[Experience with outpatient treatment for thromboses and thrombophilias].

AIM: To evaluate the efficiency of diagnosis and treatment of thromboses in patients with thrombophilia in an outpatient setting. SUBJECTS AND METHODS: One hundred and seventy-two patients with different forms of thrombophilic states were examined. One hundred and thirty-two patients were found to have genetic mutations, of them 125 patients had multiple mutations. Thromboses were diagnosed in 130 patients with genetic disorders. RESULTS: The most common laboratory markers of thrombophilias were hyperhomocysteinemia (55%), sticky platelet syndrome (41%), and laboratory findings of antiphospholipid syndrome. Thrombogenic mutations, such as plasminogen activator plasminogen inhibitor-1 (73%), methylene tetrahydrofolate reductase (60%), platelet glycoprotein 1a receptors (50%), and fibrinogen (42%), were most often diagnosed. The efficiency of treatment was shown to largely depend on the duration of an initial thrombotic process. CONCLUSION: Outpatient treatment for thromboses is more economical and comfortable for patients. To avoid hospital admissions, it is necessary to time detect the disease and to start its treatment as soon as possible. The concurrent use of ultrasonography, genetic and laboratory diagnostic methods accelerates the identification and localization of the pathology, which facilitates its treatment and frequently rules out the need for patient hospitalization.

[The problem of hemorrhagic syndrome in its treatment with vitamin K antagonists (a review of literature)].

Vitamin K antagonists (warfarin, syncumar, phenylin, etc.) are commonly used to treat and prevent thrombotic diseases. The risk for varying degrees of hemorrhagic syndrome (intracranial hemorrhage in particular) is the most important problem in the use of drugs from this group. The rapid neutralization of the effects of used anticoagulants, which is verified by correcting the international normalized ratio (INR), is required in these cases and when emergency surgical interventions are needed. Transfusions of prothrombin complex concentrates (PCCs) in combination of vitamin K preparations are optimal for this purpose. The reason for the rational use of PCCs to promptly correct INR is the balanced composition of this transfusion medium (a combination of blood coagulation factors and biological anticoagulants). This regimen for emergency correction of INR minimizes the risk of thrombotic events.

[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).

[A case of transient complete suppression of cerebral electrical activity during anesthesia based on propofol].

In an anesthesiologist's practice, except the occurrence of clinical death on the operating table a long-term complete suppression of the electrical activity of the brain may arise only from the medical staff's crude error when administering intravenous anesthetics from the unlikely breakage of the anesthesia apparatus vaporizer. However, the authors assert that such a phenomenon may develop during general anesthesia using propofol given in its usual doses. Clinical examples are given. Whether the depth of general anesthesia should be controlled by the principle of feedback, by making neurophysiological monitoring is discussed.

[A regular internal auditing and registration of critical incidents regarded as safety maintenance elements within the anesthetic management of patients]. / Reguliarnyi vnutrennii audit i registratsiia kriticheskikh intsidentov kak elementy podderzhaniia bezopasnosti anesteziologicheskogo obespecheniia bol'nykh.

The paper summarizes a 5-year experience of evaluating the safety of anesthetic management of patients with thermal lesions treated at the department of thermal lesions of Vishnevsky's Institute of Surgery, Russia's Academy of Medical Sciences. Regular internal auditings, based on the principles of registering the critical incidents, the course of 1473 general anesthesia managements was analyzed in 168 patients. The conclusion is that the introduction of protocols of anesthetic management as well as a regular monitoring over meeting the fixed targets cut the total frequency of critical incidents from 2.85 to 1.19 as estimated per one general anesthesia. Finally the authors suggest a concept whose essence in that the operation of the modern anesthesiology department must be based on a scientifically substantiated technology of anesthetic management.

[Clofelin in the regimen of intravenous anesthesia during surgery for severe burns]. / Klofelin v skheme vnutrivennoi anestezii pri operatsiiakh u tiazheloobozhzhennykh.

The data on clofelin effect on the course of total anesthesia are contradictory. Clofelin effect on hemodynamics, drug doses, depth of anesthesia, and time of awakening after surgery was studied in 28 male patients with extensive deep thermal injuries in a state of acute burn toxemia and septicotoxemia. Randomized double blind study was carried out in 2 groups: study group, in which clofelin was injected intravenously (2.6 +/- 0.15 micrograms/kg) before induction to anesthesia and placebo group (0.9% NaCl, 20.0). Similar operations were carried out in both groups: debridement of burn wounds with autodermoplasty on body surface of different area. Methods of anesthesia were similar in both groups: premedication with reladorm at night and phenasepam before surgery; induction with phentanyl and thiopental and laryngeal mask installation; maintenance anesthesia with midasolam, thiopental, fentanyl, tracrium, and artificial ventilation of the lungs. The following parameters were recorded: hemodynamic (HR, ADsys, dia, mean); EEG (bispectral index--BIS, 95% right spectrum frequency--SEF-95). Drug consumption, volume of infusions, blood loss, and time of awakening were recorded. The authors failed to detect pronounced analgesic and sedative effects, which are assigned to clofelin, after its single use in the above mentioned dose, but noted its obvious stabilizing effect on hemodynamics, which persisted for up to 1.5 h after injection. Clofelin is recommended to be used in a dose of 2.5 micrograms/kg 10-15 min before induction in patients with burns with hyperdynamic circulation.

[Propofol-based protocol of general anesthesia for operations in patients with severe burns with ASA class III-IV]. / Protokol obscchei anestezii na osnove propofola pri operatsiiakh u tiazheloobozhzhennykh III-IV klassa ASA.

Use of propofol in surgery on critical patients is limited because of the possibility of poorly corrected hypotonia. The effects of total anesthesia with propofol + fentanyl + nitric oxide under conditions of artificial ventilation of the lungs (tracrium) were evaluated during 63 operations on 42 patients with severe burns (ASA III-IV), divided into 2 groups depending on the protocol of anesthesia. The difference in the protocols consisted in the method of choice of anesthetic doses: in group A we proceeded from EEG data (bispectral index--BIS) and in group B relied only on general clinical and hemodynamic signs with a retrospective analysis of BIS. Prevention of hemodynamic disorders in both groups included infusion loading (7-8 ml/kg), dopamine (5-7 micrograms/kg/min) and decrease of the velocity of propofol infusion to 15 mg/kg/h during induction anesthesia. This method leveled the hypodynamic effects of propofol. Simultaneous monitoring of BIS showed that the propofol dose needed for adequate induction narcosis with subsequent intubation should be higher than the dose usually recommended for patients with ASA class III-IV. Use of BIS monitoring during the operation resulted in a decrease of the propofol and fentanyl doses. The authors do not recommend decreasing the velocity of propofol infusion below 3 mg/kg/h (at FiN2) = 0.6) because of the risk of awakening during narcosis.

[Bispectral index (BIS)--a new ideology in solving an old problem]. / Bispectral index (BIS)--novaia ideologiia v reshenii staroi problemy.

A new method of electroencephalogram (EEG) processing is discussed: bispectral index (BIS), used for monitoring the depth of total anesthesia. The technology of BIS estimation is a principally novel approach to EEG processing, which can be denoted as an expert conclusion. EEG monitor Aspect A-100 (Aspect Medical System, USA) has been used for 3 years in the operation room during narcoses with barbiturates, propofol, midasolam, fentanyl, calypsol, isoflurane, and nitric oxide. BIS is a convenient and reliable method for evaluating the depth of total anesthesia with anesthetics with pronounced hypnotic effects at all stages of surgery. The disadvantages of the method are enumerated. The authors claim that monitors designed for expert evaluations hold good promise.

[Cryopreservation of erythrocytes at moderately low temperature with transportation simulation]. / Kriokonservirovanie éritrotsitov pri umerenno nizkikh temperaturakh s imitatsiei transportirovki.

Cryopreservation of red cell mass at -75-80 degrees C as concentrates warrants its prolonged storage (up to 1.5 years) in functional condition and transfusion without centrifugation. The above cryoconcentrates are resistant to temperature fluctuations and keep morphologically and functionally safe in response to a temperature rise to -32 degrees C (transportation simulation). Transport freezers efficient for frozen erythrocytes transportation have been tested.

[Nephrogenic mechanism of post-traumatic hemolysis]. / K voprosu o nefrogennom mekhanizme posttravmaticheskogo gemoliza.

The crush-syndrome model was introduced for experimental evaluation of the kidney-related mechanism of red cell destruction in an early posttraumatic period (1 day). Absolute and relative counts of the red cells, HCT were found reduced, while serum hemoglobin was on the increase in rats with crush syndrome against the controls and rats subjected to trauma and nephrectomy. Renal perfusion in situ with syngeneic blood brought about a decline in rat erythrocyte functional performance and a rise in the level of free hemoglobin. The findings support participation of the local nephrogenic hemolytic component in pathogenesis of early posttraumatic anemia.

[Features of general anesthesia and infusion-transfusion therapy in extensive surgery of the organs of the abdominal cavity]. / Osobennosti obshchei anestezii i infuzionno-transfuzionnoi terapii pri rasshirennykh operatsiiakh na organakh briushnoi polosti.

The article discusses variants of infusion-transfusion therapy (ITT) in early stages of expanded operations on the abdominal organs attended by massive blood loss (2 to 4 BCV and more). Seventy-three patients were examined, they underwent resection of the liver (30), pancreatoduodenal resection (37), or removal of a retroperitoneal tumor (6 patients). On the basis of precise study of central and peripheral hemodynamics, acid-base equilibrium, and blood oxygen transport function the authors find it necessary to increase the volumes of ITT to 70-80% BCV in the first stage of the operation with a colloid/crystalloid ratio of 1:4. The described method makes it possible to avoid critical fluctuations of cardiac output and blood pressure in massive bleeding. At the same time, such hemodilution causes no considerable decrease in hemoglobin concentrations (which was 79.0% of the initial level at the beginning of the main stage) and specific oxygen transport (85.0%, respectively). In absolute expression the specific oxygen transport before the hemorrhage is 465 + 29 ml/min/m2, which significantly exceeds the critical value. The authors believe the ITT method to be indicated in inevitable blood loss and absence of serious cardiovascular diseases. From comparative analysis of the different variants of general anesthesia, the authors conclude that the following combination of agents is preferable for the discussed category of patients: phentanyl, droperidol, seduxen, kalipsol (ketamine), and dalargin. Their balanced use ensures stability of the main homeostasis indices in all stages of the intervention; the hepato- and pancreatoprotective properties of dalargin are also of importance.

[The possibility of predicting the antinociceptive effect of dalargin in the preoperative period]. / Vozmozhnost' prognozirovaniia antinotsitseptivnogo éffekta dalargina vpredoperatsionnom periode.

The antinociceptive effect of dalargin was studied by its influence on the amplitude of somatosensory induced potentials (IP) and by changes in the threshold pain sensitivity to heat stimulation. It was shown that it was necessary to taken into account the patients' individual sensitivity to the drug. The influence of dalargin on IP in the pre-operative period was compared with the quality of its analgetic defence in surgical interventions. The defence quality was determined according to the reduction in the consumption of the narcotic analgesic phentanyl during anesthesia. The studied parameters were found to be directly related to the correlation coefficient 0.75 (p less than 0.05). The findings allow for a reliable prediction of the antinociceptive effect of dalargin in its application in anaesthesiological practice.