5 research outputs found
ΠΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠ°, Π΄ΠΈΠ°Π³Π½ΠΎΡΡΠΈΠΊΠ° ΠΈ Π»Π΅ΡΠ΅Π½ΠΈΠ΅ ΡΡΠΎΠΌΠ±ΠΎΡΠΌΠ±ΠΎΠ»ΠΈΡΠ΅ΡΠΊΠΈΡ ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΠΉ Π² ΡΡΠ°Π²ΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΠΈ ΠΈ ΠΎΡΡΠΎΠΏΠ΅Π΄ΠΈΠΈ: ΠΌΠ΅ΡΠΎΠ΄ΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΡΠ΅ΠΊΠΎΠΌΠ΅Π½Π΄Π°ΡΠΈΠΈ
The guidelines describe modern approaches to the prevention, diagnosis, and treatment of thromboembolic complications in patients with injuries and after musculoskeletal surgery, in accordance with the interdisciplinary draft of the Clinical Guidelines (2022) Deep vein thrombosis of the extremities, which has passed public hearings and is being approved by the Russian Ministry of Health. The guidelines are designed for doctors of various specialties to provide medical care to specialized patients: orthopedic surgeons, anesthesiologists, resuscitators, clinical pharmacologists, health care organizers, medical students, residents, graduate students.Π ΠΌΠ΅ΡΠΎΠ΄ΠΈΡΠ΅ΡΠΊΠΈΡ
ΡΠ΅ΠΊΠΎΠΌΠ΅Π½Π΄Π°ΡΠΈΡΡ
ΠΎΠΏΠΈΡΠ°Π½Ρ ΡΠΎΠ²ΡΠ΅ΠΌΠ΅Π½Π½ΡΠ΅ ΠΏΠΎΠ΄Ρ
ΠΎΠ΄Ρ ΠΊ ΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠ΅, Π΄ΠΈΠ°Π³Π½ΠΎΡΡΠΈΠΊΠ΅ ΠΈ Π»Π΅ΡΠ΅Π½ΠΈΡ ΡΡΠΎΠΌΠ±ΠΎΡΠΌΠ±ΠΎΠ»ΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΠΉ Ρ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ ΡΡΠ°Π²ΠΌΠ°ΠΌΠΈ ΠΈ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΡΠΌΠΈ Π½Π° ΠΎΠΏΠΎΡΠ½ΠΎ-Π΄Π²ΠΈΠ³Π°ΡΠ΅Π»ΡΠ½ΠΎΠΌ Π°ΠΏΠΏΠ°ΡΠ°ΡΠ΅ Π² ΡΠΎΠΎΡΠ²Π΅ΡΡΡΠ²ΠΈΠΈ Ρ ΠΌΠ΅ΠΆΠ΄ΠΈΡΡΠΈΠΏΠ»ΠΈΠ½Π°ΡΠ½ΡΠΌ ΠΏΡΠΎΠ΅ΠΊΡΠΎΠΌ ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΈΡ
ΡΠ΅ΠΊΠΎΠΌΠ΅Π½Π΄Π°ΡΠΈΠΉ 2022 Π³. Π’ΡΠΎΠΌΠ±ΠΎΠ· Π³Π»ΡΠ±ΠΎΠΊΠΈΡ
Π²Π΅Π½ ΠΊΠΎΠ½Π΅ΡΠ½ΠΎΡΡΠ΅ΠΉ, ΠΏΡΠΎΡΠ΅Π΄ΡΠΈΠΌ ΠΎΠ±ΡΠ΅ΡΡΠ²Π΅Π½Π½ΡΠ΅ ΡΠ»ΡΡΠ°Π½ΠΈΡ ΠΈ Π½Π°Ρ
ΠΎΠ΄ΡΡΠ΅ΠΌΡΡ Π½Π° ΡΡΠ²Π΅ΡΠΆΠ΄Π΅Π½ΠΈΠΈ Π² ΠΠΈΠ½Π·Π΄ΡΠ°Π²Π΅ Π ΠΎΡΡΠΈΠΈ. ΠΠ΅ΡΠΎΠ΄ΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΡΠ΅ΠΊΠΎΠΌΠ΅Π½Π΄Π°ΡΠΈΠΈ ΡΠ°ΡΡΡΠΈΡΠ°Π½Ρ Π½Π° Π²ΡΠ°ΡΠ΅ΠΉ ΡΠ°Π·Π»ΠΈΡΠ½ΡΡ
ΡΠΏΠ΅ΡΠΈΠ°Π»ΡΠ½ΠΎΡΡΠ΅ΠΉ, ΠΎΠΊΠ°Π·ΡΠ²Π°ΡΡΠΈΡ
ΠΌΠ΅Π΄ΠΈΡΠΈΠ½ΡΠΊΡΡ ΠΏΠΎΠΌΠΎΡΡ ΠΏΡΠΎΡΠΈΠ»ΡΠ½ΡΠΌ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠ°ΠΌ: ΡΡΠ°Π²ΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΎΠ²-ΠΎΡΡΠΎΠΏΠ΅Π΄ΠΎΠ², Ρ
ΠΈΡΡΡΠ³ΠΎΠ², Π°Π½Π΅ΡΡΠ΅Π·ΠΈΠΎΠ»ΠΎΠ³ΠΎΠ²-ΡΠ΅Π°Π½ΠΈΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΎΠ², ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΈΡ
ΡΠ°ΡΠΌΠ°ΠΊΠΎΠ»ΠΎΠ³ΠΎΠ², ΠΎΡΠ³Π°Π½ΠΈΠ·Π°ΡΠΎΡΠΎΠ² Π·Π΄ΡΠ°Π²ΠΎΠΎΡ
ΡΠ°Π½Π΅Π½ΠΈΡ, ΡΡΡΠ΄Π΅Π½ΡΠΎΠ² ΠΌΠ΅Π΄ΠΈΡΠΈΠ½ΡΠΊΠΈΡ
Π²ΡΠ·ΠΎΠ², ΠΎΡΠ΄ΠΈΠ½Π°ΡΠΎΡΠΎΠ², Π°ΡΠΏΠΈΡΠ°Π½ΡΠΎΠ²
ΠΠ΅Π±Π»Π°Π³ΠΎΠΏΡΠΈΡΡΠ½ΡΠ΅ ΡΠ΅Π½Π΄Π΅Π½ΡΠΈΠΈ Π² ΡΡΠΈΠΎΠ»ΠΎΠ³ΠΈΠΈ ΠΎΡΡΠΎΠΏΠ΅Π΄ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ: ΡΠ΅Π·ΡΠ»ΡΡΠ°ΡΡ 6-Π»Π΅ΡΠ½Π΅Π³ΠΎ ΠΌΠΎΠ½ΠΈΡΠΎΡΠΈΠ½Π³Π° ΡΡΡΡΠΊΡΡΡΡ ΠΈ ΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΠΈ Π²Π΅Π΄ΡΡΠΈΡ Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Π΅ΠΉ
Osteomyelitis remains one of the most intractable diseases. The nature of the pathogen and its resistance to antibiotics significantly affect the outcome and cost of treatment.The aim of the study: to analyze the dynamics of the spectrum and antibiotic resistance of the leading pathogens of orthopedic infection for the period 2012β 2017.Material and methods. The structure of pathogens isolated from the focus of infection from 2774 patients with periprosthetic infection and chronic osteomyelitis was retrospectively analyzed. Antibiotic resistance of the leading pathogens that occupied more than 4% in the species structure was studied. Comparative analysis of changes in the spectrum of pathogens and antibiotic resistance was carried out for the periods 2012-2013, 2014β2015 and 2016-2017. Epidemiological analysis was performed in the program βmicrobiological monitoring systemβ Microbe-2. Statistical processing of the obtained data was carried out using the Z-criterion.Results. From 2774 patients with orthopedic infection have been isolated 4359 strains, in the structure of which about 73.5% were occupied by S. aureus, S. epidermidis, E. faecalis, E. faecium, P. aeruginosa, Acinetobacter sp. representatives of the family Enterobacteriacea. In 27% of the cases, microorganisms of other species were identified. Microbial associations were identified in 19.4% of cases. In the structure of the leading Gram(+) pathogens, a significant decrease in the incidence of S. aureus was detected, while the share of S. epidermidis increased significantly. Among the leading Gram(-) microorganisms, a significant increase in the proportion of representatives of the fam. Enterobacteriacea was found, against the background of a decrease in the share of Acinetobacter sp. and P. aeruginosa. The level of resistance of MSSA to the studied antibiotics ranged from 0.1 to 8.8%, for MSSE the spread was from 1.9 to 16.7%. Negative dynamics of growth of resistance of non-fermenting bacteria is established. The strains of Acinetobacter sp. demonstrated greater resistance to tested antibiotics in comparison with P. aeruginosa.Conclusion. An increase in the role of S. epidermidis and K. pneumoniae in the etiology of orthopedic infection was established. The revealed increase in the resistance of microbial pathogens to most tested and used antibiotics should be taken into account in the appointment of empirical antibiotic therapy. The extremely high frequency of resistance of gram-negative bacteria to cephalosporins and fluoroquinolones excludes the possibility of their empirical use, which requires the management of carbapenems in the starting treatment regimens. High resistance to fluoroquinolones limits the ability of oral antibiotic therapy in patients with periprosthetic infection.Β ΠΡΡΠ΅ΠΎΠΌΠΈΠ΅Π»ΠΈΡ Π΄ΠΎ Π½Π°ΡΡΠΎΡΡΠ΅Π³ΠΎ Π²ΡΠ΅ΠΌΠ΅Π½ΠΈ ΠΎΡΡΠ°Π΅ΡΡΡ ΠΎΠ΄Π½ΠΈΠΌ ΠΈΠ· ΡΠ°ΠΌΡΡ
ΡΡΡΠ΄Π½ΠΎΠΈΠ·Π»Π΅ΡΠΈΠΌΡΡ
Π·Π°Π±ΠΎΠ»Π΅Π²Π°Π½ΠΈΠΉ. Π₯Π°ΡΠ°ΠΊΡΠ΅Ρ Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Ρ ΠΈ Π΅Π³ΠΎ ΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΡ ΠΊ Π°Π½ΡΠΈΠ±ΠΈΠΎΡΠΈΠΊΠ°ΠΌ Π·Π½Π°ΡΠΈΠΌΠΎ Π²Π»ΠΈΡΡΡ Π½Π° ΠΈΡΡ
ΠΎΠ΄ ΠΈ ΡΡΠΎΠΈΠΌΠΎΡΡΡ Π»Π΅ΡΠ΅Π½ΠΈΡ.Π¦Π΅Π»Ρ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ β Π²ΡΡΠ²ΠΈΡΡ Π΄ΠΈΠ½Π°ΠΌΠΈΠΊΡ ΡΠΏΠ΅ΠΊΡΡΠ° ΠΈ ΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΠΈ ΠΊ Π°Π½ΡΠΈΠ±ΠΈΠΎΡΠΈΠΊΠ°ΠΌ Π²Π΅Π΄ΡΡΠΈΡ
Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Π΅ΠΉ ΠΎΡΡΠΎΠΏΠ΅Π΄ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΈΠΌΠΏΠ»Π°Π½ΡΠ°Ρ-Π°ΡΡΠΎΡΠΈΠΈΡΠΎΠ²Π°Π½Π½ΠΎΠΉ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ Π·Π° ΠΏΠ΅ΡΠΈΠΎΠ΄ 2012β2017 Π³Π³.ΠΠ°ΡΠ΅ΡΠΈΠ°Π» ΠΈ ΠΌΠ΅ΡΠΎΠ΄Ρ. Π Π΅ΡΡΠΎΡΠΏΠ΅ΠΊΡΠΈΠ²Π½ΠΎ ΠΏΡΠΎΠ°Π½Π°Π»ΠΈΠ·ΠΈΡΠΎΠ²Π°Π½Π° ΡΡΡΡΠΊΡΡΡΠ° Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Π΅ΠΉ, Π²ΡΠ΄Π΅Π»Π΅Π½Π½ΡΡ
ΠΈΠ· ΠΎΡΠ°Π³Π° ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ ΠΎΡ 2774 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ ΠΏΠ΅ΡΠΈΠΏΡΠΎΡΠ΅Π·Π½ΠΎΠΉ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠ΅ΠΉ ΠΈ Ρ
ΡΠΎΠ½ΠΈΡΠ΅ΡΠΊΠΈΠΌ ΠΎΡΡΠ΅ΠΎΠΌΠΈΠ΅Π»ΠΈΡΠΎΠΌ. ΠΡΠ»Π° ΠΈΠ·ΡΡΠ΅Π½Π° ΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΡ ΠΊ Π°Π½ΡΠΈΠ±ΠΈΠΎΡΠΈΠΊΠ°ΠΌ Π²Π΅Π΄ΡΡΠΈΡ
Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Π΅ΠΉ, ΠΊΠΎΡΠΎΡΡΠ΅ Π·Π°Π½ΠΈΠΌΠ°Π»ΠΈ Π² Π²ΠΈΠ΄ΠΎΠ²ΠΎΠΉ ΡΡΡΡΠΊΡΡΡΠ΅ Π±ΠΎΠ»Π΅Π΅ 4%. Π‘ΡΠ°Π²Π½ΠΈΡΠ΅Π»ΡΠ½ΡΠΉ Π°Π½Π°Π»ΠΈΠ· ΠΈΠ·ΠΌΠ΅Π½Π΅Π½ΠΈΡ ΡΠΏΠ΅ΠΊΡΡΠ° Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Π΅ΠΉ ΠΈ Π°Π½ΡΠΈΠ±ΠΈΠΎΡΠΈΠΊΠΎΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΠΈ ΠΏΡΠΎΠ²ΠΎΠ΄ΠΈΠ»ΠΈ ΠΏΠΎ ΠΏΠ΅ΡΠΈΠΎΠ΄Π°ΠΌ 2012β2013, 2014β2015 ΠΈ 2016β2017 Π³Π³. ΠΠΏΠΈΠ΄Π΅ΠΌΠΈΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΈΠΉ Π°Π½Π°Π»ΠΈΠ· Π²ΡΠΏΠΎΠ»Π½ΡΠ»ΠΈ Π² ΠΏΡΠΎΠ³ΡΠ°ΠΌΠΌΠ΅ Β«Π‘ΠΈΡΡΠ΅ΠΌΠ° ΠΌΠΈΠΊΡΠΎΠ±ΠΈΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΠΌΠΎΠ½ΠΈΡΠΎΡΠΈΠ½Π³Π° Β«ΠΠΈΠΊΡΠΎΠ±-2Β». Π‘ΡΠ°ΡΠΈΡΡΠΈΡΠ΅ΡΠΊΠ°Ρ ΠΎΠ±ΡΠ°Π±ΠΎΡΠΊΠ° ΠΏΠΎΠ»ΡΡΠ΅Π½Π½ΡΡ
Π΄Π°Π½Π½ΡΡ
Π²ΡΠΏΠΎΠ»Π½ΡΠ»Π°ΡΡ Ρ ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΠ΅ΠΌ Z-ΠΊΡΠΈΡΠ΅ΡΠΈΡ.Π Π΅Π·ΡΠ»ΡΡΠ°ΡΡ. ΠΡ 2774 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ ΠΎΡΡΠΎΠΏΠ΅Π΄ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠ΅ΠΉ Π±ΡΠ»ΠΎ Π²ΡΠ΄Π΅Π»Π΅Π½ΠΎ 4359 ΡΡΠ°ΠΌΠΌΠΎΠ², Π² ΡΡΡΡΠΊΡΡΡΠ΅ ΠΊΠΎΡΠΎΡΡΡ
73,5% Π·Π°Π½ΠΈΠΌΠ°Π»ΠΈ S. aureus, S. epidermidis, E. faecalis, E. faecium, P. aeruginosa, Acinetobacter sp. ΠΈ ΠΏΡΠ΅Π΄ΡΡΠ°Π²ΠΈΡΠ΅Π»ΠΈ ΡΠ΅ΠΌ. Enterobacteriaceae. Π 27% ΡΠ»ΡΡΠ°ΡΡ
Π±ΡΠ»ΠΈ ΠΈΠ΄Π΅Π½ΡΠΈΡΠΈΡΠΈΡΠΎΠ²Π°Π½Ρ ΠΌΠΈΠΊΡΠΎΠΎΡΠ³Π°Π½ΠΈΠ·ΠΌΡ Π΄ΡΡΠ³ΠΈΡ
Π²ΠΈΠ΄ΠΎΠ². ΠΠΈΠΊΡΠΎΠ±Π½ΡΠ΅ Π°ΡΡΠΎΡΠΈΠ°ΡΠΈΠΈ ΠΈΠ΄Π΅Π½ΡΠΈΡΠΈΡΠΈΡΠΎΠ²Π°Π½Ρ Π² 19,4% ΡΠ»ΡΡΠ°Π΅Π². Π ΡΡΡΡΠΊΡΡΡΠ΅ Π²Π΅Π΄ΡΡΠΈΡ
Π³ΡΠ°ΠΌΠΏΠΎΠ»ΠΎΠΆΠΈΡΠ΅Π»ΡΠ½ΡΡ
Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Π΅ΠΉ Π²ΡΡΠ²Π»Π΅Π½ΠΎ Π·Π½Π°ΡΠΈΡΠ΅Π»ΡΠ½ΠΎΠ΅ ΡΠ½ΠΈΠΆΠ΅Π½ΠΈΠ΅ ΡΠ°ΡΡΠΎΡΡ Π²ΡΠ΄Π΅Π»Π΅Π½ΠΈΡ S. aureus, ΠΏΡΠΈ ΡΡΠΎΠΌ ΡΡΡΠ΅ΡΡΠ²Π΅Π½Π½ΠΎ Π²ΠΎΠ·ΡΠΎΡΠ»Π° Π΄ΠΎΠ»Ρ S. epidermidis. Π‘ΡΠ΅Π΄ΠΈ Π²Π΅Π΄ΡΡΠΈΡ
Π³ΡΠ°ΠΌΠΎΡΡΠΈΡΠ°ΡΠ΅Π»ΡΠ½ΡΡ
ΠΏΠ°ΡΠΎΠ³Π΅Π½ΠΎΠ² Π²ΡΡΠ²Π»Π΅Π½ΠΎ Π·Π½Π°ΡΠΈΠΌΠΎΠ΅ ΡΠ²Π΅Π»ΠΈΡΠ΅Π½ΠΈΠ΅ Π΄ΠΎΠ»ΠΈ ΠΏΡΠ΅Π΄ΡΡΠ°Π²ΠΈΡΠ΅Π»Π΅ΠΉ ΡΠ΅ΠΌ. Enterobacteriaceae, Π½Π° ΡΠΎΠ½Π΅ ΡΠΌΠ΅Π½ΡΡΠ΅Π½ΠΈΡ Π΄ΠΎΠ»ΠΈ Acinetobacter sp. ΠΈ P. aeruginosa. Π£ΡΠΎΠ²Π΅Π½Ρ ΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΠΈ MSSA ΠΊ ΠΈΡΡΠ»Π΅Π΄ΡΠ΅ΠΌΡΠΌ Π°Π½ΡΠΈΠ±ΠΈΠΎΡΠΈΠΊΠ°ΠΌ ΠΊΠΎΠ»Π΅Π±Π°Π»ΡΡ ΠΎΡ 0,1 Π΄ΠΎ 8,8%, Π΄Π»Ρ MSSE ΡΠ°Π·Π±ΡΠΎΡ ΡΠΎΡΡΠ°Π²ΠΈΠ» ΠΎΡ 1,9 Π΄ΠΎ 16,7%. Π£ΡΡΠ°Π½ΠΎΠ²Π»Π΅Π½Π° Π½Π΅Π³Π°ΡΠΈΠ²Π½Π°Ρ Π΄ΠΈΠ½Π°ΠΌΠΈΠΊΠ° ΡΠΎΡΡΠ° ΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΠΈ Π½Π΅ΡΠ΅ΡΠΌΠ΅Π½ΡΠΈΡΡΡΡΠΈΡ
Π±Π°ΠΊΡΠ΅ΡΠΈΠΉ. ΠΡΠΈ ΡΡΠΎΠΌ ΡΡΠ°ΠΌΠΌΡ Acinetobacter sp. Π΄Π΅ΠΌΠΎΠ½ΡΡΡΠΈΡΠΎΠ²Π°Π»ΠΈ Π±Γ³Π»ΡΡΡΡ ΡΡΡΠΎΠΉΡΠΈΠ²ΠΎΡΡΡ ΠΊ ΡΠ΅ΡΡΠΈΡΡΠ΅ΠΌΡΠΌ Π°Π½ΡΠΈΠ±ΠΈΠΎΡΠΈΠΊΠ°ΠΌ Π² ΡΡΠ°Π²Π½Π΅Π½ΠΈΠΈ Ρ P. aeruginosa.ΠΠ°ΠΊΠ»ΡΡΠ΅Π½ΠΈΠ΅. Π£ΡΡΠ°Π½ΠΎΠ²Π»Π΅Π½ΠΎ ΡΠ²Π΅Π»ΠΈΡΠ΅Π½ΠΈΠ΅ ΡΠΎΠ»ΠΈ S. epidermidis ΠΈ K. pneumoniae Π² ΡΡΠΈΠΎΠ»ΠΎΠ³ΠΈΠΈ ΠΎΡΡΠΎΠΏΠ΅Π΄ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ. ΠΡΡΠ²Π»Π΅Π½Π½ΡΠΉ ΡΠΎΡΡ ΡΡΡΠΎΠΉΡΠΈΠ²ΠΎΡΡΠΈ ΠΌΠΈΠΊΡΠΎΠ±Π½ΡΡ
Π²ΠΎΠ·Π±ΡΠ΄ΠΈΡΠ΅Π»Π΅ΠΉ ΠΊ Π±ΠΎΠ»ΡΡΠΈΠ½ΡΡΠ²Ρ ΡΠ΅ΡΡΠΈΡΡΠ΅ΠΌΡΡ
ΠΈ ΠΏΡΠΈΠΌΠ΅Π½ΡΠ΅ΠΌΡΡ
Π°Π½ΡΠΈΠ±ΠΈΠΎΡΠΈΠΊΠΎΠ² ΡΠ»Π΅Π΄ΡΠ΅Ρ ΡΡΠΈΡΡΠ²Π°ΡΡ ΠΏΡΠΈ Π½Π°Π·Π½Π°ΡΠ΅Π½ΠΈΠΈ ΡΠΌΠΏΠΈΡΠΈΡΠ΅ΡΠΊΠΎΠΉ Π°Π½ΡΠΈΠ±Π°ΠΊΡΠ΅ΡΠΈΠ°Π»ΡΠ½ΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ. ΠΡΠ°ΠΉΠ½Π΅ Π²ΡΡΠΎΠΊΠ°Ρ ΡΠ°ΡΡΠΎΡΠ° ΡΠ΅Π·ΠΈΡΡΠ΅Π½ΡΠ½ΠΎΡΡΠΈ Π³ΡΠ°ΠΌΠΎΡΡΠΈΡΠ°ΡΠ΅Π»ΡΠ½ΡΡ
Π±Π°ΠΊΡΠ΅ΡΠΈΠΉ ΠΊ ΡΠ΅ΡΠ°Π»ΠΎΡΠΏΠΎΡΠΈΠ½Π°ΠΌ ΠΈ ΡΡΠΎΡΡ
ΠΈΠ½ΠΎΠ»ΠΎΠ½Π°ΠΌ ΠΈΡΠΊΠ»ΡΡΠ°Π΅Ρ Π²ΠΎΠ·ΠΌΠΎΠΆΠ½ΠΎΡΡΡ ΠΈΡ
ΡΠΌΠΏΠΈΡΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΡ, ΡΡΠΎ ΡΡΠ΅Π±ΡΠ΅Ρ Π²Π²Π΅Π΄Π΅Π½ΠΈΡ ΠΊΠ°ΡΠ±Π°ΠΏΠ΅Π½Π΅ΠΌΠΎΠ² Π² ΡΡΠ°ΡΡΠΎΠ²ΡΠ΅ ΡΡ
Π΅ΠΌΡ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ. ΠΡΡΠΎΠΊΠ°Ρ ΡΡΡΠΎΠΉΡΠΈΠ²ΠΎΡΡΡ ΠΊ ΡΡΠΎΡΡ
ΠΈΠ½ΠΎΠ»ΠΎΠ½Π°ΠΌ ΠΎΠ³ΡΠ°Π½ΠΈΡΠΈΠ²Π°Π΅Ρ Π²ΠΎΠ·ΠΌΠΎΠΆΠ½ΠΎΡΡΠΈ ΠΏΠ΅ΡΠΎΡΠ°Π»ΡΠ½ΠΎΠΉ Π°Π½ΡΠΈΠ±Π°ΠΊΡΠ΅ΡΠΈΠ°Π»ΡΠ½ΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ Ρ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ ΠΏΠ΅ΡΠΈΠΏΡΠΎΡΠ΅Π·Π½ΠΎΠΉ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠ΅ΠΉ
ΠΠ»ΠΈΡΠ½ΠΈΠ΅ ΡΠ°ΡΠΌΠ°ΠΊΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΡΡΠΎΠΌΠ±ΠΎΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠΈ, ΡΡΡΠ½ΠΈΠΊΠ΅ΡΠ° ΠΈ Π΄ΡΠ΅Π½ΠΈΡΠΎΠ²Π°Π½ΠΈΡ Π½Π° Π³Π΅ΠΌΠΎΡΡΠ°Π³ΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΡ Π² ΡΠ°Π½Π½ΠΈΠ΅ ΡΡΠΎΠΊΠΈ ΠΏΠΎΡΠ»Π΅ ΡΠ½Π΄ΠΎΠΏΡΠΎΡΠ΅Π·ΠΈΡΠΎΠ²Π°Π½ΠΈΡ ΠΊΠΎΠ»Π΅Π½Π½ΠΎΠ³ΠΎ ΡΡΡΡΠ°Π²Π°: ΠΏΡΠ΅Π΄Π²Π°ΡΠΈΡΠ΅Π»ΡΠ½ΡΠ΅ ΡΠ΅Π·ΡΠ»ΡΡΠ°ΡΡ
Background β venous thromboembolic complications (VTC) are potential life-threatening complicationsΒ following knee arthroplasty (KA). An optimal thromboprophylaxis strategy should reduce the risk of developing VTCΒ without increasing the risk of hemorrhagic complications. The purpose of the study is to evaluate the effect of theΒ drugs (acetylsalicylic acid, dabigatran etexilate and rivaroxaban) for the pharmacological thromboprophylaxis and theΒ features of the surgical procedure (use of the tourniquet and drainage) on hemorrhagic complications in early periodsΒ after knee arthroplasty. Materials and Methods. 335 patients (65 men and 270 women), without additional risk factorsΒ for the development of thromboembolic complications, were included into the study. Those patients were admittedΒ for planned primary / revision knee arthroplasty and corresponded to inclusion / non-inclusion criteria. PatientsΒ were randomized into three clinical groups, depending on the drug used thromboprophylaxis. During the inpatientΒ treatment period, all patients recorded the development of symptomatic VTCs and the development of hemorrhagicΒ complications. According to the clinical indications, the number of knee joint punctures was taken into account:Β patella balloting, restricted flexion and a smooth joint contour. Results. Symptomatic VTCs were not observed duringΒ the study period. The volume of intraoperative blood loss did not depend on the drugs used forΒ thromboprophylaxis,Β and was determined only by the surgical technique (Οs= -0.615, p = 0.0001). The use of the tourniquet during theΒ procedure significantly reduced intraoperative blood loss (p = 0.023). No relation between surgical technique andΒ anemia on the 5th day (Οs = 0.11, p = 0.05), as well as between surgical technique and total blood loss (Οs = 0.12,Β p = 0.01) was established; weak reliable correlation between the use of the tourniquet and hidden blood loss (Οs = -0.22,Β p = 0.01) was reported. A negative average significant correlation was observed (Οs = -0.42, p = 0.01) for the volumeΒ of total blood loss and hemoglobin level on the 5th day after the surgery. The number of postoperative puncturesΒ was comparable in the study groups. Conclusion. Sample of present size is not sufficient to make conclusions aboutΒ the equal efficacy of using acetylsalicylic acid, dabigatran and rivaroxaban for thromboprophylaxis after kneeΒ arthroplasty in patients without additional risk factors for thrombosis. Data on the significant correlation of theΒ surgical technique with the volume of intraoperative and latent blood loss, as well as total blood loss and hemoglobinΒ level on the 5th day after the operation allow to suggest a possible effect of the drug for thromboprophylaxis on bloodΒ loss stargin from 2nd day after the procedure.Β ΠΠΊΡΡΠ°Π»ΡΠ½ΠΎΡΡΡ β Π²Π΅Π½ΠΎΠ·Π½ΡΠ΅ ΡΡΠΎΠΌΠ±ΠΎΡΠΌΠ±ΠΎΠ»ΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΡ (ΠΠ’ΠΠ) ΡΠ²Π»ΡΡΡΡΡ ΠΏΠΎΡΠ΅Π½ΡΠΈΠ°Π»ΡΠ½ΠΎ ΠΎΠΏΠ°ΡΠ½ΡΠΌΠΈΒ Π΄Π»Ρ ΠΆΠΈΠ·Π½ΠΈ ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΡΠΌΠΈ ΡΠ½Π΄ΠΎΠΏΡΠΎΡΠ΅Π·ΠΈΡΠΎΠ²Π°Π½ΠΈΡ ΠΊΠΎΠ»Π΅Π½Π½ΠΎΠ³ΠΎ ΡΡΡΡΠ°Π²Π° (ΠΠ‘). ΠΠΏΡΠΈΠΌΠ°Π»ΡΠ½Π°Ρ ΡΡΡΠ°ΡΠ΅Π³ΠΈΡ ΡΡΠΎΠΌΠ±ΠΎΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠΈ Π΄ΠΎΠ»ΠΆΠ½Π° ΡΠ½ΠΈΠΆΠ°ΡΡ ΡΠΈΡΠΊ ΡΠ°Π·Π²ΠΈΡΠΈΡ ΠΠ’ΠΠ, Π½Π΅ ΠΏΠΎΠ²ΡΡΠ°Ρ ΡΠΈΡΠΊΠ° ΡΠ°Π·Π²ΠΈΡΠΈΡ Π³Π΅ΠΌΠΎΡΡΠ°Π³ΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΠΉ.Β Π¦Π΅Π»Ρ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ β ΠΎΡΠ΅Π½ΠΈΡΡ Π²Π»ΠΈΡΠ½ΠΈΠ΅ Π»Π΅ΠΊΠ°ΡΡΡΠ²Π΅Π½Π½ΡΡ
ΡΡΠ΅Π΄ΡΡΠ² (Π°ΡΠ΅ΡΠΈΠ»ΡΠ°Π»ΠΈΡΠΈΠ»ΠΎΠ²ΠΎΠΉ ΠΊΠΈΡΠ»ΠΎΡΡ, Π΄Π°Π±ΠΈΠ³Π°ΡΡΠ°Π½Π°Β ΡΡΠ΅ΠΊΡΠΈΠ»Π°ΡΠ° ΠΈ ΡΠΈΠ²Π°ΡΠΎΠΊΡΠ°Π±Π°Π½Π°) Π΄Π»Ρ ΡΠ°ΡΠΌΠ°ΠΊΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠΈ ΠΠ’ΠΠ ΠΈ ΠΎΡΠΎΠ±Π΅Π½Π½ΠΎΡΡΠ΅ΠΉ ΡΠ΅Ρ
Π½ΠΈΠΊΠΈ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈΒ (ΠΈΡΠΏΠΎΠ»ΡΠ·ΠΎΠ²Π°Π½ΠΈΠ΅ ΡΡΡΠ½ΠΈΠΊΠ΅ΡΠ° ΠΈ Π΄ΡΠ΅Π½ΠΈΡΠΎΠ²Π°Π½ΠΈΡ) Π½Π° Π³Π΅ΠΌΠΎΡΡΠ°Π³ΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΡ Π² ΡΠ°Π½Π½ΠΈΠ΅ ΡΡΠΎΠΊΠΈ ΠΏΠΎΡΠ»Π΅ ΡΠ½Π΄ΠΎΠΏΡΠΎΡΠ΅Π·ΠΈΡΠΎΠ²Π°Π½ΠΈΡ ΠΠ‘. ΠΠ°ΡΠ΅ΡΠΈΠ°Π» ΠΈ ΠΌΠ΅ΡΠΎΠ΄Ρ. Π ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΠΈ ΠΏΡΠΈΠ½ΡΠ»ΠΈ ΡΡΠ°ΡΡΠΈΠ΅ 335 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² (65 ΠΌΡΠΆΡΠΈΠ½ ΠΈ 270Β ΠΆΠ΅Π½ΡΠΈΠ½), ΠΏΠΎΡΡΡΠΏΠΈΠ²ΡΠΈΡ
Π΄Π»Ρ ΠΏΠ»Π°Π½ΠΎΠ²ΠΎΠ³ΠΎ ΠΏΠ΅ΡΠ²ΠΈΡΠ½ΠΎΠ³ΠΎ/ΡΠ΅Π²ΠΈΠ·ΠΈΠΎΠ½Π½ΠΎΠ³ΠΎ ΡΠ½Π΄ΠΎΠΏΡΠΎΡΠ΅Π·ΠΈΡΠΎΠ²Π°Π½ΠΈΡ ΠΠ‘, ΠΏΠΎΠ΄Ρ
ΠΎΠ΄ΡΡΠΈΡ
ΠΏΠΎΒ ΠΊΡΠΈΡΠ΅ΡΠΈΡΠΌ Π²ΠΊΠ»ΡΡΠ΅Π½ΠΈΡ/Π½Π΅Π²ΠΊΠ»ΡΡΠ΅Π½ΠΈΡ, Π±Π΅Π· Π΄ΠΎΠΏΠΎΠ»Π½ΠΈΡΠ΅Π»ΡΠ½ΡΡ
ΡΠ°ΠΊΡΠΎΡΠΎΠ² ΡΠΈΡΠΊΠ° ΡΠ°Π·Π²ΠΈΡΠΈΡ ΠΠ’ΠΠ. Π Π·Π°Π²ΠΈΡΠΈΠΌΠΎΡΡΠΈ ΠΎΡΒ Π»Π΅ΠΊΠ°ΡΡΡΠ²Π΅Π½Π½ΠΎΠ³ΠΎ ΡΡΠ΅Π΄ΡΡΠ²Π° Π΄Π»Ρ ΡΡΠΎΠΌΠ±ΠΎΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠΈ ΠΏΠ°ΡΠΈΠ΅Π½ΡΡ Π±ΡΠ»ΠΈ ΡΠ°Π½Π΄ΠΎΠΌΠΈΠ·ΠΈΡΠΎΠ²Π°Π½Ρ Π½Π° ΡΡΠΈ ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΈΠ΅Β Π³ΡΡΠΏΠΏΡ. Π ΡΠ΅ΡΠ΅Π½ΠΈΠ΅ ΡΡΠ°ΡΠΈΠΎΠ½Π°ΡΠ½ΠΎΠ³ΠΎ ΠΏΠ΅ΡΠΈΠΎΠ΄Π° Π»Π΅ΡΠ΅Π½ΠΈΡ Ρ Π²ΡΠ΅Ρ
ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² ΡΠ΅Π³ΠΈΡΡΡΠΈΡΠΎΠ²Π°Π»ΠΈ ΡΠ°Π·Π²ΠΈΡΠΈΠ΅ ΡΠΈΠΌΠΏΡΠΎΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΠ’ΠΠ ΠΈ ΡΠ°Π·Π²ΠΈΡΠΈΠ΅ Π³Π΅ΠΌΠΎΡΡΠ°Π³ΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΠΉ. ΠΡΠΎΠΌΠ΅ ΡΠΎΠ³ΠΎ, ΡΡΠΈΡΡΠ²Π°Π»ΠΈ ΠΊΠΎΠ»ΠΈΡΠ΅ΡΡΠ²ΠΎ ΠΏΡΠ½ΠΊΡΠΈΠΉ ΠΠ‘,Β Π²ΡΠΏΠΎΠ»Π½ΡΠ΅ΠΌΡΡ
ΠΏΠΎ ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΈΠΌ ΠΏΠΎΠΊΠ°Π·Π°Π½ΠΈΡΠΌ: Π±Π°Π»Π»ΠΎΡΠΈΡΠΎΠ²Π°Π½ΠΈΠ΅ Π½Π°Π΄ΠΊΠΎΠ»Π΅Π½Π½ΠΈΠΊΠ°, ΠΎΠ³ΡΠ°Π½ΠΈΡΠ΅Π½ΠΈΠ΅ ΡΠ³ΠΈΠ±Π°Π½ΠΈΡ ΠΈ ΡΠ³Π»Π°ΠΆΠ΅Π½Π½ΡΠΉ ΠΊΠΎΠ½ΡΡΡ ΡΡΡΡΠ°Π²Π°. Π Π΅Π·ΡΠ»ΡΡΠ°ΡΡ. Π‘ΠΈΠΌΠΏΡΠΎΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΠΠ’ΠΠ Π·Π° ΠΏΠ΅ΡΠΈΠΎΠ΄ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ Π½Π΅ Π²ΡΡΡΠ΅ΡΠ°Π»ΠΈΡΡ.Β ΠΠ±ΡΠ΅ΠΌ ΠΈΠ½ΡΡΠ°ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΎΠ½Π½ΠΎΠΉ ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΠΈ Π½Π΅ Π·Π°Π²ΠΈΡΠ΅Π» ΠΎΡ ΠΠ‘, ΠΊΠΎΡΠΎΡΡΠΌ ΠΏΡΠΎΠ²ΠΎΠ΄ΠΈΠ»Π°ΡΡ ΡΡΠΎΠΌΠ±ΠΎΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠ°,Β ΠΈ ΠΎΠΏΡΠ΅Π΄Π΅Π»ΡΠ»ΡΡ ΡΠΎΠ»ΡΠΊΠΎ ΡΠ΅Ρ
Π½ΠΈΠΊΠΎΠΉ Π²ΡΠΏΠΎΠ»Π½Π΅Π½ΠΈΡ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈ (Οs = -0,615, p = 0,0001). ΠΡΠΏΠΎΠ»ΡΠ·ΠΎΠ²Π°Π½ΠΈΠ΅ ΡΡΡΠ½ΠΈΠΊΠ΅ΡΠ° Π²ΠΎΒ Π²ΡΠ΅ΠΌΡ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈ ΠΏΠΎΠ·Π²ΠΎΠ»ΠΈΠ»ΠΎ Π·Π½Π°ΡΠΈΠΌΠΎ ΡΠΎΠΊΡΠ°ΡΠΈΡΡ ΠΈΠ½ΡΡΠ°ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΎΠ½Π½ΡΡ ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΡ (p = 0,023). ΠΠ΅ ΡΡΡΠ°Π½ΠΎΠ²Π»Π΅Π½ΠΎΒ ΡΠ²ΡΠ·ΠΈ ΠΌΠ΅ΠΆΠ΄Ρ ΡΠ΅Ρ
Π½ΠΈΠΊΠΎΠΉ Π²ΡΠΏΠΎΠ»Π½Π΅Π½ΠΈΡ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈ ΠΈ Π°Π½Π΅ΠΌΠΈΠ΅ΠΉ Π½Π° 5-Π΅ ΡΡΡΠΊΠΈ (Οs = 0,11, p = 0,05), Π° ΡΠ°ΠΊΠΆΠ΅ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΎΠ½Π½ΠΎΠΉΒ ΡΠ΅Ρ
Π½ΠΈΠΊΠΎΠΉ ΠΈ ΡΡΠΌΠΌΠ°ΡΠ½ΠΎΠΉ ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΠ΅ΠΉ (Οs = 0,12, p = 0,01). ΠΡΠΈ ΡΡΠΎΠΌ Π²ΡΡΠ²Π»Π΅Π½Π° ΡΠ»Π°Π±Π°Ρ Π·Π½Π°ΡΠΈΠΌΠ°Ρ ΠΊΠΎΡΡΠ΅Π»ΡΡΠΈΠΎΠ½Π½Π°ΡΒ ΡΠ²ΡΠ·Ρ ΠΌΠ΅ΠΆΠ΄Ρ ΠΈΡΠΏΠΎΠ»ΡΠ·ΠΎΠ²Π°Π½ΠΈΠ΅ΠΌ ΡΡΡΠ½ΠΈΠΊΠ΅ΡΠ° ΠΈ ΡΠΊΡΡΡΠΎΠΉ ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΠ΅ΠΉ (Οs = -0,22, p = 0,01). ΠΡΡΠ²Π»Π΅Π½Π° ΠΎΡΡΠΈΡΠ°ΡΠ΅Π»ΡΠ½Π°Ρ ΡΡΠ΅Π΄Π½ΡΡ ΠΊΠΎΡΡΠ΅Π»ΡΡΠΈΠΎΠ½Π½Π°Ρ ΡΠ²ΡΠ·Ρ (Οs = -0,42, p = 0,01) ΠΎΠ±ΡΠ΅ΠΌΠ° ΡΡΠΌΠΌΠ°ΡΠ½ΠΎΠΉ ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΠΈ ΠΈ ΡΡΠΎΠ²Π½Ρ Π³Π΅ΠΌΠΎΠ³Π»ΠΎΠ±ΠΈΠ½Π° Π½Π° 5-Π΅ ΡΡΡΠΊΠΈ ΠΏΠΎΡΠ»Π΅ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈ. ΠΠΎΠ»ΠΈΡΠ΅ΡΡΠ²ΠΎ ΠΏΠΎΡΠ»Π΅ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΎΠ½Π½ΡΡ
ΠΏΡΠ½ΠΊΡΠΈΠΉ Π² Π³ΡΡΠΏΠΏΠ°Ρ
Π±ΡΠ»ΠΎ ΡΠΎΠΏΠΎΡΡΠ°Π²ΠΈΠΌΠΎ.Β ΠΠ°ΠΊΠ»ΡΡΠ΅Π½ΠΈΠ΅. ΠΡΠ±ΠΎΡΠΊΠΈ ΡΠ°ΠΊΠΎΠ³ΠΎ ΡΠ°Π·ΠΌΠ΅ΡΠ° Π½Π΅Π΄ΠΎΡΡΠ°ΡΠΎΡΠ½ΠΎ, ΡΡΠΎΠ±Ρ ΡΠ΄Π΅Π»Π°ΡΡ Π²ΡΠ²ΠΎΠ΄Ρ ΠΎ ΡΠ°Π²Π½ΠΎΠΉ ΡΡΡΠ΅ΠΊΡΠΈΠ²Π½ΠΎΡΡΠΈ ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΡ ΠΠ‘Π, Π΄Π°Π±ΠΈΠ³Π°ΡΡΠ°Π½Π° ΠΈ ΡΠΈΠ²Π°ΡΠΎΠΊΡΠ°Π±Π°Π½Π° Π΄Π»Ρ ΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠΈ ΠΠ’ΠΠ ΠΏΠΎΡΠ»Π΅ ΡΠ½Π΄ΠΎΠΏΡΠΎΡΠ΅Π·ΠΈΡΠΎΠ²Π°Π½ΠΈΡ ΠΠ‘ Ρ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ²Β Π±Π΅Π· Π΄ΠΎΠΏΠΎΠ»Π½ΠΈΡΠ΅Π»ΡΠ½ΡΡ
ΡΠ°ΠΊΡΠΎΡΠΎΠ² ΡΠΈΡΠΊΠ° ΡΡΠΎΠΌΠ±ΠΎΠ·Π°. ΠΠΎΠ»ΡΡΠ΅Π½Π½ΡΠ΅ Π΄Π°Π½Π½ΡΠ΅ ΠΎ ΡΡΡΠ΅ΡΡΠ²Π΅Π½Π½ΠΎΠΉ ΠΊΠΎΡΡΠ΅Π»ΡΡΠΈΠΎΠ½Π½ΠΎΠΉ ΡΠ²ΡΠ·ΠΈΒ ΡΠ΅Ρ
Π½ΠΈΠΊΠΈ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈ Ρ ΠΎΠ±ΡΠ΅ΠΌΠΎΠΌ ΠΈΠ½ΡΡΠ°ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΎΠ½Π½ΠΎΠΉ ΠΈ ΡΠΊΡΡΡΠΎΠΉ ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΡ, Π° ΡΠ°ΠΊΠΆΠ΅ ΡΡΠΌΠΌΠ°ΡΠ½ΠΎΠΉ ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΠΈΒ ΠΈ ΡΡΠΎΠ²Π½Ρ Π³Π΅ΠΌΠΎΠ³Π»ΠΎΠ±ΠΈΠ½Π° Π½Π° 5-Π΅ ΡΡΡΠΊΠΈ ΠΏΠΎΡΠ»Π΅ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈ ΠΏΠΎΠ·Π²ΠΎΠ»ΡΡΡ ΠΏΡΠ΅Π΄ΠΏΠΎΠ»ΠΎΠΆΠΈΡΡ Π²ΠΎΠ·ΠΌΠΎΠΆΠ½ΠΎΠ΅ Π²Π»ΠΈΡΠ½ΠΈΠ΅ Π»Π΅ΠΊΠ°ΡΡΡΠ²Π΅Π½Π½ΠΎΠ³ΠΎ ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΠ° Π΄Π»Ρ ΡΡΠΎΠΌΠ±ΠΎΠΏΡΠΎΡΠΈΠ»Π°ΠΊΡΠΈΠΊΠΈ Π½Π° ΠΊΡΠΎΠ²ΠΎΠΏΠΎΡΠ΅ΡΡ ΡΠΎ Π²ΡΠΎΡΡΡ
ΡΡΡΠΎΠΊ ΠΏΠΎΡΠ»Π΅ ΠΎΠΏΠ΅ΡΠ°ΡΠΈΠΈ.