[Epidural analgesia in the first stage of labor--is there an alternative?].

OBJECTIVE: To evaluate the influence of epidural analgesia and lumbar paravertebral block on the structure of the delivery, the fetus and newborn, and the quality and duration of analgesia. MATERIALS AND METHODS: Patients were randomized into three groups, 30 patients in each group. In the group-1 patients received epidural analgesia (EA), in the group-2--paravertebral block (PVB), in the group-3 patients refused pain relief in labor. Pain was assessed by VAS. Length of the first and second stage of labor the impact on the CTG and fetal blood gases from the umbilical cord of newborns in the first minute of life were fixed. Data were analyzed by Mann-Whitney U test and presented as median (25th-75th percentiles). RESULTS: In both groups of patients in pain reduction was significant adjustment contractions and after 1 hour was 94.5% in EA, and PVB group--78.7% of the initial values. Under EA opening cervix was statistically significantly greater than in the PVB (192.5 (145, 302) vs 172.5 (112, 210) min) p < 0.05. Second stage of labor was also shorter in the PVB than in the EA (30.4 (10.2, 46.5) vs 59.8 (40.2, 81.5) min), in the control group it was--40.6 (21.3, 55.4) min, p < 0.05. PVB was observed in the group of more stable hemodynamics than in the EA for the entire period of observation. There were no adverse effects on the fetus and the newborn in the arms of the study. CONCLUSION: The proposed lumbar paravertebral block is simple to perform, is effective in reducing pain in the first stage of labor does not require continuous hemodynamic monitoring may be used for the treatment of birth dystocia and is a good alternative when the use of epidural analgesia during labor is limited.

[Effect of early multimodal rehabilitation on postoperative recovery after abdominal hysterectomy].

UNLABELLED: Purpose of the study was to evaluate the impact of the use of enhanced recovery after surgery for the postoperative period, and the inflammatory response after hysterectomy. INTRODUCTION: Methods Prospectively, 50 patients ASA 1-2 aged 42-72 years were randomized into two groups: the ERAS group (n = 25) and the control group (CG) with traditional perioperative management (n = 25). combined spinal and epidural anesthesia technique was used in all patients. Patient-controlled epidural analgesia in the ERAS group and multimodal analgesia with combination of paracetamol, tramadol and ketoprofen in the control group were used postoperatively. We measured plasma concentrations of interleukin-6 (IL-6), interleuki-nIL-1beta (IL-1beta) and C-reactive protein (CRP) preoperatively and at 24 hours and 7 days after surgery. Data were analyzed by Mann-Whitney U test and presented as median (25th- 75th percentiles). RESULTS: There was no statistically significant differences in the IL-6 and IL-1beta concentrations throughout the study. At 6 and 24 hours the pain severity of according to VAS was higher in the control group at rest and on coughing during all study stages. We found no correlation between the level of pain and plasma concentrations of IL-1beta and IL-6. The plasma concentration of CRP in the control group was higher at 24 hours and at 7 days after surgery: (P < 0.01). Level of CRP in the control group tended to increase during the observation period. CONCLUSIONS: In our study, the serum concentration of IL-6 and IL-1beta did not depend on the method of postoperative pain management. Using the ERAS protocol reduced postoperative plasma concentration of CRP. The increased level of CRP in the control group may be related with autoimmune reaction in wound due to delayed mobilization of patients.

[Intralesional administration of local anaesthetics after abdominal hysterectomy: is another technique of analgesia needed?].

The efficacy and safety of continuous wound infiltration with Ropivacaine in combination with systemic anaesthesia were assessed in randomized controlled trial in 60 patients after open hysterectomy. In the trial wound administration of Ropivacaine reduced the postoperative consumption of opioids and the intensity of pain syndrome and reduced the frequency of side effects of narcotic analgesics.

[Abdominal cross section space blockade as a component of the multimodal postoperative analgesia in patients after cesarean section: blockade efficiency analysis].

UNLABELLED: RESEARCH PURPOSE: To compare postoperative analgesia after Cesarean section with abdominal cross section space (ACSB) blockade in a combination with non-opioid analgesics versus conventional system anaesthesia. MATERIALS AND METHODS: 62 patients (2 groups of 31), after planned Cesarean section were included in this randomized research. In main group ACSB was used for postoperative analgesia, in control--a system anaesthesia. Research included pain assessment with visual-analogue scale (VAS) during rest and cough after spinal block regression and 12 and 24 hrs postoperatively. Additionally vital capacity of lungs changes was measured. RESULTS: In the main group VAS data in rest and at cough at stages 12 and 24 of h. after operation were significantly lower, than in control group. Vital capacity of lungs in this group was reliably higher at a stage of 24 h. CONCLUSION: ACSB in a combination with non-opioid analgesics provides high analgesia level without narcotic analgesics application, increases postoperative patients comfort after Cesarean section.

[Realization of Fast track surgery principles during cesarean section].

The aim of the study was to evaluate the efficiency of Fast Track Surgery (FTS) program application and determine the role of the anesthesiologist in its realization during planned Cesarean section. There were 2 randomized groups formed (basic and control), which contained 22 patients each. The groups were identical by all anthropometrical indicators. The FTS was applied in the basic group while the control group was led in traditional postoperative mode. The level of postoperative pain was estimated by Visual Analogue Scale (VAS) in rest and during cough 6, 12 and 24 hours after surgery, cortisol and glucose level dynamics, Baevskiy index, nausea and vomiting frequency, defecation and urination delay, presence of anxiety and weakness were assessed. The VAS and Baevskiy index were lower in the basic group during 12th and 24th hour of investigation, p < 0.05. There was no difference in dynamic cortisol levels in both groups. The values of cortisol levels didn't exceed those of presurgical levels. The tendency of hypoglycemia in control group that testified the prevalence of ketabolic proccesses was accompanied by weakness and orthostatic reactions. In both groups urination delay, nausea and vomiting were present. The obtained data proved the efficacy and safety of FTS during Cesarean section. The study shows that the decision of FTS has to be made by the anesthesiologist. It can improve perioperative conduction of patients and result in the promt stabilization of mother's condition after surgical intervention and result to the optimized contact with the child as well as reduce the period of hospital stay and decrease the expenses.

[Effect of adrenaline on the quality of postoperative epidural analgesia].

The aim of the study was to assess the efficacy and safety of patent controlled analgesia (PCEA) combining opioid-local anesthetic mixture and adrenaline administered after thoracotomy and laparotomy. 164 adult patients after major thoracic and abdominal surgery were enrolled in prospective randomized study. All patients were given PCEA using 0.125% bupivacaine and fentanyl (2 mcg/ml) eithr without (BF group, n = 73) or with adrenaline (2 mcg/ml) (ABF group, n = 91). Pain scores were assessed in rest and coughing by 100-point visual analog scale (VAS) at 3, 6, 12 and 24 hours after ICU admission. In addition, the consumption of medication and the incidence of adverse effects (pruritis, urine retention, and nausea/vomiting) were recorded. Data were compared by the means of Student's t-test and chi2 test. p < 0.05 was regarded as statistically significant. VAS in coughing was significantly lower in the ABF group at 3rd 6th 12th, 18th and 24th hour after ICU admission. The consumption of medication requested for the adequate analgesia (VAS < 3) decreased in the ABF group compare to the BF group. The number of incidence of side effects was lower in the ABF group. The outcome of the study shows that use of PCEA with bupivacaine--fentanyl mixture with adrenaline after major surgery reduces the consumption of both bupivacaine and fentanyl and lowers the incidence of adverse effects, therefore improving the quality of analgesia.

[Balanced postoperative analgesia in abdominal surgery: efficiency of the combined use of epidural block and non-opioid analgesics].

One hundred patients who had undergone elective surgery for abdominal malignancy were enrolled in the randomized, controlled study. Postoperative analgesia included only continuous epidural analgesia (PEA) or PEA with intramuscular ketorolac, or PEA with intramuscular ketorolac and intravenous paracetamol. The systemic use of ketorolac and paracetamol in addition to continuous epidural anesthesia can reduce a need for a local anesthetic and the intensity of postoperative movement pain.

[Role of paracetamol in a balanced postoperative analgesia scheme after thoracotomy].

The efficiency of paracetamol used in the balanced multimodal analgesia after thoracotomy still remains unclear. The prospective study covered 75 adult patients operated on the chest. The patients were randomized to 3 groups. They all received epidural autoanalgesia with a mixture of fentanyl (2 microg/ml) in 0.2% ropivacaine solution and intramuscular injections of ketorolac, 30 mg, every 8 hours. In Group 1 (n = 25), paracetamol was intravenously injected in a dose of 4 g daily. In Group 2 (n = 23), rectal paracetamol was used in an equipotential dose. In Group 3 (n = 24), paracetamol was not given. Within the first 24 postoperative hours, the severity of the pain syndrome and the incidence of adverse reactions of analgesia were estimated in all the patients. The obtained data were compared using Student's t-test and x2 test, by taking into account Bonferroni's correction. The p values of < 0.0017 were determined as statistically significant. The resting VAS did not differ between the groups. In cough, the severity of the pain syndrome was significantly less in Group 1 than in Groups 2 and 3. The use of the epidural mixture of ropivacaine and fentanyl required for adequate analgesia within the first 24 hours after surgery was much less in Groups 1 and 2 than that in Group 3. The high incidence of skin itch (20%) and urinary retention (8%) was observed in Group 3 (p < 0.017). No difference was found between the groups in the development of dyspepsia. The use of paracetamol in the postoperative multimodal analgesic therapy program after thoracotomy reduces the daily dose of epidurally administered ropivacaine and fentanyl with evident upgrade of analgesia quality, and the incidence of opioid-induced adverse reactions.

[Prevention of regurgitation and aspiration during emergency care of patients under general anesthesia].

This study has provided new data on methods for preventing regurgitation and aspiration under general anesthesia, by using parenteral and enteral antacids as premedication in urgent surgery. There is evidence that with 60-minute delay in starting surgery, omeprazole, 40 mg, has the highest alkalizing effect. Second- and third-generation H2-blockers have a persistent and good antacid effect. In emergencies, 30 ml of 3% sodium citrate solution show a rapid and effective antacid effect, which eliminates or drastically reduces the likelihood of aspiration pulmonitis even in case of regurgitation and aspiration of the gastric contents. Based on the findings, the authors have developed a patient preparation protocol for general anesthesia in urgent surgery as the standard for the practical use in general anesthesiology.

[Efficiency of preemptive intravenous paracetamol analgesia in abdominal surgery].

In a randomized, controlled study, 50 patients underwent elective surgery for abdominal cancer lesions under perioperative epidural analgesia. All the patients were randomized to receive paracetamol in a single intravenous dose of 1 g or placebo 30 minutes prior to the start of surgery. The use of 1 g of paracetamol as a single intravenous preemptive dose in abdominal surgery with perioperative epidural analgesia does not reduce the consumption of the analgesic and the intensity of pain in the postoperative period.

[Efficacy of various epidural analgesia regimens after lung surgery].

A prospective study included 90 adult patients undergoing thoracic surgery. After placing an epidural catheter at the Th4-Th5 level, all the patients were randomized in 3 groups. Twenty-nine patients received controlled epidural analgesia (PCEA) with fentanyl, 2 microg/ml, in 0.2% bupivacaine solution (Group 1). In other groups, these analgesics were given either as bolus infections (Group 2; n = 30) or as a continuous epidural infusion of fentanyl, 2 microg/ml, in 0.2% bupivacane solution (Group 3; n = 27). Pain scores and the incidence of adverse effects were assessed within the first 24 hours after surgery. The data were compared using the Student's t-test and x2 test with Bonferroni correction; p < 0.017 was regarded as statistically significant. The VAS scores in coating were significantly lower in Group 1 than in Groups 2 and 3. The need for epidural opioids for adequate analgesia within the first 24 hours after surgery was significantly less in Group 1 than in Groups 2 and 3. There were no excessive sedation episodes in all the groups. In Group 2, the incidence of nausea was 20%. These adverse reactions were not found during PCEA and continuous infusion (p < 0.017). Opioid-induced pruritus was mostly (23%) observed in Group 2. Thoracic PCEA with fentanyl-bupivacaine solution provided adequate postoperative analgesia after thoracotomy and reduced the need for opioids. In addition, PCEA reduced the incidence of adverse reactions of opioids.

[Comparison of various types of epidural analgesia after abdominal operations].

The authors compare three types of epidural analgesia using a mixture of 0.125% bupivacaine solution and morphine in 102 patients after abdominal surgery. Patient-controlled analgesia was applied in Group 1; the mixture was injected as a bolus in Group 2; continuous epidural infusion was used in Group 3. The findings have indicated that patient-controlled epidural analgesia can yield an adequate analgesia with smaller doses of local anesthetics and morphine reliably and in a shorter space of time and reduce the frequency of side effects associated with the opioid.

[Monitoring of extravascular lung water in patients with severe sepsis]. / Monitoring vnesosudistoi vody legkikh u bol'nykh s tiazhelym sepsisom.

The key objective of the case study was the possibility to monitor the extravascular lung water (EVLW) in severe cases. Twelve mechanically ventilated patients with severe sepsis complicated by septic shock and by an acute lung injury (ALI) were involved in the prospective study. The measurements, performed on days 1 and 3 after the onset of sepsis, comprised hemodynamics, EVLW as assessed by Pulsion PiCCO method, blood gases and severity scores. The EVLW correlated significantly with lung injury score (r = 0.46), oxygenation (r = -0.46) and with pulmonary compliance (r = -0.58) versus the central venous pressure. The EVLW and lung injury scores were found to be essentially higher in non-survivors on day 3. The clinical situations, described in the present article, are indicative of a potential EVLW value applicable to sepsis treatment. Finally, the monitoring of EVLW is a useful tool in the purpose-oriented therapy of sepsis-induced ALI; moreover, the method has an important prognostic value.

[Optimization of intensive care of acute disseminated intravascular syndrome]. / K voprosu ob optimizatsii intensivnoi terapii ostrogo DVS-sindroma

The discrete plasmapheresis and Fraxiparin were used to optimize the intensive care scheme in acute disseminated intravascular syndrome (DIS). A total of 394 patients underwent the clinical and laboratory examinations to assess the method's efficiency. A lower degree thrombinemia was registered after the therapy versus the original values.

[Volumetric monitoring based on transpulmonary thermodilution in anesthesiology and intensive care]. / Voliumetricheskii monitoring na osnove transpul'monal'noi termodiliutsii v anesteziologii i intensivnoi terapii.

The review elucidates the technique of transpulmonary thermodilution in volumetric monitoring of critically ill patients. The experimental and clinical studies, now underway, are indicative of a great value of the discussed method for practical medicine. The key parameters of volumetric monitoring comprise Intrathoracic Blood Volume and Extravascular Lung Water as well as a wide range of other derived variables and indices. The approach is highly effective in the mechanical ventilation and inotope/vasopressor support of patients with a high risk of non-cardiogenic or cardiogenic pulmonary edema. The evaluation of volumetric parameters and of invasive monitoring of hemodynamics provide for an excellent guidance in fluid resuscitation in an overwhelming majority of ICU patients. The PiCCO technology of continuous cardiac output (CO) measurements or, the so-called "pulse contour CO" is also under discussion.

[Effects of basic therapy of ischemic heart disease on vascular-platelet hemostasis during myocardial revascularization]. / Vliianie bazisnoi terapii IBS na sostoianie sosudisto-trombotsitarnogo gemostaza pri operatsii revaskuliarizatsii miokarda.

Effects of preoperative therapy of coronary diseases with calcium antagonists and aspirin on vascular platelet hemostasis during aortocoronary shunting (ACS) have been studied in order to evaluate the role of hemostasis disorders in the pathogenesis of perioperative hemorrhagic complications. Therapy of coronary disease with these drugs during preparation to ACS can involve changes in platelet functional activity, depending on the individual sensitivity of patients. Drug-induced thrombocytopathy can induce pathological hemorrhages in the perioperative period of ACS.

[The management of resuscitative services in a multi-specialty clinic]. / Upravlenie reanimatsionnoi deiatel'nostiu mnogoprofil'noi bol'nitsy.

The authors present the results of research on validation and creation of an information mathematical model of resuscitation activity of a multiprofile hospital as an example of simulation of operative management of therapeutic and diagnostic process in medical structures of all profiles. Profound economic transformations in public health system put forward new problems before managers, economists, and administrators, who are to develop criteria for assessment of the activity of a therapeutic center and a medical worker, to define the scope and quality of work performed, to assess financial expenditures which should be adequate to the services rendered, to develop systems for continuous follow-up of grave patients and monitor the quality of the care rendered, etc. Information mathematical simulation of resuscitation activity of a multiprofile hospital will help get a detailed characterization of patients and of the activity of resuscitation wards, help assess the contribution of physicians and paramedics and the level of mastering present-day medical technologies by them.

[Systemic analysis of the activities of the intensive care and resuscitation unit in a multi-profile hospital. 3. Evaluation of the effectiveness and decision making]. / Sistemnyi analiz deiatel'nosti otdeleniia intensivnoi terapii i reanimatsii mnogoprofil'noi bol'nitsy. Chast' III. Otsenka éffektivnosti i priniatie reshenii.

The third part of this analysis deals with assessment of the efficacy of the reanimation service by reviewing the data on total and specific mortality rates, the results in critical patients, and correlation of these values to similar values in the hospital. Conclusions and resolutions on further improvement of the department activities are presented.