Седация и неинвазивная масочная вентиляция у пациентов с послеоперационным делирием и острой дыхательной недостаточностью

Aim: To compare the safety and efficacy of dexmedetomidine and haloperidol in patients with delirium and acute respiratory failure in non-invasive mask lung ventilation.Materials and methods. We carried out a retrospective analysis of data on patients with somatogenic delirium and acute respiratory failure (57 men, 4 women) experienced noninvasive ventilation (NIV) in the intensive care unit of the Botkin State Clinical Hospital in 2017–2018. Depending on the type of sedation the patients were divided into two groups: those on dexmedetomidine (n=31) and those receiving haloperidol (n=30). Dexmedetomidine was administered as a continuous infusion at a rate of 0.2–1.4 µg/kg/h while controlling the level of consciousness; haloperidol was administered by intravenous bolus injections until a sufficient level of sedation was reached in a dose of 2.5 mg 2–3 times a day.Results. The efficiency of sedation to achieve the required level of cooperation and possibility of NIV was 87.1% (27 patients) and 66.6% (20 patients) in dexmedetomidine and haloperidol groups. When estimating sedation in patients of both groups according to the RASS scale the scores did not differ significantly and were equal on the average to 1.7±0.3 (eye contact to voice). In haloperidol group in 10 out of 30 (33.3%) patients a sufficient level of sedation was not achieved, which required immediate tracheal intubation and invasive lung ventilation. Mortality in this group was 20% (6 patients), while in dexmedetomidine group it was 6.4% (2 patients).Conclusion. The use of dexmedetomidine, despite greater variability of hemodynamic parameters, allows to perform NIV with sufficient cooperation with the patient, reduces the frequency of tracheal intubation, risk of complications and mortality.Цель работы: сравнить безопасность и эффективность дексмедетомидина и галоперидола у пациентов с делирием и острой дыхательной недостаточностью при применении неинвазивной масочной вентиляции легких.Материалы и методы. Провели ретроспективный анализ данных 61 пациента (57 мужчин, 4 женщины) с соматогенным делирием и острой дыхательной недостаточностью при проведении неинвазивной масочной вентиляции легких (НИМВЛ) в отделении реанимации и интенсивной терапии ГКБ им. С. П. Боткина в 2017–2018 гг. В зависимости от вида препарата седации пациентов разделили на две группы: дексмедетомидина (n=31) и галоперидола (n=30). Дексмедетомидин назначали в виде продленной инфузии со скоростью 0,2–1,4 мкг/кг/ч под контролем уровня сознания; галоперидол больные получали в виде внутривенных фракционных введений до достижения достаточного уровня седации в дозе 2,5 мг 2–3 раза в день.Результаты. Эффективность седации для достижения необходимого уровня кооперации и проведения НИМВЛ составила в группах дексмедетомидина 87,1% (27 пациентов) и галоперидола 66,6% (20 пациентов). При оценке седации у больных обеих групп по шкале RASS показатели достоверно не различались и соответствовали в среднем 1,7±0,3 (открывает глаза на оклик). В группе галоперидола у 10 из 30 (33,3%) пациентов не удалось достичь достаточного уровня седации, что потребовало немедленной интубации трахеи и проведения инвазивной ИВЛ. Летальность в этой группе составила 20% (6 пациентов), тогда как в группе дексмедетомидина — 6,4% (2 пациента).Заключение. Применение дексмедетомидина, несмотря на более выраженную лабильность гемодинамических параметров, позволяет проводить НИМВЛ при достаточной кооперации с пациентом, уменьшает частоту интубации трахеи, риск развития осложнений и летальность

СЛУЧАЙ УСПЕШНОГО ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ТРОМБОЭМБОЛИИ ЛЕГОЧНОЙ АРТЕРИИ У БОЛЬНОЙ НА СРОКЕ БЕРЕМЕННОСТИ 11 НЕДЕЛЬ

Pulmonary embolism in pregnant women is fairly common complication, and it remains to be the one of major causes of maternal mortality in the number of countries. The need to compare risks of the mother and child makes the search for optimal treatment tactics very complicated in this specific case. The experience of the last decades provides evidences for choosing aggressive treatment tactics, accurate diagnostics and early surgical intervention. The authors of this article describe the clinical case of successful treatment of the young woman whose pregnancy course was complicated by pulmonary embolism at the 11th week of gestation. The article describes the results of laboratory and instrumental diagnostics and anasthesiological support technique within available scope of pharmacological and technical means. Also the article reviews the literature data on this problem. The conclusion contains recommendations for intra-operative management of such patients. Тромбоэмболия легочной артерии (ТЭЛА) у беременных женщин является весьма частым осложнением, она остается одной из ведущих причин материнской смертности в ряде стран. Необходимость соотнесения рисков для организма матери и ребенка делает поиск оптимальной тактики лечения в данном случае очень сложной задачей. Опыт последних десятилетий свидетельствует в пользу избрания агрессивной тактики лечения, точной диагностики и раннего оперативного вмешательства. В данной статье авторы представляют случай успешного лечения молодой женщины, течение беременности которой осложнилось ТЭЛА на сроке гестации 11 недель. Описываются результаты проведенной лабораторной и инструментальной диагностики, а также методика анестезиологического пособия в рамках доступного объема фармакологических и технических средств. Приводится анализ данных литературы по этой актуальной проблеме. В заключении даны рекомендации по интраоперационному ведению подобных больных.

Inhalational Induction and Maintenance of Sevoflurane-Based Anesthesia or Total Intravenous Anesthesia Using Propofol and Fentanyl in Patients with Concomitant Dyscirculatory Encephalopathy

Objective: to improve the results of treatment in patients with concomitant cerebrovascular diseases, by reducing the incidence of postoperative delirium due to neuroprotective properties of sevoflurane. Subjects and methods. Eighty2two patients with concomitant dyscirculatory encephalopathy were examined. The goals of the study included evaluating (a) efficiency and safety of total intravenous anesthesia (TIVA) using propofol versus inhalational induction and (b) maintenance of anesthesia (IIMA) using sevoflurane in patients with atherosclerotic and hypertensive encephalopathy undergoing noncardiac surgery. Results. The patients from both groups were susceptible to episodes of unintentional cerebral desaturation (rSO2); however, only the TIVA group showed a high correlation between a decrease in rSO2 and increases in the blood levels of S100beta protein, a marker of neuronal damage, and in the incidence of postoperative delirium (r=0.7321; p=0.0000001) diagnosed in accordance to comprehensive clinical examination and MMSE scores. The IIMA group lacked a relationship of MMSE scores to the episodes of cerebral desaturation (r=0.1609; p=0.4860), which is regarded as a manifestation of the neuroprotective effect resulted from anesthetic preconditioning. Conclusion. sevafluran2based inhalational induction and maintenance of anesthesia in patients with atherosclerotic and hypertensive encephalopathy is preferable over intravenous anesthesia with propofol and fentanyl in patients with concomitatnt disregulatory enc encephalopathy. Key words: cerebral desaturation, postoperative delirium, anesthetic preconditioning, europrotection, sevoflurane

Sedation and Non-Invasive Mask Ventilation in Patients with Delirium and Acute Respiratory Failure

Aim: To compare the safety and efficacy of dexmedetomidine and haloperidol in patients with delirium and acute respiratory failure in non-invasive mask lung ventilation.Materials and methods. We carried out a retrospective analysis of data on patients with somatogenic delirium and acute respiratory failure (57 men, 4 women) experienced noninvasive ventilation (NIV) in the intensive care unit of the Botkin State Clinical Hospital in 2017–2018. Depending on the type of sedation the patients were divided into two groups: those on dexmedetomidine (n=31) and those receiving haloperidol (n=30). Dexmedetomidine was administered as a continuous infusion at a rate of 0.2–1.4 µg/kg/h while controlling the level of consciousness; haloperidol was administered by intravenous bolus injections until a sufficient level of sedation was reached in a dose of 2.5 mg 2–3 times a day.Results. The efficiency of sedation to achieve the required level of cooperation and possibility of NIV was 87.1% (27 patients) and 66.6% (20 patients) in dexmedetomidine and haloperidol groups. When estimating sedation in patients of both groups according to the RASS scale the scores did not differ significantly and were equal on the average to 1.7±0.3 (eye contact to voice). In haloperidol group in 10 out of 30 (33.3%) patients a sufficient level of sedation was not achieved, which required immediate tracheal intubation and invasive lung ventilation. Mortality in this group was 20% (6 patients), while in dexmedetomidine group it was 6.4% (2 patients).Conclusion. The use of dexmedetomidine, despite greater variability of hemodynamic parameters, allows to perform NIV with sufficient cooperation with the patient, reduces the frequency of tracheal intubation, risk of complications and mortality

Effect of Propofol on Sevoflurane-Induced Myocardial Preconditioning in the Experiment

Objective: to estimate the magnitude of the cardioprotective properties of sevoflurane and propofol, when they are used alone and in combination in the acute experiment on rats after total ischemia/reperfusion (I/R). Materials and methods. The investigation was conducted on 50 male albino outbred rats weighing 202±19 g (M±ff), by using a total I/R model. The animals were randomized into 5 groups: 1) intraperitoneal chloral hydrate 300 mg/kg; 15-minute mechanical ventilation (MV); 2) inhalation induction with sevoflurane in an exsiccator; MV; injection of about 2—2.5 MAC sevoflurane in the expiratory breathing circuit for 15 minutes — anesthetic preconditioning simulation (APS); 3) anesthesia and APS with sevoflurane; then 10-minute ischemia simulation, followed by resuscitation and 5-minute reperfusion; 4) chloral hydrate anesthesia; injection of propofol 2.5 mg/kg in the right internal jugular vein; APS simulation; 5) chloral hydrate anesthesia; injection of propofol 2.5 mg/kg in the right internal jugular vein; and simulation of APS with sevoflurane. The hearts were extracted from all the animals and homogenized for further examination. The concentrations of total and phosphorylated glycogen synthase kinase-3/8 (GSK-3/8 and pGSK-3/8, respectively) were estimated by Western blotting. Results. The concentration of total GSK-3/8 was comparable in the groups. Group 2 showed a 1.5-fold increase in pGSK-3^ concentrations  (p<0.05), a more increment (by more than twice) was observed in Group 3 (p<0.05). The concentration of pGSK-30 rose slightly in Group 4. In Group 5, the level of pGSK-30 decreased approximately twice that in Group 1 (p<0.05). Conclusion. Sevoflurane can be expected to have cardioprotective properties manifested as a considerably elevated p-GSK-Эв level. Propofol fails to exert a significant cardioprotective effect and when it is used in combination with sevoflurane, the latter is likely to completely deprive of the cardioprotective properties, by lowering the level of p-GSK-3^ below the reference values, which may be associated with the antioxidant properties of propofol. Evidently, further investigation should be continued to form ischemia/reperfusion groups when these anesthetics are co-administered. Key words: anesthetic preconditioning, sevorane, glycogen synthase kinase-3/3, Western blotting

CLINICAL CASE OF SUCCESSFUL SURGICAL TREATMENT OF PULMONARY EMBOLISM IN THE PATIENT WITH 11 WEEK PREGNANCY

Pulmonary embolism in pregnant women is fairly common complication, and it remains to be the one of major causes of maternal mortality in the number of countries. The need to compare risks of the mother and child makes the search for optimal treatment tactics very complicated in this specific case. The experience of the last decades provides evidences for choosing aggressive treatment tactics, accurate diagnostics and early surgical intervention. The authors of this article describe the clinical case of successful treatment of the young woman whose pregnancy course was complicated by pulmonary embolism at the 11th week of gestation. The article describes the results of laboratory and instrumental diagnostics and anasthesiological support technique within available scope of pharmacological and technical means. Also the article reviews the literature data on this problem. The conclusion contains recommendations for intra-operative management of such patients