The evaluation of immunosuppressive regimens in kidney transplant Mongolian recipients / Эрүүл мэндийн лаборатори

Background@#However kidney transplantation has being performed in Mongolia since 2006, because of pre-transplant sensitization, ABO incompatibility, hepatitis B and C virus activation many patients are taken kidney transplantation in abroad. The transplantation centers use own immunosuppressive regimens.@*Objective@#Our aim was to assess the immunosuppressive regimens efficacy and toxicity in kidney transplant Mongolian recipients.@*Methods@#We analyzed data from 96 adult kidney transplant recipients who had taken kidney transplantation in different transplant centers from August 2006 through January 2014. There were 3 kinds of regimens Group I Simulect induction with standard triple /FK506/CyA+MMF/AZA+steroid/, Group II Campath-1H induction with CNI monotherapy and Group III Campath-1H induction with standard triple /FK506/CyA+MMF/AZA+steroid/. We retrospectively collected the post-transplant first two years serum creatinine. The study was performed in 2014. The questionnaire was taken and blood samples collected for determination of tacrolimus through level and for other laboratory tests. The primary end point was the first two years serum creatinine, the secondary end points included rejection episodes, blood through level of tacrolimus and some laboratory findings. @*Results@#The post-transplant first two years serum creatinine levels were significantly different in 3 groups. Group III showed similar results compared to Group I. There was not enough data of biopsy proven acute rejection episodes however group II said more rejections occurred. However participants said that rejection occurred in 15 (15.6%) biopsy was done only 3 (3.1%) cases. Blood through level of tacrolimus was significantly different in three groups. Some laboratory findings showed different between three groups. @*Conclusions@#A regimen of Campath-1H induction with CNI monotherapy (Group II) may be advantageous for short-term renal function and cost effective but there were more rejection complications and increased creatinine. The regimen of Campath-1H induction 11 with standard triple (Group III) may be advantageous for long-term renal function, allograft survival, but there should consider about infection complications and polycythemia. Simulect induction with standard triple could be best choice but transplantations were performed in experienced centers. The study enrolled few cases and cases which were performed at the beginning of transplant program so many things could influence on the result. The study was compared beginner transplant center with experienced centers. Longitudinal cohort study needed in the future.

The Effect of Pneumoperitoneum and Trendelenburg position on respiratory mechanics under general anesthesia during gynecological laparoscopic surgery / Монголын Анагаах Ухаан

Background@#Gynecological laparoscopic surgery requires pneumoperitoneum(PP) with CO₂ gas insufflation and Trendelenburg position. Pneumoperitoneum and Trendelenburg position may impact intraoperative respiratory mechanics in anesthetic management.The goal of this study was to evaluate the influence of Pneumoperitoneum and Trendelenburg position on respiratory mechanics and ventilation. @*Methods@#Twenty one patients scheduled for elective gynecological laparoscopy were evaluated. The patients had no preexisting lung and heart disease or pathologic lung function. Conventional general anesthesia with thiopental sodium, fentanyl, аtracrium and isoflurane was administered. The peak inspiratory pressure, plateau pressure, and end-tidal CO₂ were compared before after creation of pneumoperitoneum with an intraabdominal pressure of 15 mmH₂O, then after PP10, PP20, PP30 minutes in the 20° Trendelenburg position, and after deflation of pneumoperitoneum. The dynamic lung compliance was calculated.@*Results@#During of pneumoperitoneum, there were a significant increase in peak inspiratory pressure by 6 cmH₂O, plateau pressure by 5 cmH₂O, while dynamic lung compliance decreased by 11 ml/cmH₂O. General, the Trendelenburg position induced no significant hemodynamic and pulmonary changes.@*Conclusion@#The effects of pneumoperitoneum significantly reduced dynamic lung compliance and increased peak inspiratory and plateau pressures. The Tredelenburg position did not change these parameters. The end-tidal CO₂ significantly increased after pneumoperitoneum and CO₂ deflation.

Ilioinguinal and iliohypogastric nerve block / Монголын Анагаах Ухаан

Ilioinguinal (II) and iliohypogastric (IH) nerve blocks are often performed to provide intra- andpostoperative analgesia for hernia repair in children and adults. Several techniques are describedin the literature. Recently an ultrasound guided technique for II and IH nerve blocks were describedin the international journals. The block success rates are variable specially for using anatomicallandmark blind techniques. In the present study, the anatomical variations in course of the II andIH nerves are described. Knowledge of the course of these nerves in the inguinal region, and anunderstanding of variations seen in their topography, can decrease the incidence of postoperativecomplications and adverse effects. Ultrasound guidance of block performance will shorten the time,reduce the number of needle passes and shorten the block onset time. Blocks may be performedusing lower local anesthetic doses.

The critical care suffi ciency at the secondary -level hospital in Mongolia / Монголын Анагаах Ухаан

IntroductionThe hospital mortality rate in low and middle-income countries is much higher than developed countries,thus enhancing the critical and emergency services will reduce rate of mortality. Providing life savingtreatment, continuous monitoring for the critically ill patient survival is defi nitely linked to availabilityand capability of equipment, drugs, medicine and trained personnel. Therefore, the challenges aredetermined and introduce stepwise method to reduce in-hospital mortality.GoalDetermining second level hospital’s capability to provide critical care and suffi ciency of medical supply.Materials and MethodProvince and district hospitals were included in the research and cross-sectional study conducted. Thesecond level hospitals were selected from 9 Provincials hospitals in 4 regions of Mongolia, 5 districthospitals in the capital city of Ulaanbaatar were involved, clustering and randomised in research. Theresearch conducted after obtaining Medical Ethical Committee approval. Statistical analysis usingSPSS-17. Data and some materials were analyzed with Shapiro-Wilk test for assessing the populationis normally distributed.ResultNone of the hospital is able to provide with 24-specialist doctor service in the emergency room and 3 (21,4%) hospitals have available for 24 hours intensive care doctor service.In the emergency settings, capability for FAST ultrasound examination is 8 (57, 1%) hospitals and noneof the hospital is able to provide echocardiography.Even though the number of intensive care bed is 5.6, the number of ventilators of hospitals are 2.5ventilators in 100.000 populations. 1 hospital is equipped with air-oxygen system. 3 (21.4%) of hospitalsare always able to perform central venous catheterization, and only 3 of the hospitals havevet thecapability of non-invasive ventilation. Drug and medicine use for cardiopulmonary resuscitation, availableof atropine and amiodoran were 9 (64.3%) and 5 (35.7%), respectively.Conclusion: None of the intensive care units of hospital, which participated in our research, able toprovide evidence-based emergency care on acutely ill patients.

Some results of using abdominal wall block in children undergoing appendectomy surgery / Шинэ санаа Шинэ нээлт

The aim of this study was to evaluate of analgesic effect of ultrasound guided transversus abdomines plane block in children undergoing open appendectomy surgery and compare to children were used GA alone.Twenty children aged 5-15 years with ASA I-II classification were randomly enrolled in this study.Each group had 10 children and all children were received GA with same techniques. Study group(transversus abdomines plane block group) were assigned to receive ultrasound guided block using 0.3 ml/kg of Bupivacaine 0.25%. Intraoperative hemodynamic changes, postoperative maximum pain score, the time the first analgesic requirement, correllation between inflammatory process, surgical disease complication and pain intensity were studied. Statistic analysis was made in Excel usingdescriptive analysis, correlation and regressive analysis. A p-value<0.05 was considered significant.There was no differencies between the two studied groups regarding demographic and clinicalcharacteristics. Intraoperative systolic blood pressure changes was higher in control group than studygroup (17%), and HR and BP were more stable in the study group. Level of WBC had direct positive relationship with appendix inflammation (r=0.71 (p-утга <0.001) and weak positive correlation (r=0.44 p-утга <0.05) with pain intensity. Postoperative pain score was higher in control group and the first analgesic requirement time was 2h. In the study group had mild to moderate pain and the the firstanalgesic requirement time was 4h.Transversus abdomines plane block under ultrasound guidance was easy, safe, reliable and effective analgesic in children undergoing open appendectomy surgery.

ONE LUNG ANAESSTHESIS DURING THE THORACIC SURGERY / Шинэ санаа Шинэ нээлт

Thoracic surgery usually used for anesthesia double lumen endotracheal tubes, then ventilated one lung in NCC of Mongolia The clinical records of the 160 cases patients who had double-lumen endotracheal tubes to place in NCC of Mongolia. In patients during one lung anesthesia done 2012- 2014 were reviewed. All cases were performed high level thoracic epidural catheterization and put double lumen tube for jugular internal vena We are reporting 2012- 2014 anesthesia department at National Cancer Center of Mongolia. In our study involved all 160 open thoracic surgery cases with DLT. In study had anesthesia tidal volume 7.77+1.07ml/kg, one lung volume5.87+0.46 ml/kg, the Mongolian women DLT size 35.43+2.25Fr, deep 27.68+2.47 cm, Mongolian man DLT size 37.09+4.69cm, deep 28.43+2.6 cm. During anesthesia monitored average SpO2-95%+ 1.07,in analyzed arterial blood average SaO2- 92.65 %+ 5.69. (p<0.032) One lung anesthesia separating two lungs by double lumen tube (DLT) – the advantages of the method are allowing surgeons to operate safely in collapsed side of lung; there are a few reports of airway damages. The bronchoscope procedure is in need to use during the all operations in Mongolia. Other types of separation tube are required to be (especially in children) introduced. In the future lungs, esophagus, mediastinal tumors and heart, spine and vascular surgery need double lumen tube to global standards anesthesia widely available in Mongolia. The thoracic anesthesia use double lumen tube outside the epidural anesthesia decided that it can be combined with postoperative pain control. Correct technique of placing the double lumen tube one lung anesthesia surgical team and the shortness of time and the surgical risk patients with post-surgical complications and reduce mortality is of high importance in Mongolia. In our study is a dominant decided that it was linked to smoking habits

Outcome of one lung ventilation thoracic surgery / Монголын Анагаах Ухаан

Goal: Thoracic surgery usually used for anesthesia double lumen endotracheal tubes, then ventilatedone lung.Methods: The clinical records of the 160 cases patients who had double-lumen endotracheal tubes toplace in National Cancer Center of Mongolia (this structure starts from the inferior part of the larynxin the neck, opposite the 6th cervical vertebra, to the intervertebral disc between Th4-5 vertebrae inthe thorax, where it divides at the carina into the right and left bronchi). Inpatients during one lunganesthesia done 2012- and 2014 were reviewed. All cases were performed high Level thoracic epiduralcatheterization and put double lumen tube for jugularinternal vena. Double-lumen endotracheal tubesare not meant for postoperative ventilation. In addition, because of their significantly larger size andstiffness, they have a higher propensity for trauma after insertion, which may result in postoperativehoarseness or vocal cord lesions.Results: We are reporting 2012- 2014 anesthesia department at National Cancer Center. In our studyinvolved all 160 open thoracic surgery cases with DLT. In study had anesthesia tidal volume7.77+1.07ml/kg, one lung volume 5.87+0.46 ml/kg, the women DLT size 33.43+7.25Fr, deep 27.68+2.47 cm, manDLT size 37.09+7.69cm, deep 28.43+2.6 cm. During anesthesia monitored averageSaO2-95%+1.07,in analyzed arterial blood average SpO2- 92.605 %+5.69 (p<0.032).Conclusion: One lung anesthesia separating two lungs by double lumen tube (DLT) – the advantagesof the method are allowing surgeons to operate safely in collapsed side of lung; there are a few reportsof airway damages. The bronchoscopy procedure is in need to use during the alloperations. Other typesof separation tube are required to be (especially in children) introduced.

The homeostasis during cardiopulmonary bypass / Монголын Анагаах Ухаан

BackgroundOpen cardiac surgery in CPB condition has increased dramatically in the recent 5 years. Therefore,multidisciplinary researches are needed on this new technological method. The surgical results andperioperative complications depends on keeping normal level of homeostasis parameters during CPBin the open heart surgery.Materials and MethodsTo study the parameters of homeostasis during cardiopulmonary bypass, we concluded retrospectivesample survey using CPB reports from 535 patients, who underwent cardiac surgery with CPB between2008 and 2012, in 3rd Hospital’s cardiovascular surgery department.We calculated average parameters of homeostasis, and studied heart recovery process.ResultIn recent 5 years, artery blood indicators were pH=7.45±0.06, paCO2=28.8±5.86 mm.Hg,paO2=398.3±99.33 mm.Hg, BE=-4.15±2.51 mmol/l, HCO¯3=20.57±2.18 mmol/l, Ht=28.15±5%,K+=4.12±0.87 mmol/l and Na+=140±3.22 mmol/l during open cardiac surgery in CPB condition(n=535).80.3% of patients’ heart spontaneously recovered and stabilized with sinus rhythm. 16.4% of them wererecovered with fibrillation while 2.1% of them were recovered with adrenomimetic support and 1.2% ofthem were recovered with strong adrenomimetic support and defibrillation.Conclusions:1. When acid and alkaline balance was normal during CPB, hyperoxia and hypocapnia are appearedthrough gas analysis (p=0.0001).2. While blood cardioplegic solution is used, heart is refreshed with 80.3% sinusial rhythm(p=0.0001).

The influence of different types of cardioplegic solutions on homeostasis during open heart surgery / Монголын Анагаах Ухаан

BackgroundOpen cardiac surgery in CPB condition has increased dramatically in the recent 5 years. Therefore,multidisciplinary researches are needed on this new technological method. The surgical results andperioperative complications depends on keeping normal level of homeostasis parameters during CPBin the open heart surgery.Materials and MethodsTo study the influence of blood cardioplegic and Del Nido’s solution on homeostasis duringcardiopulmonary bypass, we concluded retrospective sample survey using CPB reports from 535 patients,who underwent cardiac surgery with CPB between 2008 and 2012, in 3rd Hospital’s cardiovascularsurgery department.We calculated average parameters of homeostasis, and studied an aortic cross clamp, CPB time,hemodilution and heart recovery process, on three stages of the surgery.We did comparative study on 21 cases of children, who went under congenital heart disease surgery;using Del Nido’s and blood cardioplegic solution.ResultIn recent 5 years, artery blood indicators were pH=7.45±0.06, paCO2=28.8±5.86 mm.Hg,paO2=398.3±99.33 mm.Hg, BE=-4.15±2.51 mmol/l, HCO¯3=20.57±2.18 mmol/l, Ht=28.15±5%,K+=4.12±0.87 mmol/l and Na+=140±3.22 mmol/l during open cardiac surgery in CPB condition(n=535).In case group (n=21), these indicators were pH=7.33±0.09, paCO2=37.49±12.11 mm.Hg,paO2=465.76±77.54 mm.Hg, BE=-6.2±2.78 mmol/l, HCO¯3=20.44±2.46 mmol/l, Ht=27.38±5.12%,K+=3.65±0.46 mmol/l and Na+=141.22±2.64 mmol/l. In control group (n=21), above results werepH=7.40±0.07, paCO2=28.52±6.34 mm.Hg, paO2=394±88.92 mm.Hg, BE=-5.52±2.37 mmol/l,HCO¯3=18.84±2.39 mmol/l, Ht=27.66±3.52%, K+=3.86±0.66 mmol/l and Na+=141.2±3.22 mmol/l.Conclusions:1. When acid and alkaline balance was normal during CPB, hyperoxia and hypocapnia are appearedthrough gas analysis (p=0.0001). Metabolic acidity and hyperoxia showed up in the case group, whohad used Del Nido’s solution (p=0.0001).2. As the beginning of CPB, patient’s hematocrit is reduced by 10.26% (p=0.0001). The influences ofboth Del-Nido and blood cardioplegic solutions are the same on hemodilutes (p=0.26).3. While blood cardioplegic solution is used, heart is refreshed with 80.3% sinusial rhythm(p=0.0001).4. Aortic cross clamp time and increases repetition of cardioplegic solutions are correlated with cardiacrecovery time positively (r=0.445, p=0.0001, n=520).

Arterial blood gas and acid base disbalance in intracranial hemorrhage / Монголын Анагаах Ухаан

Introduction. Approximately fifteen million people worldwide have a stroke each year. 1in 6 people around the world will have a stroke in their life time. Two-thirds of stroke deaths occur in less developed countries. PH is format used to describe the proton concentration in a solution. It is the negative logarithm10 of the H+ concentration, so when the blood pH is normal (7.35-7.45) the H+ concentration in the blood is 40 nmol.L. An acid is a substance that has the ability to give up a proton(H+-a positively charged hydrogen ion) and so when in an aqueous solution they have a low pH. A base is a substance that has the ability to accept a proton and has a high pH in solution. Respiratory alkalosis is results from the excessive excretion of CO2, and occurs when the PaCO2 is less than 4.5 kPa (34mmHg).Goal. To study and evaluate the change occurred in Glasgow coma scale and arterial blood gas, acid base balance of the patients suffering from intracranial stroke.Materials and Methods. Test for Arterial Blood Gas and Acid Base Balance were used on 112 patients with Intracranial Hemorrhage.Results. There were 66 men and 46 women between the ages of 25 and 83. Nineteen patients (17%) had normal, seventy seven (68.8%) patients had respiratory alkalosis, five patients (4.5%) had respiratory alkalosis and metabolic acidosis, two patients (1, 8%) had respiratory acidosis, four patients (3, 6%) had metabolic alkalosis, four patients (3.6%) had mixed alkalosis, and one patient (0.9%) had mixed acidosis. In cases of intracranial hemorrhage Arterial Blood Gas and Acid Base Balance is affected in most patients in the character of respiratory alkalosis and hypocapnia, due to hyperventilation. By Glasgow coma scoring system, twenty seven (24.1%) patients had 3 score, twenty eight (25%) patients had 4-8 score, twenty seven (24.1%) patients had 9-12 score, ten patients (8.9%) had 13-14 score, twenty (17.9%) patients had 15 score. In 3 score group 21 (77.8%) patients had respiratory alkalosis, 2 (7.4%) patients had respiratory acidosis, 1 patient had (3.7%)metabolic alkalosis, 1 (3.7%) patients had respiratory alkalosis and metabolic acidosis, 2 (7.4%) patients had mixed alkalosis, In 4-8 score group, 22 (78.6%) patients had respiratory alkalosis, 2 (7.1%) patients had normal, 2 (7.1%) patients had respiratory alkalosis and metabolic acidosis, 1 (3.6%) patient had mixed alkalosis, 1 (3.6) patient had mixed acidosis, In 9-12 score group, 24 (88.9%) patients had respiratory alkalosis, 1 (3.7%) patient had metabolic alkalosis, in 1 (3.7%) patient had respiratory alkalosis and metabolic acidosis, 1 (3.7%) patient had mixed alkalosis, In 13- 14 score group, 7 (70%) patients had respiratory alkalosis, 1 (10%) patient had metabolic alkalosis, 2 (20%) patients had normal, In15 score group, 3(15%) patients had respiratory alkalosis, 1 (5%) patient had metabolic alkalosis, 15 (75%) patient had normal, 1 (5%) patient had respiratory alkalosis and metabolic acidosis.Conclusion. There were significant correlations between Glasgow Coma Scale and acid base (r=0.45* p<0.001). Acid base disbalance more likely to get increased as much the Glasgow Coma Scale evaluation gets decreased.

Kidney transplantation in Mongolia using effective and economical immunosuppression - a three-year experience.

Between August 2006 and August 2009, 34 ethnic Mongolians were the recipients of a kidney transplant at the Central Clinical Hospital in Ulaanbaatar, Mongolia. In 31 of the operations the donor was either a sibling or parent. In 4 recipients the donors were 2 recently deceased accident victims following controlled cardiac arrest and after next of kin permission. All 4 recipients are alive with life-supporting function. Appropriate legislation was passed in 2008. Thirty-one of the 34 recipients (91%) are alive. The 1-year patient and graft survival is 91% and 82%, respectively. In all cases, recipients received 1 dose of Campath 1 preoperatively followed by monotherapy with either Cyclosporin or Tacrolimus. Due to the remote geographical location of some of the recipients, appropriate serum drug levels were difficult to monitor. Azathioprine was therefore added in the last 13 recipients. Except for acute rejection episodes, no patients received steroid therapy. There were 7 diagnosed and treated acute rejections in the 34 recipients (21%). The mean annual cost of the immunosuppressive therapy period compared favorably with neighboring China and with costs in Spain. We conclude that the use of Campath 1 together with a non-steroid maintenance immunosuppressive regimen provides both economical and acceptable graft and patient survival in a developing country.

Kidney transplantation achievements in Mongolia.

Between August 2006 and August 2009, 33 patients with end-stage renal disease were the recipients of kidney transplantations. The donors were living related 29 operations with 4 recipients of 2 deceased donors following accidents with cardiac arrest controlled after permission by the next of kin. We used standard techniques for the donor and recipient operations. All recipients were prescribed 1 dose of alemtuzumab (Campath 1 H 20-30 mg), peroperatively preceded by 500 mg methylprednisolone. In 2 recipients, a second infusion of Campath 1 was administered on postoperative day 2. On postoperative day 3, we prescribed monotherapy with either cyclosporine (n=29) at a starting dose of 7 mg/kg body weight or tacrolimus (n=6) at a starting dose of 0.7 mg/kg body weight. With the exception of patients treated for an acute rejection episode, no patient received steroid therapy. There were 7 acute rejection episodes, which were treated with 3 consecutive daily doses of methylprednisolone (250 mg). The 1-year patient survival was 94% and 2-year graft survival, 84.8%. We concluded that the use of Campath 1 together with a non-steroid maintenance immunosuppressive regimen provided acceptable graft and patient survival in our developing country.

Pain management in pediatric day surgery patients at The Maternal and Child Medical Research Center in Mongolia.

BACKGROUND: Pediatric day surgery shortens the hospital stay, reduces the exposure of nosocomial infections and allows for active parental participation. But pain delays the recovery and it increases the morbidity, including nausea and vomiting, and the maladaptive behavioral changes. This study was conducted to compare the effect of rectally administered paracetamol or diclofenac combined with regional nerve block with the traditional pain control method. METHODS: Two hundred forty one randomly selected pediatric patients were allocated into two groups. The empirical pain relief group (the control group, n = 120) included the patients that received intravenous sulpyrin and/or meperidine postoperatively. The patients in the multimodal preemptive pain relief group (the study group, n = 121) received regional nerve blockade with 0.25% bupivacaine combined with preoperative rectally administered paracetamol 45 mg/kg or diclofenac 1 mg/kg 60 min before surgery for cases that were to undergo lower abdominal surgery. But only paracetamol or diclofenac was rectally administered preoperatively in the other surgical cases. RESULTS: The mean time in the recovery room for the study group was shorter than that for the control group. The postoperative pain was hurts even more in 16.7%, worst in 11.8%, a whole lot in 26.5% and no pain in 27.5% of the control group patients. But the pain was hurts little more only in 11%, a little bit in 10.0% and no pain in 88.9% of the study group patients. The average postoperative VAS score was 0.21 +/- 0.6 in the study group and 8.36 +/- 1.7 in the control group, respectively. Vomiting, nausea and fever were more frequently observed in the control group. CONCLUSIONS: The pain intensity of the children who were treated with rectally administered paracetamol or diclofenac combined with regional nerve block before surgery was significantly decreased as compared to that of the children who were treated with the traditional method.

[The specialty of anesthesia outside Western medicine with special consideration of personal experience in the Democratic Republic of the Congo and Mongolia]. / Das Fachgebiet Anästhesie abseits der westlichen Medizin. Unter besonderer Berücksichtigung eigener Erfahrungen in der Demokratischen Republik Kongo und der Mongolei.

During the last decades anesthesia has developed into a wide ranging specialty in western countries, whereas in most developing and newly industrializing nations it still focuses on its core discipline, the perioperative care of the surgical patient. Poor socioeconomic status and inadequate financing of health systems result in a high burden of disease, a high rate of self-financing of healthcare costs by the patients, as well as insufficient personnel, infra-structural and material equipment of most healthcare facilities. Important limiting factors for anesthesia are low educational standards and a widespread lack of oxygen and medical gas supplies, as well as locally serviceable medical equipment. Studies evaluating the status of anesthesia in developing and newly industrializing nations in detail are urgently needed in order to provide aid on national and international as well as institutional and private levels for the development of anesthesia in poor countries.