Chronic Critical Illness: Current Aspects of the Problem (Review).

Chronic resuscitation patients who have survived the acute phase of a disease represent a fast-growing cohort of patients requiring specialized medical assistant in intensive care and resuscitation units (ICRU) for several months or years. The term "chronic critical illness" (CCI) was proposed for such patients in the mid-80s of the last century. Patients with CCI make up from 5 to 20% of ICRU. Over time, they develop homeostasis disorders resulting in multiple organ failure and death. Mortality in CCI exceeds that of the majority of malignant neoplasms and functional dependence remains in most of survivors. In the present review, the attempt is made to show the main links of CCI pathogenesis which, if acted upon, can prevent unfavorable outcome. The publications describing epidemiology of CCI, its outcomes, and clinical phenotype have been analyzed. Several researchers consider CCI as a result of persistent inflammation, immunosuppression, and catabolism syndrome. Some works show the importance of nutrition for ICRU patients. The role of gastrointestinal tract in CCI formation has been noted. The effect of intensive therapy on microbiota of the ICRU patients has been demonstrated. Microbiome disturbances in dysbiosis and sepsis have been considered, as well as the effect of intestinal microbiome on the distant organs. Post-intensive care syndrome is a significant constituent of CCI. The main sequelae of the syndrome, as well as the general questions of its prevention and treatment, have been denoted.

Prediction of the Effectiveness of Spontaneous Breathing in Patients with Brain Damage of Various Etiologies.

The aim of the study was to develop an informative method for assessing chemoreflex sensitivity and to evaluate its prognostic capacity for restoring spontaneous breathing in patients with brain damage of various etiologies. The study included 16 healthy volunteers and 38 patients on prolonged mechanical ventilation (VE) after a traumatic brain injury, anoxic brain damage, and cerebrovascular events. The external respiration variables were assessed from the initial level to the development of the first episode of desaturation with spO2 in the range of 90-80% against the background of normobaric hypoxia as indicators reflecting the development of adaptive ventilatory response and characterizing the state of peripheral chemoreflex sensitivity (PCS). The peripheral chemoreflex sensitivity index (PCSI) was calculated using the equation: PCSI = [RR(e) : RR(i)] × [Vt(e) : Vt(i)] × [VE(e) : VE(i)] × Vt(e) × VE(e), where PCSI is the peripheral chemoreflex sensitivity index in L2/min; RR(i) and RR(e); Vt(i) and Vt(e); VE(i) and VE(e) are the respiratory rate, tidal volume, minute ventilation initially (i), before a functional stress test, and during a functional test of normobaric hypoxia with spO2 in the range of 90-80% (e). With the PCSI values ≥15.6 L2/min, successful weaning from ventilators and recovery of spontaneous breathing are predicted. The sensitivity and specificity of PCSI were 78.57 [95% CI: 49.2-95.26] and 83.3% [95% CI: 62.6-95.26], respectively. The sensitivity and specificity of the traditional indicator of the success rate of weaning from ventilators and recovery of spontaneous breathing, Rapid Shallow Breathing Index (RSBI), in this cohort of patients was 69.23 [95% CI: 38.6-90.9] and 28.0% [95% CI: 12.03-49.3], respectively. A predictor of the patient's weaning from mechanical ventilation is the assessment of peripheral chemoreflex sensitivity, which can be measured by a simple non-invasive bedside test based on measuring the difference in external ventilation parameters before and during a functional normobaric hypoxic trial.

[Precursors of brain ischemia in patients in the acute stage of subarachnoid hemorrhage after the aneurysm rupture].

The authors attempted to predict an outcome of the disease using the dynamic evaluation of quantitative parameters of intracranial pressure (ICP) and linear systolic blood flow velocity (LSBFV). Seventeen patients, aged from 20 to 61 years, with acute subarachnoid hemorrhage (SAH) after the aneurysm rupture complicated with the syndrome of intracranial hypertension (SIH) and angiospasm were studied. A comparison of the clinical course and outcomes (good or bad) with corresponding quantitative parameters allows to conclude that the decrease in LSBFV (<200 cm/sec) in the syndrome of intracranial hypertension (ICP>30 mmHg) predicts the ischemic damage. LSBFV values higher than 200 cm/sec and ICP<30 mmHg reduces the risk for brain ischemia.

[Specific features of cerebral blood flow changes after surgical removal of chiasmatic-sellar region tumors using data of transcranial duplex sonography].

Aim of the study was to discover specific features of linear blood velocity in early postoperative period in patients with tumors of chiasmatic-sellar region. Measurement of linear blood velocity using transcranial duplex sonography was performed in 294 patients with tumors of hypothalamo-hypophyseal area (149 suprasellar pituitary adenomas, 145 endosuprasellar, hypophyseal and ventricular craniopharyngiomas). It was found that vasospasm of different severity was present in 62% cases after surgical removal of chiasmatic-sellar region tumors. This "primary vasospasm" was associated with intraoperative damage to a vessel. Delayed angiospasm was caused by subarachnoid hemorrhage into basal cisterns due to hyperactivation of neuroendocrine systems of adenohypophysis and aldosterone. Persistent vasospasm with linear blood velocity over 200 cm/s results in irreversible ischemic damage of subcortical and hypothalamic structures.

[Cerebral circulatory disorders in varying brain injury, as evidenced by transcranial Doppler study].

The investigation was undertaken to elucidate the specific features of cerebral blood flow in acute brain injury (BI) in relation to its severity. Cerebral circulation (CC) was studied in 83 patients aged 5 to 64 years in the acute period of BI. The authors estimated the consciousness by the Glasgow coma scale and CC from the mean linear blood flow velocity (LBFV) in both middle cerebral arteries (MCA). To calculate the hemispheric index (HI), blood flow was examined in the extracranial portion of the ipsilateral internal carotid artery. The traumatic lesion substrate was verified by computed tomography and magnetic resonance imaging. Intracranial and cerebral perfusion pressures were continuously monitored in 39 patients. The outcomes of BI were assessed by means of the Glasgow outcome scale. In accordance with the values of LBFV, all the patients were divided into 3 groups: 1) patients in whom MCA LBFV throughout the acute period of BI remained within the range of normal or low values (30-70 cm/sec); 2) those in whom MCA LBFV ranged from 80 to 120 cm/sec at a HI of less than 3.0; 3) those with vasospasm in whom MCA LBFV was more than 120 cm/sec at a HI of more than 3.0. Analysis of the studies revealed that despite the same consciousness impairments, the magnitude of CC disorders was appropriate to the severity of brain lesions in all three groups. At the same time severe and mixed brain lesions as intracranial hematomas, type 3 contusion foci, and profuse subarachnoidal hemorrhages were attended by the development of unilateral or bilateral vasospasm of MCA. In addition, the low CC values mainly associated with prehospital overall cerebral hypoxia were ascertained to be a poor factor of the outcome of BI. The best results of treatment for BI are achieved in moderate CC disorders as a moderate LBFV increase.

[Intensive care using hypervolemic hypertensive hemodilution in the acute period of subarachnoidal hemorrhages in patients with arterial aneurysms].

Cerebral vasospasm and its associated ischemia are one of the main causes of death in 23% of patients with prior aneurysmal subarachnoidal hemorrhage (SAH). At present, a diversity of approaches to treating vasospasm has been developed, among them hypertensive hypervolemic hemodilution (deriving its abbreviated name 3H-therapy) offers certain advantages. At the same time a number of aspects of application of this approach remain unclear. Fifty-four patients with significant cerebral arterial spasm (elevated linear systolic blood flow velocity > or = 200 cm/s) who had been operated on in the acute period of aneurysmal SAH were selected. Of them, 18 patients had undergone hypervolemic hypertensive hemodilution (3H-therapy) under guidance of systemic hemodynamics, by using a Swan-Ganz catheter (these patients formed a study group). Thirty-six patients who had not undergone 3H-therapy under invasive monitoring of systemic hemodynamics constituted a control group. Hypervolemic hypertensive hemodilution was performed by means of continuous intravenous infusion of a combination of colloid-crystalloid solutions. The therapy was considered to be adequate by meeting the following requirements: maintenance of cardiac index not less 3.5 l/min/m2, pulmonary capillary wedge pressure below 14-16 mm Hg or central venous pressure under to 8-10 mm Hg, packed cell volume below 28-32%, and systolic blood pressure under 200 mm Hg. Hypervolemic hypertensive hemodilution (3H-therapy) applied to patients operated on in the acute period of aneurysmal SAH was effective in increasing cardiac output, central venous pressure, systemic arterial pressure and hence cerebral perfusion with the minimum number of complications unassociated with the use of this technique. This permitted a reduction in mortality rates in patients with baseline Hunt-Hess grade I-III SAH. At the same time, it should be emphasized that 3H-therapy may be used in neurosurgical patients, by thoroughly monitoring the parameters of central hemodynamics, blood coagulation system, cerebral circulation and, desirably, intracranial pressure.

[Transcutaneous dilation tracheostomy in children].

The paper presents the experience of transcutaneous dilatation tracheostomy (TDT) in 16 children. Up to date, childhood has been a contraindication for TDT. The experience gained at the Department of Resuscitation, Institute of Neurosurgery, in performing TDT in more than 300 adult patients has permitted this procedure to be also used in childhood. Based on the analysis of the outcome of 16 TDTs, the authors have posed indications for TDT, its performance modification, approaches to preventing perioperative complications, by taking into account the anatomic and physiological characteristics of childhood.

[Water-electrolyte and endocrine disorders after craniopharyngomectomy in a child]. / Vodno-élektrolitnye i éndokrinnye narusheniia posle udaleniia kraniofaringiomy u rebenka.

The paper considers a type of three-phase course of diabetes insipidus with the development of the syndrome of inadequate secretion of antidiuretic hormone (SIADH) in a child after radical removal of endosupracellar craniopharyngoma. The parameters of cerebral blood flow, homeostatic fluctuations, the blood levels of thyroid hormones were compared with the time course of changes in the patient's clinical status. SIADH was accompanied by impaired consciousness, convulsion, developed common edematous syndrome, including interstitial edema of the lung, progressive suprarenal and thyroid insufficiency. The concurrence of SIADH with polyhormonal deficiency and the edematous syndrome determined the lines of intensive care.

[Nosocomial pneumonia in patients with severe craniocerebral trauma in intensive care units]. / Nozokomial'naia pnevmoniia u bol'nykh s tiazheloi cherepno-mozgovoi travmoi v otdalenii reanimatsii i intensivnoi terapii.

Eighty-three patients with severe craniocerebral injuries (CCI) were treated at Institute of Neurosurgery in 1999. Pulmonary infectious complications occurred in 16 of 25 patients with severe CCI. Early nosocomial pneumonia (NP) was diagnosed in 18% and the so-called late NP (associated with artificial ventilation of the lungs) in 35%. Coma longer than 4 days increased the incidence of NP to 62%. The main pathogens of NP are gram-negative aerobic bacteria (61%), the predominant agent being Pseudomonas aeruginosa (18.9%). 76% isolated microorganisms were multiresistant. The most significant risk factors as regards NP in patients with severe CCI were coma combined with bulbar and pseudobulbar disorders.

[Endogenous intoxication and its treatment with sodium hypochlorite in neurosurgical patients]. / Endogennaia intoksikatsiia i ee lechenie s primeneniem gipokhlorita natriia u neiroreanimatsionnykh bol'nykh.

Blood plasma levels of medium-mass molecules (MMM), antioxidant activity (AOA), and malonic dialdehyde (MDA) were measured in 51 neurosurgical patients before and directly and 24 h after intravenous drip infusion of sodium hypochlorite (SHC) solution. Preliminary in vitro studies showed the most expressed drop of initially high MDA and MMM levels to be associated with an increase of AOA. It was observed at SHC concentration of 0.05 mg/ml, corresponding to infusion of SHC in a concentration of 600 mg/liter in 0.1 of the total circulating blood volume. Even a single dose of SHC alleviated endogenous intoxication and decreased the concentration of MMM and lipid peroxidation products. The proper AOA of the blood did not drop in this case, and in patients with initially low AOA it appreciably increased. Infusion of SHC normalized the values of Kp, which reflected its high detoxifying activity in endogenous poisoning caused mainly by inflammatory changes.