of antithrombin iii--at-iii), which are characteristic of sirs, lose their informativeness in the early diagnosis of advt and pate risks identification. In this regard, early advt diagnosis in polytrauma should be based on doppler study results, and the adequacy of anticoagulant and antiplatelet therapy should be determined by the levels of crp, f.viiia, D-dimer, activated partial thromboplastin time--aptt, anti- xa heparin activity, international normalized ratio--inr, platelet aggregation, thrombodynamic potential, at-iii.

[Pathogenetical features of the first period of trauma disease with acute respiratory insufficiency].

The pathogenetical features of acute respiratory insufficiency (ARI) were studied as a clinical form of the first period of the trauma disease (TD)--the period of acute impairments of the important for life functions (the first 8-12 h after trauma). In 17 casualties with a severe combined trauma the severity of the first period of the disease depended on the ARI caused by a serious injury of the chest not accompanied by a direct injury of the heart. It was shown that ARI is an independent clinical form of the first period of TD. The indices of the systemic hemodynamics in ARI are within the limits of the normal values. ARI resulting from the "primary" injury of the lungs results in a decreased delivery of oxygen to the tissues and of its consumption. When ARI takes place during the first period of TD the metabolic function of the lungs is sharply suppressed and pronounced endotoxemia is observed.

[Pathogenetical peculiarities of the first period of trauma disease in acute heart failure].

Under observation there were 29 casualties with severe combined trauma complicated by acute heart failure (AGF) caused by a direct injury of the heart, without severely disturbed consciousness and valuable blood loss. In 65% of the patients the trauma was severe, in 35%--extremely severe. Higher ST wave was registered in ECG of 40% of the patients in standard leads, in 30% there was no wave R in chest leads. Disturbed rhythm was noted 2-2.5 times more often than in other kinds of injuries. Ventricular extrasystoles, paroxysmal ciliary arrhythmia, atrioventricular and ideoventricular rhythm were determined since the first day after trauma. The results of the investigation have shown that the primary injury of the myocardium was followed by a decreased heart work. Circulatory insufficiency of blood circulation was developed. The impaired systemic hemodynamics led to inadequate delivery of oxygen to the tissues and of oxygen consumption, to the development of tissue hypoxia and respiratory disorders closely connected with it. The circulation disturbances caused also a suppression of detoxication mechanisms of organism, the development of disseminated intravascular coagulation and endotoxicosis.

[C-reactive protein in severe combined trauma not complicated and complicated by sepsis].

The role of C-reactive protein (CRP) was studied in the development of nonbacterial systemic inflammation response, infectious complications, severe sepsis in severe combined trauma. It was shown that daily quantitative indicators of CRP in blood of patients in the intensive care unit allowed prognosis of the development of nonbacterial systemic inflammation response, infectious complications and sepsis. The CRP level >40 mg/l in the first day under conditions of not using glucocorticoids manifests a risk of the development of infectious complications. Prolonged reduction of CRP from the 3rd day is characteristic of a favorable course of trauma disease, maintenance of the level or its elevation - of pyo-infectious complications. With the following development of sepsis CRP in blood during the first week is higher than 120 mg/l. The nonbacterial systemic inflammation response is determined on the 2nd day after trauma in 14.8% of casualties not being followed by the development of septic complications and in 44.5% - followed by sepsis. Glucocorticoids and specific immune medicines used in treatment of sepsis result in a reduced amount or complete disappearance of CRP in blood during administration of these medicines. Rejection of them is followed by the appearance of CRP in the amount showing the effect of treatment. Gradual reduction of CRP in sepsis associated with decreased activity of the infectious processes was observed only in casualties without a polyorganic insufficiency.

[The severe combined cerebro-cranial trauma. Pathobiochemical characterization]. / Tiazhelaia sochetannaia cherepno-mozgovaia travma. Patobiokhimicheskaia kharakteristika.

The indices of the endocrine system, systemic transport and consumption of oxygen, metabolism, hemostasis in the femoral artery, central and internal jugular veins were investigated in 144 patients with severe combined cerebro-cranial traumas (CCT) during the first 7 days after trauma. In 15 of them liquor was investigated. The results of the investigation have shown that in not severe CCT (FS-II: 0.50+/-0.25 scores) the ACTH level in blood was 1.9 times higher and cortisol 5.6 times higher than normal. In the cerebral tissue aerobic oxygenation of glucose prevailed (aerobic index: 90+/-2%): metabolic disorders were caused by extracranial injuries--the content of lactate, malon dialdehyde (MDA), middle molecular peptides (MCM238-302) was higher in the central vein than in the jugular vein. In patients with the superior truncal form of severe contusion of the brain (Field Surgery-II: 11.8+/-0.2 scores) in the cerebral tissue there was prevalence of anaerobic glycolysis (aerobic index: 60.1+/-3.5%), lactate oxygen index grew to 0.160+/-0.018. The inferior truncal form of brain contusion (FS-II: 18.8+/-0.2 scores) had sharply decreased both aerobic and anaerobic oxidation of glucose in the cerebral tissue. In cases of severe and extremely severe CCT there was a suppression of central regulatory mechanisms--in response to the trauma the elevation of the level of ACTH and cortisol in blood was insignificant. Thrombinemia and prevailing endotoxemia were noted in the jugular vein. Great concentrations of lactate, MDA, MCM were determined in the liquor. So, liquor sorption is thought to be expedient. Lower index of oxygenation (1.9+/-0.3), higher respiratory index (1.5+/-0.1) and alveolar dead space (37.7+/-7.2%) evidenced secondary injury of the lungs in cases of severe and extremely severe combined CCT.

[Application of superoxide dismutase preparation for the prophylaxis of post-traumatic broncho-pulmonary complications]. / Primenenie preparata superoksiddismutazy dlia profilaktiki posttravmaticheskikh bronkholegochnykh oslozhnenii.

The effectiveness of endobronchial application of superoxide dismutase (SOD) for prevention of posttraumatic bronchopulmonary complications was analyzed in 11 patients with severe combined traumas and dominating injuries of the chest. It was shown that severe combined traumas sharply initiate processes of free radical oxidation in tissues, intensify prooxidative activity, deplete total antioxidative activity and its important link--plasma and erythrocyte SOD. Endobronchial instillation of SOD after a severe combined trauma results in increased intracellular activity of catalase, total antioxidative activity, SOD, decreased production of lipid peroxides in homogenate of the pellet of bronchoalveolar lavage (BAL), reduced number of neutrophiles and higher number of lymphocytes in BAL pellet. Posttraumatic endobronchial instillation of SOD reliably improves the respiratory and metabolic function of the lungs, improves the surfactant system of the lungs, bronchial patency, reduces the number of cases of posttraumatic pneumonia.

[Pathogenetical features of the acute period of traumatic disease. Traumatic shock as a special manifestation of the acute period]. / Patogeneticheskie osobennosti ostrogo perioda travmaticheskoi bolezni. Travmaticheskii shok -- chastnoe proiavlenie ostrogo perioda.

Clinico-pathogenetical features of the acute period of trauma disease due to a severe combined injury were studied in 644 patients. An analysis of clinical indices was made in 428 of them, clinico-laboratory indices--in 216 patients. The results have shown that the main form of the acute period of the trauma disease are traumatic shock (62.8%), traumatic coma (18.3%), acute respiratory insufficiency (5.7%). Dramatically decreased delivery and consumption of oxygen lower than the metabolic requirements of the tissues accompany the traumatic shock which results in the suppression of tissue metabolism. Pronounced endotoxicosis developing along with the traumatic shock results not from the degree of injured tissues only, but from the centralization of blood circulation. It is also supported by the insufficient detoxicating function of the kidneys. A severe degree of the traumatic shock causes disseminated intravascular coagulation (DIC) of the II-III degree. After helping out from shock the patient has normocoagulation or the I degree DIC. Traumatic shock with marked hypotension and metabolic acidosis is a significant factor of high risk of the development of acute lesion of the lungs.

[Metabolic bases of the pathogenesis of severe multiple trauma]. / Metabolicheskie osnovy patogeneza tiazheloi sochetannoi travmy.

Under analysis there were data of hormonal activity of the hypothalamo-hypohysis-adrenocortical system and the incretory apparatus of the pancreas, metabolism (of proteins, lipids, carbohydrates) and concentration of microelements (iron, zinc), lipid peroxidation (content of malonic dialdehyde and diene conjugates, on the one hand, and total oxidative activity of blood, superoxide dismutase (SOD), ceruloplasmin, catalase, SH-group, on the other hand) and results of its therapeutic correction (with superoxide dismutase, ionole, extracorporeal laser irradiation and laser irradiation of the wounds), content of the inflammatory reaction markers (tumor necrosis factor and IL-1) in patients with a severe combined trauma in the dynamics of traumatic disease. The results obtained and literature data allow a conclusion to be made that the basis of metabolic changes in severe combined traumas are formed by a developing adaptation reaction of organism immediately after trauma integrated with the systemic aseptic inflammatory response caused by vast necrosis of tissues, hypo- and reperfusion processes. The intensity of these reactions depends on severity of the trauma, determines its clinical course and outcome. The therapeutic correction of higher activity of the lipid peroxidation system (caused by a systemic inflammatory response) ionol, extracorporeal laser irradiation of blood, laser therapy of the wounds increase the antioxidative volume of blood and decrease the production of lipid peroxidation. Early intrabronchial instillation of homogenic SOD increases the total antioxidative activity, the level of SOD and catalase, decreases the content of malonic dialdehyde in the sediment of broncho-alveolar lavage and in blood.

[Endotoxicosis in severe multiple trauma]. / Endotoksikoz pri tiazheloí sochetannoí travme.

The article touches upon the practical significance of methods of extracorporeal detoxication, pathogenesis of endotoxicosis, phases of its development. An analysis of data was made concerning treatment of 98 wounded and patients having injuries of three and more anatomical areas and who were in severe and critically severe states. Practical conclusions were made determining the expediency of using the methods of extracoprporeal detoxication in traumatic disease, special attention being given to optimization of functioning the detoxicating systems of organism.

[Diagnosis of heart contusions in patients with multiple trauma of the chest]. / Diagnostika ushiba serdtsa u postradavshikh s sochetannymi travmami grudi.

A complex investigation of effectiveness of different methods of detection of heart contusion in patients with combined traumas of the chest allowed detailed elucidation of the criteria of diagnostics of heart contusions by means of electrocardiography, integral rheography of the body, ultrasonography, enzyme diagnostics. A comparative analysis has shown that none of the available now methods can be taken as absolute. The complex use of these methods only can make the maximum objective diagnosis of heart contusion. This approach allowed the authors to make the amount of diagnostic errors 18% less in patients with a combined trauma of the chest and thus to improve the results of treatment.

[Antipyrine test in evaluation of patient's hepatic failure in early postoperative period]. / Antipirinovaia proba v otsenke pechenochnoi nedostatochnosti u bol'nykh v rannem posleoperatsionnom periode.

In victims of severe combined trauma in early postoperative period there are disorders in the system of monooxygenase detoxication of hepatocytes--the duration of antipyrine semiexcretion period in the blood was 2.5 times longer than in healthy people. In 40% of injured parallelism in changes of values of the antipyrine test and general blood bilirubin are detected; in 18% of cases hyperbilirubinemia is revealed in antipyrine clearence being normal, and in 42% a sharp decrease of antipyrine clearence at the background of normal bilirubin content is detected. Hypoproteinemia, hypoalbuminuria, and activation of ALT and AST was revealed, which evidenced of the reaction of urgent adaptation. Under conditions of development of the postoperative stress-reaction the examination of monooxygenaze system of hepatocytes' detoxication is the most specific test of revealing early hepatic insufficiency. A sharp decrease or increase of antipyrine clearence is a sign of irreversibility of hepatic insufficiency.

[The role of middle-molecule peptides in the pathogenesis of traumatic disease]. / Rol' srednemolekuliarnykh peptidov v patogeneze travmaticheskoi bolezni.

On the basis of study of mass-spectrum of blood plasma ultrafiltrate in 21 injures with severe associated trauma during first four posttraumatic days and in healthy persons one can suggest that combinations with molecular weights of 300-1050 Da are to be one of the important regulatory mechanisms of posttraumatic adaptative processes. With increasing of the injury gravity reorientation of the levels of adaptative reactions management and level enhancing of mediomolecular regulators are found to be occurred.

[The intensive therapy of acute respiratory failure in severe combined trauma with a closed chest injury]. / Intensivnaia terapiia ostroi dykhatel'noi nedostatochnosti pri tiazheloi sochetannoi travme s zakrytym povrezhdeniem grudi.

The authors present a program of rational improvement of intensive therapy of acute respiratory insufficiency responsible for the development of normal compensatory processes of external ventilation. The main components of intensive therapy are: rational analgesia (continuous subpleural blockades), elimination of obstruction of respiratory pathways by sessions of independent respiration with oxygen mixture with positive pressure at the end of breathing out with phytoncides, moderate hemodilution, early recovery of enteral coming of fluid, prevention and treatment of respiratory infection. The use of the proposed intensive therapy in 41 patients improved the function of external ventilation and made the amount of pulmonary complications 4 times less.

[Traumatic disease in wounded patients]. / Travmaticheskaia bolezn' u ranenykh.

Results of clinico-physiological, pathobiochemical, immunological and hemocoagulative studies performed at the postshock period in 186 patients with battle wounds have shown their coincidence with data obtained in critical mechanical trauma of peace-time. A conclusion is made that critical gunshot wounds are followed by trauma disease having main regularities similar to those in a critical mechanical trauma of peace-time. One can speak only about specific features of battle injuries, but to distinguish "wound disease" as an independent clinical form is thought to be illegal.

[Postaggressive metabolism in severe mechanical trauma]. / Postagressionnyi obmen veshchestv pri tiazheloi mekhanicheskoi travme.

Posttraumatic adaptive reactions are divided by the authors into three periods: the period of "urgent" adaptation (1-2 days), intermediate period (3-7 days) and the period of "long-term" adaptation (after 7 days). The period of "urgent" adaptation may be considered to be more favorable for surgical interventions under conditions of adequate anesthesiological maintenance. A critical associated trauma unlike an isolated one was found to cause more pronounced and continuous strain of the endocrine and metabolic reactions related with the "urgent" adaptation which influences the frequency of complications and lethal outcomes.

[Status of the blood coagulation system in traumatic disease]. / Sostoianie sistemy gemokoaguliatsii pri travmaticheskoi bolezni.

Under examination there were 198 patients with severe mechanical traumas at their admission to the clinic and on the 1st, 3d, 7th, 14th and 21st days by 25 hemocoagulation parameters determined by common present-day methods. The direction and degree of hemocoagulation alterations were found to be related with the severity of trauma, blood loss volume and severity of shock. It was shown that disseminated intravascular coagulation (DIC) of the II and III degree was developing in critical associated traumas, massive blood loss and severe shock in acute period of the disease. The acute form of DIC with reactive fibrinolysis was established in the lethal outcome during the shock period, latent (slow) DIC with local fibrinolysis took place in lethal outcomes in later periods.

[Immunological status and somatotropic activity of the pituitary in combined abdominal injuries complicated by peritonitis]. / Sostoianie immuniteta i somatotropnoi aktivnosti gipofiza pri sochetannoi travme zhivota, oslozhnennoi peritonitom.

Associated injuries of the abdomen result in peritonitis twice more often than isolated ones, the peritonitis having more severe course and being the cause of lethal outcomes in 57% of the victims. The immune deficient state is thought to be one of the causes responsible for the reduced resistance to infection and the development of peritonitis in the postshock period. Patients with associated traumas show a considerable inhibition of the immune system within several hours and an impairment of its regulation which grows during the next day. So, even at the early terms the operative methods must be similar to those used in operations for the developed peritonitis.