[Combined anaesthesia in reconstructive operations on carotid arteries].

MATERIAL AND METHODS: The authors analysed the protocols of anaesthesia in a total of 100 patients operated on carotid arteries. Depending upon the method of anaesthesiological management, the patients were subdivided into 4 groups comparable by age, gender, physical status, and the scope of the intervention. Group One patients received only propofol-fentanyl total intravenous anaesthesia (TIVA). Group Two, Three and Four patients received combined anaesthesia which was as follows: in Group Two - TIVA based on propofol and fentanyl with superficial cervical plexus block (SCPB), in Group Three - combined anaesthesia based on sevoflurane in a combination with SCPB, and in Group Four - combined anaesthesia based on isoflurane and fentanyl in a combination with SCPB. Analysing the results, we assessed the parameters of arterial pressure, BIS values, also calculating the doses of the anaesthetics and demand for narcotic analgesics during anaesthesia. The quality of the postoperative period was evaluated according to the 5-point vertebral rating scale (VRS). RESULTS: Comparing the need in fentanyl for maintaining general anaesthesia revealed considerably higher doses thereof in Group One patients. Analysing the dynamics of the parameters of mean arterial pressure showed their higher stability in Groups 2, 3 and 4, which was conditioned by better antinociceptive protection with SCPB added. The degree of the postoperative pain syndrome within 48 hours according to the VRS in Group One patients was higher as compared with that in Groups Two, Three and Four patients who additionally received SCPB. CONCLUSION: TIVA based on propofol and fentanyl combined with SCPB provides better analgesia in the area of the operation and decreases the demand for narcotic analgesics. Combined anaesthesia provides better stability of the haemodynamic parameters at the stages of surgery, also decreasing the degree of postoperative pain.

[Peripheric blockades in plastic and reconstructive surgery: up-to-date trends and prospects (a 30-year experience)].

The article presents the own 30-year experience in the use of more than 1000 prolonged peripheral nerves and plexus block anaesthesia in reconstructive surgery, based on experimental and clinical studies. The evolution peripheric blockades technique is given:from a separate anaesthesia method to balanced anesthesia based on peripheric blockades. The current state of the problem was analyzed according to the literature.

[The effect of the cervical plexus block on anti-nociceptive protection during surgeries on the interior carotid arteries].

MATERIALS AND METHODS: 77 anaesthesia protocols during a. carotis interna (ACI) operations were analyzed. All the patients were divided into 3 groups. In the 1-st group a total intravenous anaesthesia - TIV4 (propofol and fentanyl) was used. In the 2nd and 3rd groups was used combined anaesthesia: in the 2nd - TIVA + superficial CPB, in the 3rd - combined anesthesia (sevortane+fentanyl+CPB). When analyzing the results, BP, BIS data, anaesthetic doses and the need for opioid analgesics were evaluated. Assessment of the postoperative pain quality was conducted within 48 hours of the postoperative period on a verbal assessment scale (VAS). RESULTS: The need for fentanyl was considerably higher in the 1st group. The analysis of the BP data dynamics showed better stability in the 2nd and 3rd groups. CONCLUSIONS: TIVA + CPB provides better analgesia and reduces the need for opioid analgesics; greater stability of hemodynamic parameters during operation stages, as well as the best brain perfusion during a. carotis interna occlusion; postoperative analgesia and allows to avoid the early appointment of systemic analgesics.

[New possibilities of complex monitoring of the cardiovascular system during thoraco-abdominal surgeries].

The aim of the study was to compare effectiveness of combined cardiovascular monitoring in assessment of quality of anesthetic protection during combined general anesthesia with thoracic level epidural analgesia during thoraco-abdominal surgeries. The study included 56 patients (ASA II-IV). The preoperative examination consisted off: ECG (rest), ECG (stress), 24 hour ECG monitoring. The intraoperative hemodynamic parameters (BPsist., BPdiast., BPmed., HR) were monitored both by invasive and non-invasive methods. Using the measurements of cardiac output (extrasternal dopler) the cardiac index, specific peripheral vascular resistance and stroke index were calculated. During intra and postoperative period (1st and 5th day) ECG monitoring was made. The received data was compared according to the following parameters: character of rhythm, circadian index, supraventricular and ventricular ectopic activity, dynamics of the ST segment. The results show that inclusion of thoracic epidural blockade combined with general or total intravenous anesthesia during thoraco-abdominal surgeries is accompanied by more favorable hemodynamic restructuring, heart rate stability and well expressed anti-ischemic effect. Thus, inclusion of modern combined cardiovascular monitoring methods during anesthesia widens the diagnostic abilities and noticeably increases the patient safety during high risk surgeries.

[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.

[Pharmacology of nociception].

The paper reviews the literature on the effect of different groups of pharmacological agents on nociceptive processes. It also describes the mechanisms of possible action of agents both conventionally used in anesthesiological practice and the drugs used to treat pathological pain. The paper allows one to become aware of the currently available approaches to achieving multimodal anesthesia.

[Central hemodynamics under conditions of combined anesthesia on the basis of a thoracic epidural block].

The authors set themselves a task of assessing systemic hemodynamic parameters under combined general anesthesia on the basis of a thoracic epidural block (TEB) versus combined general anesthesia during thoracoabdominal interventions. Thirty patients were examined. Their physical status was in ASA Class II-IV. The preoperative examination was as follows: electrocardiography (ECG) (at rest), ECG (during exercise), and 24-hour ECG monitoring. Hemodynamic parameters, such as systolic blood pressure (BP), diastolic BP, mean BP, and heart rate), were intraoperatively measured by invasive and noninvasive techniques. By using the measurements of cardiac output (extrasternal Doppler study), the authors calculated cardiac index, specific peripheral vascular resistance (SPVS), and stroke index (SI). They made 24-hour ECG monitoring intra- and postoperatively (on days 1 and 5, respectively). The findings suggest that inclusion of TEB in a complex of anesthetic maintenance of thoracoabdominal operations along with combined or total intravenous anesthesia shows better hemodynamic changes, as indicated by a 31% increase in SI and a 32.6% decrease in double product with the stable values of mean BP and heart rate, which was not noted in the control group. The dose of narcotic analgesics was decreased by 2.6 times.

[A method for assessing analgesia--nociceptive evoked potentials: the first clinical cases].

The paper describes a new method for assessing analgesia, which is based on the use of a Caube-type electrode. It provides evidence that, unlike stimulation with the standard electrode for somatosensory evoked potentials, Caube-type electrode stimulation may cause late (long-latent) potentials in healthy volunteers, showing the fundamental capacity of selective nociceptor excitation. By using two cases with the pronounced pain syndrome, the authors show changes in nociceptive evokes potentials during epidural analgesia.

[Psychoemotional comfort--is it a special component of anesthesia?].

The paper provides a rationale for using a special component of balanced multicomponent anesthesia based on regional blocks. Based on their own data and the analysis of the data available in the literature, the authors describe the etiology and pathogenesis of psychoemotional discomfort. Particular emphasis is placed on the causes and mechanisms of psychoemotional disorders and the patients' long positioning on a operating table. Based on the detected pathogenetic mechanisms, the authors show possible ways of achieving the patients' psychoemotional comfort under regional anesthesia--from premedication and various sedation modes to the monitoring of psychoemotional reactions.

[Subarachnoidal anesthesia in patients with concomitant diseases of the cardiovascular system].

Age-related changes limit blood circulatory reserves in vital organs, by increasing the risk of ischemic and hypoxic lesions. Patients from a peripheral vascular surgery department form a high cardiac risk group. Subarachnoidal anesthesia is the most optimal anesthetic support (if there are no absolute contraindications) during operations for lower extremity varicose veins. Thirty patients operated on for this condition were examined to solve the problem associated with the effectiveness and safety of this method of anesthesia and to define the pattern of hemodynamic rearrangement more precisely. All the patients had concomitant cardiovascular diseases, which forced them to be referred to as ASA Classes III-IV. The authors monitored basic hemodynamic parameters, such as systolic blood pressure (BP), diastolic BP, mean BP (BP(mean)), heart rate, and cardiac output, by using a noninvasive procedure by means of a computer equipped with a Doppler flowmetric transducer, and ST-segment changes by ECG). The values of total and specific peripheral vascular resistance and cardiac index were estimated by a calculating method. Analysis of hemodynamic changes revealed no significant differences between the groups of elderly and senile patients. On examination, all the patients were divided into 2 groups by the type of circulation: 1) those with eukinetic circulation and 2) those with hypokinetic circulation. Hyperkinetic circulation was not found in the study groups of patients. The patients with cardiac disease were observed to have increased vascular resistance, in those with hypokinetic circulation, this increase being more marked (p < 0.05). In addition, ST-segment had a more stable position in patients with hypokinetic circulation. There was a great scatter in ST-segment changes in patients with eukinetic circulation in the presence of decreased peripheral resistance under preganglionic sympathetic block. With the described changes, noteworthy was the stability of BP(mean) values that did not decreased below the critical ones. This fact permitted the authors to state that the compensatory reserves of the cardiovascular system were preserved under subarachnoidal blockade, which in turn suggests the effectiveness and safety of the used anesthetic procedure.

[Epidural block as a component of anesthesiological provision during abdominal operations].

Two modes of general anesthesia with artificial ventilation in combination with epidural block differing in a hypnotic component (inhalational or intravenous) were studied in 27 patients. A combination of general and epidural anesthesia afforded the best protection from surgical stress during major abdominal operations. Inhalational or intravenous anesthetics may be equally used to induce unconsciousness. The fact that there may be blood loss is not an absolute contraindication to epidural anesthesia. The safety and controllability of combined anesthesia increase when its individual components are monitored and the protocol is strictly observed. There is a need for further development of objective criteria for efficient regional block under general anesthesia.

[Lumbar sympathectomy in treatment of obliterating diseases of lower limbs: state of the art]. / Primenenie poiasnichnoi simpatéktomii v lechenii obliteriruiushchikh zabolevanii arterii nizhnikh konechnostei -- sovremennyi vzgliad na problemu.

The article deals with analysing examination and surgical treatment of 80 patients with predominant lesions to the distal arterial bed of the lower extremities, who were operated on at the RRSC from 1996 to 2003 with various degree on the background of chronic obliterating diseases of lower limbs arteries. All the patients were subdivided into two groups according to the outcomes of the epidural block: Group I -- with positive outcomes consisted of 36 (45 %) patients, and Group II -- with a negative outcome -- included 44 (55 %) patients. The patients from the both groups underwent the following operations: lumbar sympathectomy combined with direct and indirect methods of revascularisation, as well as lumbar sympathectomy as an independent therapeutic method. To solve the problem concerning feasibility of either done, or concomitant lumbar sympathectomy, we devised assessment of microcirculation state (alterations in volumetric blood flow indices in epidural block in relation to the indices at rest, as well as in the immediate or remote postoperative period) and peripheral haemocirculation (dynamics of the onkle brachial index values on the background of epidural block test, nitroglycerine test in relation to the ARI at rest both in the short-, and long-term postoperative period) by data of scintigraphy and dopplerography of the lower limbs.

[Clinical-and-pathophysiological prerequisites of impaired breathing and ensuring of safety in drug-induced depression of consciousness]. / Kliniko-patofiziologicheskie predposylki dlia narusheniia vneshnego dykhaniia i vozmozhnye puti dostizheniia bezopasnosti pri medikamentoznoi depressii soznaniia.

Seventy-three patients operated on under anesthesia based on regional blocks were examined. Thiopental-sodium (T; n = 29), myadozalam (M; n = 10) and propofol (P; n = 24) were used for sedation. The conditions of breathing and of gas exchange were evaluated by the findings of pneumotachography: V(peak insp), P(peak insp), P(100) Raw, breathing pattern, SpO2, PEtCO2 and EMG from mouth-diagram muscles. The obtained results were made use of to draw up a rating scale for impaired breathing, which is based on the respiratory volume and respiration rate of gas exchange as well as on different variations of respiratory support. Irrespective of a sedation type and of a degree of consciousness suppression, the impaired breathing was registered in 90-100% of cases: obstruction of the respiratory tracts was predominant in T (higher Raw); in M--depression of the respiratory center (lower P(100); in P--a pronouncedly lower of EMG, and, respectively, a weakened contraction of diaphragm (lower P(peak insp)). Depression of the respiratory center was found to occur irrespectively of a drug used in sedation, however, the mechanisms of obstruction were different: in T--impaired breathing; in M--impaired phase muscle activity. Sedation by P was not accompanied by any clinically valuable obstructive signs.

[Subarachnoid anesthesia in patients with high surgical risk]. / Subarakhnoidal'naia anesteziia u bol'nykh s vysokim operatsionnym riskom.

The hemodynamics was intraoperatively studied in 43 patients with multicentric atherosclerosis, ASA III-IV, operated on the peripheral vessels of legs with balanced anesthesia based on subarachnoid block. It was established in regional sympathetic block and in the course of the whole surgery that the parameter of AP were decreased by 20-25%, those of heart rate--by 15% and of TPVR--50%, whereas, the parameters of cardiac performance were stable. The authors discuss the specificity of hemodynamic restructuring under subarachnoid block in patients with at surgical risk due to vascular pathology.

[A new method of monitoring the psycho-emotional condition in patients during balanced anesthesia based on regional blockades]. / Novyi metod monitoringa psikhoémotsional'nogo sostoianiia patsientov vo vremia sbalansirovannoi anestezii na osnove regionarnykh blokad.

The potentialities of a skin-galvanic reaction (SGR) were studied, to evaluate the psycho-emotional status, in 9 sedated (midazole, thiopental-sodium, propofol) classes I and II ASA patients operated (10 interventions) under regional block. An original software was designed to analyze the SGR; it detects the signs of psycho-emotional discomfort (including positional discomfort) in drug-induced depression of consciousness as well as the uncontrollable moments of falling-asleep and awakening.

[Sleep and sedation: clinical and electrophysiological parallels]. / Son i sedatsiia: kliniko-élektrofiziologicheskie paralleli.

Clinical and electrophysiological studies were performed in 10 volunteers and 45 patients with Classes I and II, as stated by the American Society of Anesthesiologists, to evaluate consciousness during sedation. Prior studies on volunteers showed that there was a clear correlation between N-REM sleep and SEF in 90% of cases. Based on these findings, the authors propose a modified suppressed consciousness scale whose rating was adjusted to the levels of N-REM sleep. Irrespective of the type and technique of sedation (infusion of thiopental and propofol; PCS, midazolam), changes in the levels of drug-depressed consciousness were found to be the same.

[Hazards and complications of central segmental blockade. I. Epidural anesthesia (retrospective analysis)]. / Opasnosti i oslozhneniia tsentral'nykh segmentarnykh blokad: I. Epidural'naia anesteziia (retrospektivnyi analiz).

A total of 700 reports about complications of epidural anesthesia over more than 30 years are analyzed. Four groups of complications have been distinguished: 1) errors and complications caused by technological errors; 2) complications caused by atypical dissemination of an anesthetic; 3) complications caused by side and toxic effects of local anesthetics or effects of epidural block; and 4) complications caused by damage to nerve structures. Causes, pathogenesis, prevention and treatment of complications are discussed. The cause-and-effect analysis of complications of epidural anesthesia helped objectively formulate and validate the relative and absolute contraindications to the use of this method.