[Airway stenting in patients with complex benign tracheobronchial stenosis]. / Odnomomentnoe endoprotezirovanie trakhei i glavnykh bronkhov pri rubtsovom stenoze.

Tracheal and bronchial stenting is actively used for cancer and benign airway stenosis. This procedure is common in patients with advanced cancer. Stenting ensures breathing and availability of early chemo- and radiotherapy without the need for tracheostomy. This procedure is less common in patients with benign tracheal stenosis. In this case, isolated tracheal or bronchial stenting is performed. Complex tracheobronchial stenosis is extremely rare and creates significant difficulties. We present 3 cases of tracheobronchial stenting for cicatricial stenosis. In each case, stenosis was dilated with a rigid bronchoscope or balloon dilatation. Then, a silicone stent was installed. Resection with an appropriate anastomosis was contraindicated due to advanced pathological process. Thus stenting was regarded as a palliative operation. The follow-up periods were 9 months, 3 and 10 years. Each patient underwent inhalation therapy, endoscopy and repeated stenting if necessary.

[Comparison of modern methods of respiratory oxygenation during double level tracheal resection and reconstruction (clinical report)].

UNLABELLED: The problem of respiratory support in tracheal surgery is still discussed in recent days. Anaesthesiologist must choose the most effective and safe respiratory technique during tracheal resection and reconstruction. The article deals with a case of comparison of apneic oxygenation (AO) and high frequency jet ventilation (HFJV) during double level tracheal resection and reconstruction in patient with multifocal tracheal stenosis and underlying cerebral trauma. MATERIALS AND METHODS: AO and HFJV were used due to surgical need for 20 min each technique. PvO2, PvCO2, hematocrit, blood glucose, acid-base balance in the v. Jugularis interna, noninvasive arterial pressure, heart rate, ECG and body temperature were fixed before and after the changing of respiratory support type. Additionally peak systolic speed (S) of blood flow in the a. Cerebralis media sinister was fixed by transcranial Doppler ("Angiodin BIOSS", Russia). RESULTS: Oxygenation of venous blood was sufficient after the both HFJV and AO use; PvO2 was 67.6 and 74.3 torr respectively. Speed of PvCO2 increasing was higher during AO (1.46 torr per min) than during HFJV (0.73 torr per min). Increase of S was bigger during AO than HFJV as well (59 vs 37%). The changes of PvCO2 and S were normalized in 15 min after reconnection to conventional mechanical ventilation. Other fixed parameters were normal and same during the use of both respiratory techniques. The patient involved in the study did not have any neurological or surgical complications in early postoperative period. CONCLUSIONS: Both studied respiratory techniques provide sufficient blood oxygenation and can be accompanied with hypercapnia and cerebral hyperemia. These observations evident about the necessity to study the role of hyperoxia, hypercapnia and cerebral hyperemia in patients with underlying cerebral trauma undergoing tracheal resection and reconstruction. The study will help to make a strategy of the foreground use of HFJV and AO in these patients.

[Transesophageal tracheal intubation in patient with tracheoesophageal fistula and double level cicatricial tracheal stenosis].

The article deals with a case of successful anaesthesia management during the surgery due to tracheoesophageal fistula and double level cicatricial tracheal stenosis. Such surgeries are accompanied with technical and organizational difficulties both for an anaesthesiologists and endoscopist. The article discusses tactics of anaesthesia management during transesophageal balloon dilatation of tracheal stenosis, transesophageal tracheal intubation and respiratory techniques during the separation of tracheoesophageal fistula and tracheal resection.

[A differentiated approach to the diagnosis and treatment of portal hypertension in children].

The authors analyze their experience with diagnosis and treatment of 182 children with syndrome of portal hypertension (PH) from 1991 through 2010. Two groups of patients were considered. The first group included 74 newborns with high risk of the development of PH (infants after catheterization of the umbilical vein who endured omphalitis with USI diagnosed thrombosis of the portal vein, patients with cavernous transformation of the portal vein, hepatosplenomegaly). The second group consisted of 108 children aged from 6 months to 14 years with realized syndrome of PH. Investigation of hemostasis (international normalized ratio, fibrinogen, VIII and IX factors) immunogram of the 2nd level, determination of gene polymorphism (prothrombin, V factor, MTHFR, PAI-1), Bonacini index were included in the complex of examination, besides clinical and biochemical analyses of blood. The degree of disturbance of hemodynamics in the portal system was estimated by the data of USI, dopplerography, FEGS. It was established that children with extrahepatic portal hypertension have markers of hereditary thrombophilia in 98% of cases. Bonacini index allows determination of early signs of the development of secondary fibrosis of the liver in children with PH without using liver biopsy.

[Intraoperative myocardial protection with extracellular cardioplegic solutions in patients with cardiac valve diseases].

A hundred patients operated on under extracorporeal circulation (EC) with bicaval cannulation in the moderate general hypothermia mode were intraoperatively examined. According to the used cardioplegic solution, all the patients were divided into three groups: 1) Konsol; 2) Konsol MF; 3) St. Thomas (a control group). All the groups were matched by age, gender, the duration of myocardial ischemia (MI) (37-128 min), that of EC (52-186 min), and the nature of surgical interventions, of which mitral valve replacement amounted to 72-78%. To prepare a modified solution, 20 ml of 40% glucose, 20 units of insulin, and 200 mg of creatine phosphate (Neoton) were added to a flask containing 400 ml of Konsol. The efficiency of myocardial protection was evaluated by the data characterizing cardiac arrest and cardiac performance resumption, as well as by heart rate and the use of inotropic support in the reperfusion period. The parameters of central hemodynamics and systemic coronary blood flow, the concentrations of glucose and lactate, the blood gas and electrolyte composition of the coronary sinus (CS), myocardial oxygen consumption and the oxygen-utilizing coefficient were monitored. The cardioplegic solutions Consol and Consol MF were found to have a more effective cardioprotective activity in patients with cardiac valvular disease, operated on under EC and moderate hypothermia that St. Thomas'solution. Modification of the Consol solution by adding glucose, creatine phosphate, and insulin improves the protective effect of the solution, promoting a rapider transition of the myocardium from anaerobic to aerobic metabolism.

[Use of sevoflurane during cardiosurgical and endovascular operations in children].

The good tolerability of sevoflurane, the mild and prompt onset of a hypnotic state, the absence of airway irritation, and the safe use of the agent make the anesthetic of choice for introductory anesthesia in pediatric cardiosurgery. The purpose of the study was to develop and assess the procedure of sevoflurane anesthesia during cardiosurgical and endovascular operations in children with congenital heart diseases. Twenty-five children aged 2-9 years (of them 15 children with congenital heart disease) operated on under extracorporeal circulation (EC) were examined. Ten children underwent X-ray surgical endovascular interventions: closure of the patent arterial duct with an "Amplatzer ductus occluder" system. The duration of operations under EC was 116 to 289 min; that of EC was 60-20 (49 +/- 8) min. Endovascular operations lasted 60-80 min. Premedication was made with ketamine, midazolam, and methacin during cardiosurgical operations. The children were referred without premedication, escorted by their parents for endovascular surgical interventions where in the parents' presence the children were given inhalational sevoflurane at a concentration of 5-6% through the mask of an anesthetic apparatus until they fell asleep. This made it possible to avoid the child's weeping and resistance and to puncture the peripheral vein without pain. Steady-state hemodynamics and metabolism suggest that combined anesthesia using sevoflurane at a concentration of 1.3-22% of the minimal alveolar one is adequate in correcting congenital heart disease in children. The application of this anesthetic procedure permitted extubation of 73% of children within 1-2 hours when their condition met the criteria for early activation and extubation.

[Changes in cerebral circulation in patients with coronary heart disease during myocardial revascularizing operations under combined xenon anesthesia].

Twenty-five patients with coronary heart disease were examined in the preperfusion stage of myocardial revascularing operations under extracorporeal circulation. All the patients received combined anesthesia with xenon (Xe) as minimum flow anesthesia with flow of gases: oxygen, 0.4 l/min; Xe, 0.9 to 0.4 l/min. Cerebral circulation was investigated by transcranial Doppler study. The following parameters of the circulation: maximum systolic and diastolic blood flow velocities and pulsatile index were bilaterally estimated, by insonating the middle cerebral artery (MCA). When the concentration of Xe was as high as 50-60%, systolic and diastolic blood flow velocities along the MCA increase and the pulsatile index decreased. Opposite results were obtained 8 minutes after Xe feed was stopped. The findings provide evidence that Xe increases cerebral circulation and has a significant hypnotic effect. The increased systolic and diastolic blood flow velocities with the decreased peripheral resistance index in the MCA suggest that Xe diminishes peripheral vascular resistance in the pial arteries of the brain.

[Comparative evaluation of clinical use of cardioplegic solutions custodiol and konsol in the correction of cardiac valvular diseases].

The efficiency of myocardial protection with cold crystalloid cardioplegia (CC) during operations on the heart under total ischemia and extracorporeal circulation was studied. Two hundred and fifty patients who underwent prosthetic or plastic repair of the aortic and mitral valves or plastic repair of the tricuspid valve were examined. Group 1 comprised 218 patients in whom the myocardium was protected with Konsol solution ("Biofarm "research-and-production enterprise, Russia); Group 2 included 32 patients in whom Custodiol solution ("Dr Franz Kohler Chemia GMBH", Germany). The volume of the Konsol solution required for CC was 400-2000 ml, with the duration of myocardial ischemia (MI) being 75 +/- 33 min; that of the Custodiol was 2000-4000 ml, with the duration of MI being 80 +/- 22 min. The used algorithm of administration of the solutions provided a persistent cardioplegic effect in both groups. After aortic declamping, there was a spontaneous recovery of cardiac performance in 84 and 40% in Groups 1 and 2, respectively. In the reperfusion period (RP), no significant differences were found in the basic hemodynamic parameters (heart rate, blood pressure, and central venous pressure) in both groups. After defect correction, cardiac output equally increased in both groups. The groups did not differ in the rate of inotropic support either. In RP, transient cardiac rhythm and conduction disturbances occurred in 19 and 28% in Groups 1 and 2, respectively.

[Stenting for treatment of scarry stenoses of the esophagus in children].

The article contains results of examination and treatment of 160 children with scarry stenoses of the esophagus. Radical operations were made in 4 children, 4 children were treated by a direct bougieurage, 73 by bougieurage with a thread, in 79 children esophagus stenting was used. Stents of different shape and different methods of their fixation were used. The time of treatment and number of bougieurages in children when stents were used was much less than when only bougieurage was used although the same results were obtained.

[Cryoplasma-antienzymatic therapy for aspiration pneumonia in neonatal infants with esophageal atresia].

The results of treatment were analyzed in 75 neonatal infants with aspiration pneumonia in the presence of esophageal atresia. The analysis of the hemostatic system in this category of patients has shown that changes occurred as hypocoagulation with its pronounced activation. Cryoplasma transfusion in combination with an antienzymatic drug improved the result of treatment in neonatal infants with aspiration pneumonia in the presence of esophageal atresia, reduced the duration of treatment at an intensive care unit, the incidence of postoperative complications, and mortality rates.

[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.

[Hemodynamic parameters and saturation of the cerebral cortex blood with oxygen during extracorporeal circulation in heart surgery]. / Vliianie parametrov gemodinamiki na nasyshchenie kislorodom krovi kory golovnogo mozga vo vremia iskusstvennogo krovoobrashcheniia pri operatsiiakh na serdtse.

Sixty-three patients were intraoperatively examined during heart surgery with extracorporeal circulation (AEC). They were operated on for an affected heart-valve apparatus (AHVA) and ischemic heart disease (IHD). There was a perioperative monitoring of central hemodynamics, pressure in the bulb of superior jugular vein (BSJV) and electroencephalography (EEG). Regional oxygenation of the brain was made in real time by a INVOS3100 oximeter (SOMANETICS, USA). A maximal saturation of the cortex blood with oxygen at AEC was registered in patients with AHVA at an average pressure below 70 mm Hg, and in patients with IHD--at 85 mm Hg. An increased pressure in BSJV at a constant mean arterial pressure and at AEC is related with blood outflow from the venous collector of the brain.

[Cerebral oximetry during cardiac surgery under extracorporeal circulation]. / Opyt ispol'zovaniia tserebral'noi oksimetrii pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

The time course of changes in rSO2 were studied in 58 patients during the uncomplicated course of cardiac operations under extracorporeal circulation (EC) and moderate hypothermia. rSO2 was also compared with central hemodynamic parameters, bioelectrical cerebral activity, and hemoglobin oxygen saturation of the bulb of the internal jugular vein (jbSO2). In the pre- and postperfusion period there was a significant correlation of rSO2 and jbSO2 (p = 0.01), yet with a low correlation coefficient (r = 0.348). During EC, no correlation was found between rSO2 and jbSO2 (p = 0.09, r = 0.386). Changes in rSO2, blood pressure, EEC, body temperature were analyzed in 2 groups of patients at the stages of an operation under EC. Group 1 comprised patients with cardiac valvular apparatus lesions and Group 2 included those with coronary heart disease who differed not only in age, but also in the history of mainly cerebrovascular atherosclerotic lesions, hypertensive disease, myocardial infarction, etc. In patients from both groups, a reduction in rSO2 occurred at the beginning of EC and at the maximum of cooling. But if in Group 1 patients, the significant reductions in rSO2 at the beginning of EC coincided both with that in mean blood pressure (BPmean), as compared to the baseline values (from 75.55 +/- 10.68 to 66.5 +/- 11.73 mm Hg, p = 0.01), and with the change in the frequency spectrum of EEC (a decrease in the frequency of the right edge, as compared to the baseline values, from 20.77 +/- 1.44 to 19.58 +/- 1.14 Hz, p = 0.01), in Group 2 patients, all significant decreases in rSO2 were accompanied only by a significant reduction in BPmean, but without changes in the frequency spectrum of EEG. It should be noted that over the uncomplicated course of an operation all changes in rSO2 were in the normal range of age-related values.

[Anesthesia during liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

Different methods and components of anesthesia during operations in donors and recipients were studied by using the experience in maintaining anesthesia during 39 relative and 7 cadaveric hepatic transplantations. The experience in using epidural anesthesia and total intravenous anesthesia at the donor stage of hepatic lobar transplantation was comparatively analyzed. Combined epidural anesthesia (CEA) may be used during long-term and traumatic operations dealing with hepatic lobectomy in a relative donor since it is noted for low hepatotoxicity and no drastic hemodynamic exposures. CEA can substantially reduce pharmacological loading with opioids or myorelaxants, which is particularly important in taking the lobe of the liver. This reduces the recovery period of adequate own respiration, activates a patient more rapidly, substantially reduces the risk for postoperative iatrogenic complications. Balanced general anesthesia whose major component is inhalational anesthesia with isoflurane is the method of choice in performing an operation in the recipient. The use of isoflurane in the minimal-flow mode is cost-effective and safe. When anesthesia is performed in the recipient, it is necessary to take in account drastic hemodynamic pattern changes at the liverless stage during vein-venous bypass surgery, including the liver into systemic circulation, and the likelihood of development of significant reperfusion and concomitant metabolic and coagulative disorders.

[Clinical experience with low- and minimal-flow isoflurane in extensive resections of the liver and liver transplantation]. / Klinicheskii opyt ispol'zovaniia izofliurana v rezhimakh low- i minimal-flow pri obshirnykh rezektsiiakh i transplantatsii pecheni.

A comparative study was performed of general balanced anesthesia on the basis of neuroleptic analgesia (NLA) and inhalation low- and minimal-flow anesthesia with isoflurane in anesthesiological management of extensive operations on the liver. A total of 75 anesthesias were conducted. Because of low hepatotoxicity, absence of its metabolites' pharmacological activity, fast elimination from the body unchanged, isoflurane is effective in long and traumatic operations on the liver. Low-flow isoflurane significantly lowers pharmacological load with opiates, myorelaxants which is essential in patients with hepatic diseases. This leads to more rapid recovery of adequate spontaneous respiration and activation of the patient in low risk of postoperative iatrogenic complications.

[Perfusion management in liver transplantation]. / Perfuziologicheskoe obespechenie transplantatsii pecheni.

Veno-venous bypass (VVB) with a Biopump centrifugal pump (Biomedicus, USA) was used in 36 patients with liver diseases during orthotopic transplantation of the liver. Volume rate of perfusion (VR), systolic, diastolic, and mean arterial pressure (AP), and central venous pressure (CVP) were monitored. VR during liver-free period was 850-1350 (1064.2 +/- 87.5) ml/min in femoral-axillary bypass and 1700-3500 (2630.5 +/- 112.3) ml/min in femoral-porto-axillary bypass. A trend to a decrease of the mean AP to 65 mm Hg was observed at the end of liver-free period (p < 0.05), while CVP decreased to 2 mm Hg (p < 0.05); there was a trend to a moderate tachycardia. No significant shifts in acid-base balance, oxygen balance, and blood electrolytes were observed during the liver-free period. Maximum blood loss occurred during the liver-free period and reperfusion of the transplant. Blood loss was evaluated by the amount of washed autoerythrocytes obtained after processing of collected blood in the Cell-Saver device. VVB had a favorable impact on the course of orthotopic transplantation of the liver, maintaining stable hemodynamic and biochemical parameters and preventing ischemia of the abdominal organs. Preservation of autoerythrocytes by the Cell-Saver device minimized the need in donor erythrocytes, thus ruling out the complications associated with homologous blood transfusion.

[The anesthesiological support of liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

The choice of anesthesia for a high risk operation, orthotopic transplantation of the liver (OTL), is discussed. The authors propose a protocol of anesthesia for OTL. For induction anesthesia, intravenous drugs should be preferred; the liver-free stage of the operation is carried out under anesthesia with a closed isoflurane contour, and the initial metabolic disorders of patients are corrected. When the bloodflow is let in the transplanted organ, intravenous drugs (ketamine, phentanyl, and benzodiazepines) should be administered in order to reduce the vasodilating effect of isoflurane and vasopressors for preventing relative hypovolemia. At the final stage of anesthesia, isoflurane is used. Before transporting the patient into intensive care ward, phentanyl in a dose of 1.5-3 micrograms/kg was injected, because of rapid elimination of isoflurane and awakening of the patient. This protocol maintained the hemodynamics and the major metabolic parameters at the optimal level.