[Application of high thoracic epidural analgesia with naropine to patients with acute coronary syndrome].

The perioperative period was studied in 50 patients aged 44-79 years who had acute coronary syndrome. The patients underwent aortocoronary bypass surgery at O. M. Filatov Moscow City Clinical Hospital No. 15 in 2002 to 2004. They were divided into 2 groups: 1) 25 patients (21 males and 4 females) who received high thoracic epidural naropine analgesia at least 24 hours before surgery (a study group); 2) 25 patients (19 males and 6 females) who were prepared for surgery through conventional antiischemic therapy. The indication for surgical myocardial revascularization in these patients was not only severe coronary bed lesion, but also frequent resting anginal attacks. The occurrence of resting anginal episodes during the maximally possible antianginal therapy was a criterion for inclusion of patients into this study. The purpose of the study was to improve the results of surgical treatment of patients with acute coronary syndrome, by using high thoracic epidural naropine analgesia.

[Methods of cardiac output determination during extracorporeal detoxication]. / Metody opredeleniia serdechnogo vybrosa pri provedenii ékstrakorporal'noi detoksikatsii.

Two new methods of determining the cardiac output (CO) in extracorporeal detoxication (ECD) by thermal dilution were verified. The CO values, determined by the dilution of electrical impedance indicators (COimp) and by COimp thermal dilution (COtd), were compared within 31 matched analysis in 20 patients. The correlation coefficient: r = 0.98; n = 31; COtd = 0.98*, COimp + 0.19 (p < 0.01). The CO values, determined by ultrasound dilution (COus) and by thermal dilution (COtd), were compared within 31 matched analysis in 11 patients. The correlation coefficient: r = 0.97; COus = 1;* COtd = 0.32, (p < 0.01).

[Normovolemic hemodilution during surgical revascularization of the myocardium]. / Normovolemicheskaia gemodiliutsiia pri khirurgicheskoi revaskuliarizatsii miokarda.

The hemodynamic efficiency of hydroxyethyl tarch 130/0.4 "Voluven" (HET) was investigated within a method of acute normovolemic hemodilution in 11 patients with ischemic heart disease (IHD) during the implementation of surgical revascularization of the myocardium under the conditions of extracorporeal artificial blood circulation. It was shown, that in case of invasive monitoring of central hemodynamic and of the oxygen-transport function of the blood circulation system, an exfusion of 13.28 +/- 1.53 ml/kg can be regarded as a permissible blood-saving procedure in IHD patients during revascularization of the myocardium. The application of HET 130/0.4 "Voluven" provides for an adequate correction of shifts in the blood circulation system and in its oxygen function--such shifts occur in implementing the acute normovolemic hemodilution in IHD patients.

[Therapy of arterial hypertension with verapamil hydrochloride in patients after myocardial revascularization]. / Korrektsiia arterial'noi gipertenzii verapamilom gidrokhloridom u bol'nykh posle revaskuliarizatsii miokarda.

Verapamil hydrochloride, a calcium blocker from a group of phenyl alkylamines, was tested for its effect on central hemodynamics (CH) and blood oxygen-transporting function (BOTF) in 14 patients with arterial hypertension after surgical myocardial revascularization. CH and BOTF were studied by using a Swan-Hanz catheter and directly measuring blood pressure (BP). There was a significant reduction in BPmean, total peripheral vascular resistance index, left ventricular stroke outcome index, and oxygen delivery index. Verapamil in an average dose of 80.4 +/- 18.02 mg at the injection rate of 24.6 +/- 3.9 micrograms/kg/min was shown to make BPmean normal 16.8 +/- 6.35 min later. The agent is comparable with other calcium blockers, such as nifedipine and isradipine in its action on CH and BOTF, as well as in its efficiency and safety.

[Extrarenal purification of blood in patients with multiple organ failure: results and prognostic criteria]. / Vnepochechnoe ochishchenie krovi u bol'nykh s poliorgannoi nedostatochnost'iu: rezultaty, prognosticheskie kriterii.

Acetate hemodialysis (HD) with an artificial kidney an continuous hemofiltration were used in the treatment of 49 patients with the multiple organ failure syndrome (MOFS) developing as a complication of aortocoronary and mammary-coronary shunting and heart valve replacement. MOFS involved failure of the function of 3.5 +/- 0.2 vital organs on average. Acute circulatory disorders were observed in 100% of patients, acute renal failure in 75.5%, and perioperative myocardial infarction in 34.7%. In 93.9% of patients HD and HF were combined with forced ventilation of the lungs, in 97.9% with catecholamine infusion, in 26.5% with assisted circulation, and in 57.1% with the Swan-Ganz monitoring of the central hemodynamics and of oxygen transporting function of circulation. Multiple-modality intensive care resulted in survival of 21 (42.8%) patients. The survival of patients with MOFS depended on the number of involved organs, method of extracorporeal detoxication, and monitoring of central hemodynamics and oxygen-transporting function of the blood. Acute renal failure, respiratory distress syndrome, and shock deteriorated the prognosis for patients with MOFS.

[Pharmacological correction of low cardiac output syndrome in hemofiltration]. / Farmakologicheskaia korrektsiia sindroma nizkogo serdechnogo vybrosa pri provedenii gemofiltratsii.

Low cardiac output was corrected by catecholamines in the course of hemofiltration (HF) administered to 37 patients with multiple organ failure after surgery. Catecholamines (adrenaline hydrochloride, noradrenaline hydrotartrate, dopamine hydrochloride, and dobutamine hydrochloride) were used as monotherapy or in various combinations (two, three, or four drugs). Ninety percent of patients with low cardiac output subjected to HF were administered combined catecholamine therapy. Catecholamines provided the hemodynamic stability of HF in patients with low cardiac output. The frequency of noradrenaline administrations and its mean doses were reliably decreased in the course of HF, whereas the mean doses of adrenaline, dopamine, and dobutamine remained virtually the same.

[Pulmonary gas exchange function during hemofiltration in patients with multiple organ failure]. / Gazoobmennaia funktsiia legkikh u bol'nykh s poliorgannoi nedostatochnost'iu pri provedenii gemofil'tratsii.

Pulmonary gas exchange was examined in 37 patients with multiple organ failure in the course of long forced ventilation of the lungs (FVL) and hemofiltration (HF). Acute respiratory distress syndrome (ARDS) was observed in 25 (65.7%) patients. Assessment of the effect of HF on the lungs for the entire group and for patients with ARDS showed no changes in the pulmonary gas exchange function in the course of 24-hour HF. On the other hand, during the first 7-8 h of HF the oxygenation function of the lungs either improved (group 1, n = 11) or deteriorated (group 2, n19). In group 1 the paO2 reliably (by 36%) increased, paO2/FiO2 increased by 36%, (A-a)O2 reliably (16%) dropped, as did the Os/Ot (by 30%) during 7-8 hours. In group 2 PaO2 decreased by 14%, PaO2/FiO2 by 16%, and the oxygen index (O2I) increased by 24% (p < 0.05), these values remaining at levels requiring no more intensive respiratory support or other intensive care. Gas exchange function of the lungs was studied in 18 patients in the course of isotonic dehydration. The pulmonary capillaries wedge pressure dropped by 25%, central venous pressure by 18% in the course of dehydration. Changes in other values were unreliable. Due to decrease of extracellular hyperhydration the alveolar-arterial O2 gradient dropped by 17.5% and the intrapulmonary shunt by 21% (p < 0.05). Oxygen tension in the arterial blood remained the same in the group in general.

[Criteria for the choice of the extracorporeal detoxication method in patients with postoperative renal failure]. / Kriterii vybora metoda ékstrakorporal'noi detoksikatsii u bol'nykh s posleoperatsionnoi pochechnoi nedostatochnost'iu.

Criteria for the choice of a method for extracorporeal detoxication (acetate hemodialysis, intermittent or continuous hemofiltration or hemodiafiltration, or plasmapheresis) were defined on the basis of a detailed examination of cardiorespiratory function (central hemodynamics, oxygen-transporting function of the blood) in 88 patients with acute postoperative renal failure (PRF). Multiple organ failure occurred in 90% of the patients examined in the postoperative period. The severity of visceral and metabolic disorders was the principal criterion in the choice of extracorporeal detoxication method. Hemofiltration is the method of choice for the treatment of PRF combined with multiple organ disorders, primarily with acute circulatory, respiratory, and metabolic disorders, due to its stabilizing effect on the hemodynamics and a wide spectrum of pathologic substances removed by it. Acetate hemodialysis is indicated for patients with PRF and slow recovery of renal function only after elimination of grave hemodynamic and respiratory disorders, provided there are no general cerebral symptoms, because of its negative effect on the circulation and oxygen balance of the organism and central nervous system. Plasmapheresis is a pathogenetically valid method for the treatment of the initial stages of PRF in cases with massive intravascular hemolysis and sepsis, which may be combined with other methods for extracorporeal detoxication, if necessary.

[Dynamics of the content of the pulmonary extravascular fluid during extracorporeal detoxication in critical state patients]. / Dinamika pokazatelia ob"ema vnesosudistoi zhidkosti legkikh pri provedenii ékstrakorporal'noi detoksikatsii u bol'nykh v kriticheskikh sostoianiiakh.

Time course of the content of interstitial, cellular, and total fluid in the lungs, of plasma osmolality and sodium concentration was studied in 20 patients with acute renal failure after repair surgery on the heart, thoracic and abdominal organs. Water balance of the lungs was studied by dissolution of electroimpedance indicators before and after removal of 2000-2500 ml of ultrafiltrate. Ultrafiltration of the blood in the course of hemodialysis (group 1) did not lead to a reliable reduction of the volume of intravascular fluid, whereas in group 2 a reliable reduction of the volume of interstitial fluid of the lungs by 34% and of the total liquid volume of the lungs by 29% occurred in the course of hemofiltration.

[Mechanisms of extracorporeal effects of hemofiltration on blood circulation in open heart surgery patients]. / Mekhanizmy ékstrakorporal'nogo vozdeistviia gemofil'tratsii na sistemu krovoobrashcheniia u bol'nykh, operirovannykh na "otkrytom serdtse".

The parameters of central hemodynamics and oxygen balance were studied over the course of prolonged venovenous hemofiltration (VVHF) in 16 patients with the syndrome of multiorgan failure (acute renal, pulmonary, cardiovascular insufficiency and shock), which developed after open heart surgery. The measurements were carried out 3, 8, 16, and 25 h after VVHF was started. The rate of ultrafiltration was 30 to 60 ml/min. Stabilization of arterial pressure (diastolic and mean) and normalization of the total peripheral vascular resistance were observed in all the patients irrespective of the status of the central hemodynamics before hemofiltration session. The doses of catecholamines with the predominant vasopressor effect were reduced. Integrative parameters of cardiorespiratory delivery and consumption of oxygen were unchanged. Addition of VVHF to a complex of intensive care measures used in patients with the multiorgan failure syndrome helped attain satisfactory results in 9 (56%) patients. Seven (44%) patients died in various periods after VVHF, shock occurring in 6 of them.

[The use of isolated ultrafiltration for the treatment of congestive circulatory failure]. / Primenenie izolirovannoi ul'trafil'tratsii dlia lechniia zastoinoi nedostatochnosti krovoobrashcheniia.

Clinical and hemodynamic efficacy of isolated ultrafiltration (IUF) has been assessed during treatment of congestive coronary failure in 11 patients. Forty IUF sessions have been performed. High therapeutic efficacy of the technique has been established. It has been shown that during IUF a decrease in volumic heart overload is accompanied by an increase in heart performance and O2 consumption. In terminal stages of heart failure IUF may lead to an imbalance between higher oxygen consumption and the capacity of cardiorespiratory system to deliver O2, which might cause the onset of circulatory hypoxia in the course of IUF.

[Hemodynamic aspects of the use of hemodialysis and hemofiltration in patients with low cardiac output syndrome in the postoperative period]. / Gemodinamicheskie aspekty primeneniia gemodializa i gemofil'tratsii u bol'nykh s sindromom nizkogo serdechnogo vybrosa v posleoperatsionnom periode.

Central hemodynamics and oxygen balance have been studied in 23 patients with low cardiac output syndrome during postoperative hemofiltration and acetate hemodialysis. Hemodialysis and hemofiltration caused considerable changes in circulation whose nature depended both on the initial state of central hemodynamics and oxygen balance and on detoxication technique. The data have been obtained that hemofiltration as a technique of extracorporeal detoxication was preferable in patients with postoperative low cardiac output syndrome.

[Results of the use of intraaortic balloon counterpulsation in patients with perioperative myocardial infarct]. / Rezul'taty primeneniia vnutriaortal'noi ballonnoi kontrpul'satsii u bol'nykh s perioperatsionnym infarktom miokarda.

The results of complex intensive therapy of cardiogenic shock have been studied in 17 patients with acute myocardial infarction developed as a complication of reconstructive surgery for ischemic heart disease. Complex therapy of cardiogenic shock included the use of intraaortic balloon contrapulsation, adrenomimetic agents, controlled lung ventilation and other intensive care procedures. 11 patients (64.7%) recovered from cardiogenic shock, 4 of them survived and were discharged from hospital. In 6 patients (35.3%) the combined use of adrenomimetics and intraaortic balloon contrapulsation had no effect. The results of intensive care procedures were shown to depend on the size of perioperative myocardial infarction, which affected the severity of hemodynamic disturbances and duration and efficacy of complex intensive therapy of cardiogenic shock. The use of intraaortic balloon contrapulsation in cardiogenic shock resistant to adrenomimetic agents led to temporary hemodynamic stabilization without improving the prognosis.