TREATMENT OF CHYLOTHORAX - ANESTHESIOLOGICAL OR SURGICAL PROBLEM?.

BACKGROUND: The progress of surgery, the widespread use in the clinic of cardiac surgery and extended lymphadenectomy in thoracic surgery led to a greater incidence of the thoracic lymphatic duct ' trauma. That is why the actuality of treatment of chylothorax and chylorrhea is increased. The aim; improvement of diagnostics, prevention and treatment results ofpatients with chylothorax and chylorrhea. MATERIALS AND METHODS: 37 patients (14 women and 23 men) with chylothorax had been treating with our participation in different hospitals from 2004 to 2014. The age of the patients was from 32 to 71 years. In 34 patients chylothorax occurred after surgery, in 3 patients - during the decompensation of the therapy diseases with the use of central venous catheterization, with an earlier clinic of thrombosis of the large veins of the neck. RESULTS: Conservative therapy had good clinical effect of 83.8%. 1 patient died due to pneumonia of the single lung on the background of chylothorax developed in the postoperative period after right-sided pneumonectomy. In other cases, chylothorax was eliminated and in the late period had no recurrence. CONCLUSION: prevention of chylothorax depends on the experience of the operating surgeon. If there is doubt intact thoracic lymphatic duct, it has tightened with the stitching surrounding adipose tissue. Conservative therapy is the method of choice in the treatment of chylothorax. Surgery is indicated for failure of conservative therapy within the first two weeks, or when massive chylorrhea takes place.

[REVIEW OF THE CURRENT METHODS OF RESPIRATORY SUPPORT FOR TRACHEAL SURGERY.]

Currently, surgery on the trachea underwent significant progress including in the latest methods of complex resections and reconstructions of the respiratory tract. In this regard, anesthesiologist needs the knowledge and skills of using various special respiratory techniques. Modern respiratory methods in tracheal surgery are "shunt-breath", high frequency jet ventilation, methods of extracorporeal oxygenation and respiratory relatively new technology - apneic oxygenation. This review deals with the pathophysiologicalfeatures of each of these techniques. Searching for information was made on the database: Scientific electronic library, Central Scientific Medical Library, PubMed, Scopus and Web of Science.

[Respiratory support in anaesthetic management for thoracic surgery and their comparative characteristics: over 2000 anaesthesia experience].

The article deals with the first comparative study of haemodynamics, gas exchange, and metabolic lung finction in patients with underlying respiratory and cardiovascular diseases. Different anaesthesia and ventilation (conventional AVL, OLV differentiated ALV) techniques were used. Respiratory support methodology with the use of HFV or CPAP during the main phase of thoracic surgery in patients with severe associated cardio-respiratory diseases was developed. Indications for differentiated AL V in thoracic surgery were developed.

[Ketamine versus propofol during one-lung ventilation in thoracic surgery].

A comparative analysis of gas, the metabolic rate, pressor, resistive and volumetric characteristics of pulmonary blood flow, central and intracardiac hemodynamics in patients undergoing thoracic surgery was conducted. 2 methods of anesthesia maintenance: on the basis of ketamine - fentanyl - pipecuronium and propofol - fentanyl - pipecuronim were compared. Invasive monitoring system PiCCOplus for the behaviour of the transpulmonary thermodilution (TT) in combination with VoLEF for the pulmonary thermodilution (PT) the change of ventilation mode ALV - OLV - ALV was used. OLV lasted for more than 1.5 hours.

[High level thoracic epidural analgesia as a special component of anesthesia during thoracic surgeries].

This article is devoted to assessing the adequacy and safety of total intravenous anesthesia based on constant dosed infusion of propofol and high thoracic epidural analgesia in thoracic surgical procedures requiring an artificial one-lung ventilation in patients with concomitant chronic cardiorespiratory disorders compared to TIVA without a high thoracic epidural analgesia. Comparative analysis of gas exchange, metabolic rate, pressor, resistance and volumetric characteristics of pulmonary blood flow, central and intracardiac hemodynamics was conducted. We used high technology invasive monitoring system PICCOplus for transpulmonary thermodilution in combination with VoLEF for pulmonary thermodilution in changing modes of ventilation MV-MSL V-MV. MSL V lasted more than 1.5 hours.

[Effect of propofol-based combined anesthesia on the development of adaptive mechanisms to the prolonged one-lung artificial ventilation].

The paper deals with the assessment of the adequacy and safety of multicomponent anesthesia based on propofol at lung surgery requiring one-lung ventilation (OLV) in patients with chronic respiratory diseases and with the evaluation of the effect of propofol on the development of adaptive mechanisms in various ventilation modalities in thoracic surgery. The pressor, resistive, and volume characteristics of pulmonary blood flow, systemic and intracardiac hemodynamics under artificial ventilation (AV) and OLV of a duration of up to 1.5 hours by a combination of pulmonal and transpulmonal thermodilution on a PiCCO plus device with a VOLEF attachment were compared. Multicomponent balanced anesthesia based on continuous graduated propofol infusion provides adequate protection of patients during thoracic operations, including those with concomitant respiratory abnormality.

[Respiratory provision of reconstructive operations for extended and multifocal tracheal stenosis].

The paper describes new approaches to anesthetic maintenance of reconstructive operations for multifocal and extended tracheal stenoses. The authors state a pathophysiological concept of and guidelines for respiratory approaches ensuring effective gas exchange and adequate hemodynamics at stages of various plastic repairs. Specifically, they describe the specific features of respiratory provision of rare surgical interventions: two-level tracheal resection and reconstruction and thyrotracheal complex transplantation in subtotal tracheal lesion. The advantages of high-frequency jet artificial ventilation using a Mansoon apparatus (Acutronic Medical Systems AG, Switzerland) are given.

[Closed tracheal injury--surgical or anesthesiologic-and-resuscitative problem].

Closed chest injury with rupture of the trachea and main bronchi is a rare and extremely life-threatening pathology. In suspected tracheal injury, as well as in severe closed chest injury with the gas syndrome, diagnostic tracheobronchoscopy with possible intubation is indicated in order to isolate the airway lumen from the paratracheal space. Tracheal intubation through a fibrobronchoscope should be considered to be the first aid. Tracheostomy is not the operation of choice and it is indicated only when there is no available technology or experience in intubating the airways under endoscopic guidance. Most small tracheal ruptures in closed chest injury, as well as those of iatrogenic postintubational genesis, may be medically eliminated. A surgeon jointly with an anesthetist and a bronchological endoscopist should determine indications for the operation. The operation should be performed as early as possible. It should be started from the intubation of the airways and the insertion of the end of an intubational tube caudally the rupture. When the breathing circuit is depressurized, all alternative gas exchange maintenance techniques available at an anesthetist's disposal, including high-frequency artificial ventilation and a shunt-breathing system, are indicated, which should provide a patient's safety and surgical comfort.

[Role of a credit system in the development of continuous postgraduate training of physicians within the framework of the innovation educational space formation program of the I. M. Sechenov Moscow Medical Academy].

Russia 's joining the European higher educational space and an increase in the international competitive capacity of the European higher educational system envisage first of all that the European credit test system (ECTS) should be accepted and introduced into all national higher educational schools, which ensures both credit test and cumulative functions and guarantees the academic recognition of the education abroad. The issues of modernization of approaches to reforming the continuous postgraduate training of physicians, by using the credit test system, as well as new forms and technologies for an educational process in accordance with the European educational system principles are under discussion. The novelty of the proposed development is that the credit test system is first applied to the continuous postgraduate training of physicians within the framework of the Russian higher medical educational system. The Russian continuous postgraduate medical training pattern that is common in form and content is proposed in accordance with the Bologna declaration principles; approaches have been developed to incorporating the European educational traditions into the Russian national continuous postgraduate medical training system, by employing the credit test system; criteria have been elaborated for adapting the European credit test system at all stages of reformation of the Russian educational system; guidelines have been worked out for the conversion of academic load of various forms of the continuous postgraduate training of physicians to the credit test system; ways of introducing the new forms and technologies into an educational process have been proposed in accordance with the European education system principles, by taking into account the credit test system. The introduction of new technologies of an educational process, by using the credit test system will contribute to personality formation in a physician who has a high competence, a capacity for valuable independent work in health cared facilities and further postgraduate training during his/her professional activities, which is required to provide a high-skill aid to patients in compliance with his/ her work status and employment place.

[Sevoflurane and isoflurane during thoracic operations under artificial one-lung ventilation in patients at a high surgical and anesthesiological risk].

The specific features of balanced anesthesia utilizing sevoflurane (versus isoflurane) during thoracic operations under artificial one-lung ventilation (AOL ) have been studied in patients at high operative and anesthetic risks. Unlike isoflurane, sevflurane fails to cause vasodilatation in both the greater and lesser circulation (including in the gas-exchange part ofpulmonary circulation). The difference of the anesthetics in their vasodilating capacity in the vessels of pulmonary and systemic circulation determines various mechanisms of pathophysiological and adaptive circulatory changes in pulmonary collapse and under AOL V Under sevoflurane anesthesia, compensatory blood flow limitation along the collaborated lung due to permanently vasohypertension in gas-exchange microcirculation is accompanied by a systemic circulatory response that is aimed at reducing right ventricular load. Termination of hypoxic pulmonary vasoconstriction in the collaborated lung occurs not early than 80-125 min of AOLV, fails to lead to recovery of impaired gas exchange due to vasohypertension and high shunt in the ventilated lung, and is attended by right ventricular overload. The latter differentiates sevoflurane anesthesia from isoflurane one wherein completion of pulmonary hypoxic vasoconstriction upon 80-125-min exposure to AOL V results in the recovery of gas exchange to the baseline levels. The pattern of reperfusion changes in ventilation emergence in the operated lung under anesthesia using both sevoflurane and isoflurane is of no significant pathological tinge and it is followed by no pulmonary and systemic metabolic disturbances. Isoflurane should be recognized to be preferable component at the stage of anesthesia maintenance in patients with cardiopulmonary diseases during thoracic operations under prolonged AOL V (more than 2 hours).

[Impact of combined anesthesia using isoflurane on the development of adaptation mechanisms on changing ventilation conditions in thoracic surgery].

The paper deals with the effect of isoflurane (IF) as a component of combined anesthesia during thoracic interventions in the lateral position on the development of adaptation mechanisms to a change in artificial ventilation (AV) modes--from ventilation of both lungs to that of one lung (unilateral ventilation, ULV), long exposure to ULV and to a change from ULV to ventilation of both lungs. Eighteen patients at a high operation-anesthetic risk were examined. Measurements were made in 6 steps, including conditions in AV, exposure to ULV for 15-30, 55-60, and 80-120 minutes, AV after 20-min exposure to ULV, and at the end of surgery in the supine position. While analyzing the results, the authors made an important observation that IF has a property of preventing capillary formation in the ventilated portions, without impairing the mechanism of pulmonary hypoxic vasoconstriction in the area of atelectized alveoles. This contributed to the optimization of a ventilation-perfusion relationship and creates conditions for adequate oxygenation. The use of IF as a component of combined anesthesia during thoracic operations associated with a need for artificial unilateral ventilation in patients at a high operation-anesthetic risk created conditions for optimizing gas exchange and blood circulation at all stages of an operation and anesthesia.

[Age-related changes of somatotype and body mass components in girls].

The longitudinal and transverse studies of girls aged 7 to 17 years living in Moscow and the town of Yelabuga were performed to monitor the dynamics of their growth processes, parameters of ectomorphism, mesomorphism and endomorphism depending on the type of body build. Anthropometric, anthroposcopic metods and cluster analysis were used to evaluate the type of body build according to V.G. Shtefko and A.G. Ostrovskiy (1928). Quantitative assessment of parameters of endo-, meso- and ectomorphism was performed using Heath-Carter method (1980). It was shown that the age-related variability of the types of body build appeared in association with the developmental heterochronism, which resulted from the uneven growth rate of different body components. The least variable parameters were found in the girls of digestive and asthenoid types of body build, while in girls of muscular and thoracic types these parameters changed more frequently. The critical periods during which the significant changes of somatotype were increased in number, were defined as 9 to 10 years and puberty period--11 to 14 years. Most sensitive time points in the time-course of somatotype establishment in girls are the ages of 12 and 14 years.

[Application of two dilution techniques using Swan-Ganz-REF and PICCO-Plus technologies to the evaluation of systemic and pulmonary circulation].

The paper considers two thermal dilution methods for monitoring central and pulmonary hemodynamics, such as pulmonary thermal dilution (Swan-Ganz-REF) and transpulmonary thermal dilution (PICCO-Plus technology) in the context of their invasiveness, informative value, and the easiness-to-use in high-risk patients during thoracotomic interventions. They have been comparatively analyzed. The limitations of and contraindications to their use have been systematized. It has been found that these methods are not only interchangeable, but they also complement each other. Concurrent application of these methods may be recommended in high-risk patients during traumatic thoracotomic interventions.

[Anesthesiological problems in the surgical treatment of chronic obstructive pulmonary disease]. / Anesteziologicheskie problemy pri khirurgicjeskom lechenii khronicheskoi obstruktivnoi bolezni legkikh.

Maintenance of effective gas exchange made with respect to surgical comfort and lower risk of intraoperative lung damage is the main problem in the anesthetic management of surgical reduction of pulmonary volume (SRPV). Described in the paper is the experience of anesthetic management made in 10 patients in SPRV. The method of differential ALV (DALV) with continuous positive pressure in airways (CPPA) made for the ventilation support of the independent lung was found to be the only effective technique ensuring an adequate gas exchange in surgery for SPRV in patients with diffusive pulmonary emphysema (DPE). It accounts for the pathophysiological specificity of diffusive pulmonary lesion. At the same time, it provides for an optimal surgical comfort and for the most cautious manipulations on the lung. Such a combination improves the overall surgical results. The high-frequency respiratory support to the operated lung is contraindicated in such patients because of hyperinflation of the affected lung.

[New russian myorelaxant vero-pipecuronium (pipecuronium bromide) used for the anesthetic management of operations on the thorax and abdomen organs]. / Novyi otechestvennyi miorelaksant vero-pipekuronii (pipekuronii bromid) v anesteziologicheskom obespechenii operatsii na organakh grudnoi i briushnoi polosti.

The experience of clinical use of the new Russian myorelaxant of the non-depolarizing action vero-pipecuronium (pipecuronium bromided) manufactured by "Veropharm" is described. Vero-pipecuronium was found to ensure splendid and good conditions for the intubation of the trachea and to maintain reliably myorelaxation. The recommended doses and availability of an antidote (prozerine) provide for a sufficiently controllable myorelaxation. Vero-pipecuronium does not virtually exert any effect on the parameters of hemodynamics and can be successfully used in patients with a high anesthetic risk including heart surgeries. Thus, Russian vero-pipecuronium has now an effective and safe myorelaxant manufactured inside the country, whose parameters are not inferior to those of pipecuronium bromide (arduan) manufactured by "Gedeon Richter", Hungary. Since the described drug is made in Russia, one can hope it will be highly effective both economically and pharmacologically.

[Continuous positive airway pressure and high-frequency independent lung ventilation in patients with chronic obstructive lung diseases]. / Postoiannoe polozhitel'noe davlenie v dykhatel'nykh putiakh i vysokochastotnaia ventiliatsionnaia podderzhka nezavisimogo legkogo u patsientov s khronicheskimi obstruktivnymi zabolevaniiami legkikh.

The original hypoxemia, hypercapnia, high pulmonary hypertension, high resistance of microcirculation vessels, right volumetric ventricular overload, persistent sub-edema of pulmonary intersticium as well as disparity of ventilation and perfusion between both lungs are the main problems in patients with chronic obstructive disease of the lungs (CODL). Such patients are, as a rule, intolerant to the independent lung collaboration or artificial single-stage ventilation (ASV). Patients with respiratory insufficiency, stages 2 and 3, and with a pronounced impaired type of ventilation have originally a deranged blood gas composition, like hypoxemia or hypercapnia. The application of volume-controllable bi-pulmonary ASV in such patients maintains an adequate gas exchange hemodynamics. However, ASV is accompanied by a significantly reduced gas-exchange function of the single ventilated lung and by essentially worsened intrapulmonary hemodynamics. Therefore, what is needed is to use alternative methods of independent lung ventilation in order to eliminate the gas-exchange impairments and to enable surgical interventions at thoracic organs in such patients (who are intolerant to ASV). A choice of a method and means of oxygen supply to the independent lung is of great importance. The possibility to avoid a high pressure in the airways, while maintaining, simultaneously, an adequate gas exchange, makes the method related with maintaining a constant positive pressure in the airways (CPPA) a priority one in case of CODL patients. The use of constant high-frequency ventilation in the independent lung in patients with obstructive pulmonary lesions does not improve the gas exchange or hemodynamics. Simultaneously, a growing total pulmonary resistance and an increasing pressure in the pulmonary artery are observed. Consequently, the discussed method must not be used for the ventilation support of the independent lung in patients with the obstructive type of the impaired external breathing function.

[Diagnosis of gluten enteropathy and efficiency of its treatment]. / Diagnostika gliutenovoi énteropatii i otsenka éffektivnosti ee lecheniia.

AIM: To develop screening diagnosis of gluten enteropathy (GEP), indications to administration of glucocorticoid hormones and objective criteria of effective treatment. MATERIAL AND METHODS: Clinical, immunological (antibodies-Abs to alpha-gliadin, reticulin and endomisium) examinations, enterobiopsy with morpho- and stereometry of small intestinal mucosa were made in 200 GEP patients. The examination was repeated 6 months to 5 years and later after the discharge from the hospital. RESULTS: Mean values of Abs to alpha-gliadin was 6 times higher than normal values. Positive titers of Abs to endomisium and reticulin were in 100 and 87.5% patients, respectively. Formed stool was registered 1.5 times more frequently, polyfecalia occurred 2.5 times less frequently, hypovitaminosis and trophic disorders were relieved 3 times more frequently, malabsorption syndrome reduced in patients given prednisolone vs those untreated with it. CONCLUSION: Screening diagnosis of GEP may be based on Abs tests to alpha-gliadin, reticulin and endomisium. Improvement of clinical condition of GEP patients can be stated by decreased diarrhea, polyfecalia and malabsorption symptoms. The treatment efficacy may be judged by clinical improvement, recovery of morphological structure of small intestinal mucosa, normalization of concentration of Abs to alpha-gliadin, reticulin, endomisium. Administration of prednisolone provides more complete and rapid rehabilitation of the patients.