[Complex intensive care for acute gastroduodenal hemorrhages in patients after operations on the heart and vessels].

The purpose of the study was to define the most effective principles of intensive care for acute gastroduodenal hemorrhages in patients undergoing operations on the heart and vessels. The outcomes of 13,345 operations on the heart and vessels, performed at the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, were analyzed. Gastroduodenal hemorrhages were diagnosed in 114 patients, which amounted to 0.8% of the total number of operated patients. In the vast majority (86.8%) patients, gastroduodenal hemorrhages occurred after surgery under extracorporeal circulation. The results of medical and surgical treatment were analyzed. The medical treatment for gastroduodenal hemorrhages included intensive drug therapy and endoscopic hemostasis. The comprehensive and intensive approach to performing antiulcer therapy (concomitant use of the antisecretory agents: proton pump inhibitors, gastric protectors, and reparative agents) could reduce the incidence of recurrent bleeding and the timing of epithelization of gastrointestinal mucosal defects. Analyzing the results of the treatments has indicated that the efficiency of conservative measures significantly exceeds the beneficial effect of the treatment of gastroduodenal bleedings, including urgent abdominal surgical interventions. Emergency surgical interventions for gastroduodenal hemorrhages in cardiosurgical patients deteriorate the postoperative period and lead to an increase in postoperative morbidity, which determines the expediency of their performance only when conservative measures are ineffective. An algorithm of tactical actions has been developed for gastroduodenal hemorrhages occurring after operations on the heart and vessels.

[A present-day variant of intermitttent replacement renal therapy in patients with multiple organ failure after cardiovascular surgery]. / Sovremennyi variant intermittiruiushchei zamestitel'noi pochechnoi terapii u bol'nykh s sindromom poliorgannoi nedostatochnosti posle operatsii na serdtse i sosudakh.

The efficiency of "semi-prolonged" replacement renal therapy (RRT) was assessed in patients with multiple organ dysfunction (MOD) after cardiovascular surgery. The results of semiprolonged RRT are analyzed in 65 patients (36-69 years, mean age 52.4 +/- 15.7 years, body weight 57-105 kg, mean 79.4 +/- 21.6 kg) operated on at A. N. Bakulev Cardiovascular Surgery Center, Russian Academy of Medical Sciences. Bicarbonate hemodialysis (BHD) was carried out in 50 patients, on-line hemodiafiltration (HDF) in the rest patients. Interventions on the heart and vessels of different complexity were carried out. The results indicate that semiprolonged SRT in complex with intensive care measures notably reduced the mortality of patients with MOD and improved the survival rate in this category of patients. Semiprolonged RRT is an effective method, which can and should be used in critical patients. This method meets all the requirements to modern RRT and ensures adequate filtration of nitrous metabolism products, corrects water-electrolyte and acid base balance, allows infusion/transfusion therapy and parenteral nutrition, and has no negative impact on the hemodynamic values, which is particularly important after cardiovascular interventions.

[Peritoneal dialysis in the newborn and infants after radical correction of complex congenital heart defects]. / Peritoneal'nyi dializ u novorozhdennykh i grudnykh detei posle radikal'noi korrektsii slozhnykh vrozhdennykh porokov serdtsa.

The efficiency of peritoneal dialysis (PD) was evaluated in newborns and infants with multiple organ dysfunction (MOD) after cardiosurgery. In 1996-2001 at A. N. Bakulev Cardiovascular Surgery Center, Russian Academy of Medical Sciences, PD was used as permanent renal replacement therapy (RRT) in 19 newborns and infants aged under 1 year after radical correction of congenital heart diseases. The mean age of infants was 6.2 +/- 4.3 months, body weight 6.1 +/- 1.7 kg. Radical correction of congenital heart diseases was carried out in all patients. The immediate postoperative period was complicated by MOD in all patients. Pronounced cardiac, respiratory, and renal insufficiency was observed in all cases. The main indication for the beginning of PD was oligouria, hypervolemia, edematous syndrome with progressive cardiorespiratory insufficiency. Multiple-modality intensive care including PD resulted in positive changes in the clinical status of infants by days 4-5 of PD: hemodynamic values, gaseous exchange function of the lungs, and laboratory values improved. Hence, PD as an RRT method in newborns and infants subjected to radical cardiosurgery proved to be effective in the complex of intensive care measures for MOD. This sufficiently simple method, requiring no expensive equipment, adequately corrects hyperhydration and hypervolemia, metabolic and electrolyte disorders, and other MOD symptoms in newborns and infants.

[Significance of tissue pH in the prognosis of postoperative complications in heart surgery patients]. / Znachenie tkanevogo pH dlia prognoza posleoperatsionnykh oslozhnenii u kardiokhirurgicheskikh bol'nykh.

Ischemia of the gastrointestinal mucosa is characterized by acidosis in the submucosal layer during the majority of interventions, which necessitates monitoring of tissue pH (pHi) of the abdominal organs during aortocoronary bypass surgery and the immediate postoperative period. The pHi was measured by gastrotonometry with a nasogastral tube (Trip catheter) and Tonocap-TC200 device (Datex Engstrom, Finland); pHi was measured in 17 patients in department of intensive care on days 1 or 2 after cardiosurgical interventions with at least 120-min artificial circulation and in 23 patients during the operation. Surgical treatment consisted in correction of acquired valvular diseases, myocardial revascularization (shunting operations), and combinations of these operations. The first stage of investigation revealed a relationship between decreased pHi level to the acid values and complicated course of the postoperative period. The second stage showed that postoperative complications occurred in 27.2% cases only in patients subjected to long artificial circulation bypass (more than 120 min). The frequency of complications were 2-fold more in the patients with tissue acidosis (pHi < 7.35) during surgery than in patients with normal and alkaline pHi values. The following complications occurred: acute pancreatitis, acute peptic ulcer, acute renal and polyorgan failure. Comparative analysis of pHi and other metabolic markers of arterial blood showed a correlation between these parameters, but pHi was more specific for the diagnosis of tissue ischemia. Hence, a low invasive highly specific method of gaseous gastrotonometry helps evaluate the blood supply to abdominal organs during and after cardiac surgery with artificial circulation and predict postoperative gastrointestinal and grave systemic complications (sepsis, acute renal failure, and polyorgan failure).

[An endoscopic method of the treatment of complicated acute calculous cholecystitis]. / Endoskopicheskii sposob lecheniia oslozhnennogo ostrogo kal'kuleznogo kholetsistita.

Surgical treatment of acute cholecystitis attended by an affection of the extrahepatic bile ducts often leads to severe complications, particularly in elderly and old-aged patients, the mortality rate in such cases reaches 5-12%. The authors developed and introduced into practice a method of endoscopic treatment of acute combined diseases of the gallbladder and bile ducts, which included endoscopic papillotomy, antegrade catheterization of the gallbladder (laparoscopic cholecystostomy, transhepatic gallbladder drainage), antegrade perfusion with antiseptics under pressure, and various types of ante- and retrograde lithotripsy. Endoscopic method of treatment of combined diseases of the gallbladder and bile ducts makes it possible to remove the acute inflammatory process and in some cases may be an alternative to an emergency surgical operation.