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Background Actuality of the problem of infection in critically ill patients remains high. Addition a local infectious processes have a tendency to rapid generalization and sepsis. Neutrophilsfunction failure plays a key role in the patho- genesis of infectious complications and sepsis. The hypothesis about the role of microbial metabolites in the formation of immunosuppression, in particular in the inhibition of phagocytic activity of neutrophils as the first line of defense against bacteria is acquiring more and more supporters. Among the microbial metabolites aromatic compounds, such as phenylcarbinol acid (PCA) are of particular interest. Their concentration in the blood reaches a maximum in case of generalized infection, and correlates with mortality in patients in critical conditions, and PCA biological activity confirmed by earlier researches in vitro. The purpose of the study was to reveal the relationship of the PCA with the severity of bacterial infections and to assess the effect of PCA on neutrophils phagocytic activity., Materials and Methods: At the first stage the levels of PCA (GCh-FID method) in the serum ofpatients (n=57) with a documented bacterial infection of varying severity, confirmed APACHE II and SOFA scales were analyzed comparing with healthy donors (n=72). During the second stage the effect of clinically-relevant concentrations of PCA on neutrophils phagocytic activity ofperipheral blood was analyzed in vitro., Results: The levels ofphenylacetic (PAA), phenyllactic (PLA), hydroxyphenylacetic (p-HPAA) and hydroxyphenyllactic (p-HPLA) acids in patients were significantly higher than in healthy donors, reaching the highest values in severe infection. High direct correlation of PCA levels with the indicators ofscales APACHE II and SOFA was detected. A significant decrease in the number ofphagocytic neutrophils under the influence PAA, p-HPAA and PLA was identified in vitro experiment on average 11%. The most significant influence p-HPAA, PLA and p-HPLA have made on the intensity of the neutrophils absorption capacity reducing this parameter by an average of 26%. Also noted that phenylpropionic acid (PPC) which is in blood of healthy donors, disappears in critical ill patients., Conclusion: Phenolcarbonic acids level in the blood serum shows the severity of bacterial inflammatory process. Ex- periment in vitro shows that the PCA in clinically-relevant concentrations is able to suppress the neutrophilsphagocytic activity.

Nosocomial pneumonia is the most common infection in intensive care units. Currently the problem of resistance of noso-comial pathogens to miost of antibiotics is crucial. Using of inhaled antibiotics in combination with intravenous drugs is eff ective and safe method for treatment of nosocomial pneumonia. The literature review describes current opportunities of ihhaled antibiotic therapy of nosocomial pneumonia, descriptions of drugs, the advantages and disadvantages of this treatment. Special attention is paid for using inhaled aminoglycosides for nosocomial pneumonia.

The paper summarizes results of experimental studies and clinical observations of the pathogenesis and effectiveness of respiratory, non-respiratory and pharmacological treatment methods for acute respiratory distress syndrome caused by direct and indirect damaging factors. The article deals with differences and peculiarities of morphological changes and lung functional disorders, clinical, laboratory and instrumental signs of various origins in ARDS and justifies necessity of differential diagnosis and differential treatment of ARDS, depending on the reasons for its development. Furthermore the article discusses an algorithm for differential diagnosis and differential treatment for ARDS caused by direct and indirect damaging factors.

Objective of the study was to investigate cerebral and extracerebral insufficiency in survived and died patients after surgical treatment of hemorrhagic stroke for outcome prognosis and decision making on postoperative intensive care. The study included 224 patients after transcranial surgery for hemorrhagic stroke. 119 patients survived and 105 patients died SOFA scale and SIRS criteria were used to assess severity of the patients state. Hemorrhagic stroke before the operation was accompanied with cerebral insufficiency (Glasgow Coma Scale < or = 9) in 19% of patients. Lungs and kidneys dysfunction (SOFA = 1-2) were common. In the early postoperative period 54% of patients had cerebral insufficiency and 36%--organ dysfunction. Acute cerebral insufficiency was closely associated with systemic inflammatory response. Severity of organs (heart, lungs, kidneys) failure and SIRS correlated with GCS score in early postoperative period. There was close correlation between MODS and SIRS scores in survived patients and there wasn't such phenomenon in died patients. This indicates leading role of CNS in homeostasis regulation. SOFA scale using for express diagnosis of perioperative complications is useful for providing adequate intensive therapy.

In patients with acute respiratory distress syndrome (ARDS) lungs consist of aeration zones and zones of alveolar collapse, which lead to intrapulmonary shunting and hypoxemia. ALV may increase alveolar collaps and potentially lead to lung damage arising out of displacing surfaces tension between aerated and collapsed lung parts and re-closing and opening of the alveoli. Based on the strategy of the "open lung" the recruitment maneuver can be used to achieve the alveolar recruitment, while PEEP prevents alveolar collapse. There are many recrutment types, including a long inflated to a higher pressure, reccuring breath, gradual increase of PEEP, and PIP etc. Data on the use of recruitment in ARDS patients, show varied results with increased efficiency in patients with early ARDS, good complaisance of the chest and extrapulmonary Genesis of lung damage. In this review, we discuss the pathophysiological basis of recruitment use, recent evidence and contradictions of the application of this method.

The paper presents the results of a clinical trial using the new modified gelatin-based drug hemofusin to correct dyshidria in patients with blood loss and sepsis. Based on the findings, the authors provide evidence for the high clinical efficacy of this drug and the expediency of its incorporation into a complex of infusion therapy in this patient contingent.

A hundred and one patients (51 males and 50 females) aged 66.2 +/- 5.0 years who had Stages II-III colonic malignancies concurrent with type 2 diabetes mellitus were examined. Two algorithms of postoperative management using the traditional diet and early enteral feeding were comparatively analyzed. The use of an early enteral feeding protocol improves central hemodynamics, oxygen and nutritive status, prevents moderate protein-energy deficiency in the early postoperative period, and reduces the number of complications and deaths in patients with colonic malignancies concurrent with type 2 diabetes mellitus.

The perioperative period was studied in 50 patients aged 44-79 years who had acute coronary syndrome. The patients underwent aortocoronary bypass surgery at O. M. Filatov Moscow City Clinical Hospital No. 15 in 2002 to 2004. They were divided into 2 groups: 1) 25 patients (21 males and 4 females) who received high thoracic epidural naropine analgesia at least 24 hours before surgery (a study group); 2) 25 patients (19 males and 6 females) who were prepared for surgery through conventional antiischemic therapy. The indication for surgical myocardial revascularization in these patients was not only severe coronary bed lesion, but also frequent resting anginal attacks. The occurrence of resting anginal episodes during the maximally possible antianginal therapy was a criterion for inclusion of patients into this study. The purpose of the study was to improve the results of surgical treatment of patients with acute coronary syndrome, by using high thoracic epidural naropine analgesia.

Severe diseases of different etiology are generally accompanied by significant neurohumoral stress and catabolism. The use of insulin and insulin-like growth factor 1 (IGF-1) regulates the rate of protein and carbohydrate catabolism, retards increasing azotemia, thus normalizing protein metabolism. By taking into account the physicochemical properties of IGF-1 and the high resolving capacity of the modes of renal replacement therapy (RRT), it cannot be ruled out the possibility that the really significant amount of this polypeptide is eliminated, which may negatively affect the patient's metabolic adaptation. In this connection, the authors studied the levels of IGF-1 in patients with multiple organ dysfunction during hemofiltration/hemodiafiltration (HF/HDF). All the patients were found to have the maximum low content of IGF-1 both before and during RRT. There was a high elimination of this hormone with an effluent during RRT. The clearance of IGF-1, calculated for 24 hours of a procedure was equal to that of the proinflammatory cytokines TNFa and IL-Ibeta during HF/HDF. The results lead to the conclusion that early replacement therapy for hypercatabolism should be performed in patients with multiple organ dysfunction.

The critical states occurring during pregnancy, labor, and early puerperium were analyzed. Seventy puerperas treated at intensive care units (ICU) were examined. The patients were divided into 5 groups: 1) those with preeclampsia (n = 15); 2) eclampsia (n = 22); 3) massive blood loss (n = 17); 4) pyoseptic complications (n = 10); 5) acute respiratory failure (n = 6). The APACHE II scale severity was 22 +/- 5.3 scores. The mean age of puerperas is 29.2 +/- 7.2 years. Total mortality was 14.3%. Parametric and non-parametric statistic methods were used to analyze the reasons for referral of the patients to ICU, their age composition, the association of an outcome to the time of their referral to ICU, the duration of stay there and at hospital, mortality, the time of controlled ventilation, the incidence of multiorgan failure. The common reasons for referral of the puerperas from maternity homes to ICU were eclampsia, preeclampsia, and massive blood loss. Acute respiratory distress syndrome (52.9%), encephalopathy (44.3%), coma (47.1%), and intestinal insufficiency (38.6%) were predominant in the pattern of multiorgan failure in intensive care obstetric patients. When emergencies occurred in puerperas, earlier referral from maternal homes to ICU caused a reduction in mortality from 33.% at referral on day 3 after their occurrence to 23.5% at referral on day 2, and to 11.5 at referral on day 1.

Perftoran (PF) was used within a complex intensive care of 74 patients with purulent-inflammatory urological diseases and with signs of generalized inflammation. Positive effects were found to be made by PF on the parameters of microcirculation, oxygen status, dynamics of the serum content of cytokines, condition of their balance and immune status, which entailed a regression of endogenous intoxication and arrested the inflammatory lesion in the kidneys. PF cut the intensive care time of patients with complicated urological infection by 4.2+/-0.4 days (p < 0.05). The conclusion is that PF is a novel pathogenetic treatment method applicable to patients with purulent-inflammatory urological diseases.

It was established, while modeling the global transient cerebral ischemia in experiments with 51 anesthetized nonlinear white rats (weight 300-330 g), that a preliminary administration of perftoran in the discussed pathology does not only improve the reperfusion process in the brain but also levels the deficits of crystalloid solutions used as blood substitutes (by the example of physiological solution). Therefore, the drug has a cytoprotective action on the vascular-system endothelium. A direct admixture of perftoran to the autoblood introduced after global transient cerebral ischemia improves essentially the reperfusion-period course in the brain versus the combination of physiological solution and autoblood.

The paper contains the study results of some lipid-metabolism indices in patients with severe mechanical injury. Changing concentrations of total cholesterol, triglycerides and of different lipoprotein fractions in blood plasma are demonstrated. It was established that the investigated lipid-metabolism indices reflect a degree of liver malfunction in severely impaired homeostasis. It can be stated on the basis of comparing the study results with the clinical outcome that the dynamic concentration of total cholesterol in blood plasma is an important prognostication factor. Changing ratios of high-density lipoproteins, low-density lipoproteins and extra-low-density lipoproteins were observed in survivors yet by day 15, which is indicative of a commencing dislipidemia.

The multi-factor effect of pharmacological preparations reamberine and citotoflavine, which contain succinate, in critical conditions is preconditioned by the impact they produce on a total energy deficit caused by a long-term hypoxia. The correction of energy deficit improves the therapy of patients in coma, which resulted from poisonings by neurotropic substances. The therapeutic effect manifested itself through a shorter state of coma from 25 to 12.5%. However, an analysis of died patients, who received the metabolic antihypoxants, showed that these drugs are not effective, when the time lapse from poisoning to medical aid exceeded 20 hours. When perftoran, a corrector of oxygen transport, and antihypoxant cytoflavin were added to the therapy scheme, it resulted in that 22 of 24 patients, who were also taken to clinic in the state of coma after 20 and more hours, survived, while all patients in the comparison group (20 patients) died despite an intensive therapy.

The paper discusses how to choose the optimum shape of a pulse for electric defibrillation of the heart. The authors' data are given on the values of an induced field in the contracting myocardial structure when a defibrillator evokes pulses. Mono- and bipolar pulse-induced changes of the transmembranous potential on the hyper- and depolarized sides of a cell are calculated. Mechanisms of defibrillation in the use of pulses of different shapes are considered.

Kinetic simulation in terms of urea and creatinine is the best way of prescribing a dialysis dose and assessing its quality as it considers differences in a patient's body weight, the level of catabolism, the rate of equilibration, including the recirculation phenomenon noticeably observed under shock. A 2-pool model of distribution of urea and creatinine was employed in the study. The latter was carried out in 31 patients (17 males and 14 females) with sepsis and multi-organ failure receiving 50 sessions of continuous hemodiafiltration (CHDF). The mean duration of CHDF was 73.8 +/- 7.0 (4.0-207.0) hours, the daily volumes of a substitute, a dialysate, and an effluent (filtrate + dialysate) were 33 +/- 1.0 (5.0-60.0), 43.9 +/- 0.8 (2.6-62.0), and 80.4 +/- 1.6 (12.0-122.3) liters a day, respectively. An analysis confirmed the high efficiency of CHDF close to that of the daily volume-body weight ratio and showed that such conditions of the procedure are optimal in maintaining azotemia at the subnormal level irrespective of the degree of cababolism.

The studies were carried out on 76 albino noninbred male rats weighing 210-420 g. Ischemia of a jejunal segment was induced by applying a tourniquet to the base of a loop with the mesentery until the circulation fully stopped. Nonoxygenated perfluorane (an experimental group) or saline solution (a control group) was injected in a dose of 0.8-1.0 ml/100 g intraarterially 15 minutes before the termination of ischemia. During 90 min of reperfusion, there was a progressive decline of blood pressure (BP) with reference to the ischemic period by 39.8 +/- 20.9 and 20.8 +/- 14.6% in an experimental and control groups, respectively (p > 0.05). Biomicroscopy indicated that by min 5 of reperfusion, a relative reduction in the diameter (50-400 microns) of nutrient mesenteric arteries was half as large as that in the control group (24.0 +/- 5.5 and 45.1 +/- 3.6%; p < 0.05); by min 90, differences decreased (41.5 +/- 4.2 and 50.3 +/- 2.8%, respectively; p > or = 0.05). In the experimental group, perfluorane prevents the development of irreversible structural changes in the reperfusion period: the remaining cryptal epithelium is a source of regeneration of the integumentary epithelium of forming villi of the small intestinal mucosa.

The paper provides evidence for that it is expedient to perform multi-stage intravascular low-intensity laser blood radiation in patients with severe mechanical trauma and massive blood loss in the early posttraumatic period. The use of laser radiation at a wavelength of 632.0 nm by inserting a disposable light guide (its end power was 1.5-2.0 mW, and the duration of a session--30 min) as part of complex therapy in this group of patients romotes the increase of plasma albumin transport ability and the general stimulation of natural detoxifixation mechanisms.

Acute hemorrhage is a main cause of reduction of blood oxygen capacity. The main aim of correction of sequels of acute hemorrhage is to maintain effective gas exchange by restoring central circulation and microcirculation, the rate of diuresis, by normalizing water-salt exchange, to eliminate anemia, hypoproteinemia, and acute blood coagulability disorders. The values of oxygen budget with calculated oxygen delivery and consumption and those of hemoglobin and hematocrit which are of great value only after recovery of circulating blood volume are considered to be major indications for hemotransfusion. A relationship is established between the extraction and uptake of oxygen and its delivery. The concept of the critical level of oxygen delivery is considered, ways of correcting oxygen indebtedness are presented. Alternatives to the use of hemotransfusions by employing the solutions of modified hemoglobulin and perfluorocarbon-containing emulsions are under consideration. A possible algorithm of aid rendering in acute hemorrhage is given.

Hemodiafiltration (HDF) is a method of pathogenetic therapy for the systemic inflammatory response syndrome in patients with sepsis and shock irrespective of renal failure. Systemic hemodynamics was examined in 18 patients with septic shock treated by HDF (2 groups). HDF was associated with stabilization of systemic hemodynamics in 50% patients (cardiac index, total peripheral resistance, index of the left heart work increased and the number of heart beats, central venous pressure, mean pressure in the pulmonary artery, pulmonary capillary wedging pressure decreased, oxygen consumption index increased, etc.), which allowed a reduction of the initial dopamine and norepinephrine doses 3-fold and lower by the end of days 3-4 of HDF treatment. An opposite tendency was observed in group 2 (refractory shock). Despite high (72.2%) mortality which was mainly caused by the progress of multiple organ dysfunction or untimely surgical intervention, it is obvious that HDF created conditions for surviving the critical period of disease in patients with progressive sepsis.

Signs of oxygen debt were studied in 28 patients with systemic inflammatory response and polyorgan failure. The parameters of oxygen debt, oxygen consumption, saturation of mixed venous blood, and heart rate can be used as criteria of therapy efficiency. The probability of a favorable outcome is increased if the mean 24-h oxygen debt is less than 30 ml/min x m2, oxygen consumption more than 158 ml/min x m2, mixed venous blood saturation less than 64%, and heart rate less than 114 stroke/min.

Plasma lipid metabolism was studied in critical patients with severe combined injuries. Decrease in cholesterol concentration and increase in triglyceride concentrations were more pronounced in patients with lethal outcomes. The authors conclude that plasma cholesterol and triglyceride concentrations can be used as prognostic signs in patients with severe combined injuries.

A general somatic syndromal approach to evaluation of clinical status by SAPS II and APACH II scores was used in 41 patients operated on for gastric cancer. Epidural analgesia in these patients promoted rapid regression of the severity of condition, did not require high opioid doses, had a positive effect on the peristaltic activity of the intestine, and accelerated treatment in intensive care wards.

Blood coagulation and fibrinolysis were studied in 34 patients with diffuse peritonitis treated in intensive care wards of common profile. Forced ventilation of the lungs was carried out for 2-26 days in 32 of 34 patients. The causes of peritonitis were perforating gastroduodenal ulcers (22 cases), acute perforating ulcers of the small intestine (5 cases), and acute phlegmonous perforative cholecystitis (7 cases). Disseminated intravascular coagulation, depressed fibrinolysis first in the plasma and then in whole blood were observed early (2-16 h) after surgery in all patients (17 survived and 17 died). These changes progressed by days 3-5 of treatment in all patients, being the most pronounced in cases with complications (failure of sutures after gastroduodenal ulcer suturing, acute gastroduodenal ulcers complicated by hemorrhages, acute perforating ulcers of the small intestine, etc.), particularly in the patients who died.

Acute lung injury syndrome is one of the most frequent components of polyorgan failure, particularly resultant from sepsis. Replacing renal therapy can correct uremic disorders in the hemostasis and gaseous exchange disorders in the lungs by eliminating excessive fluid in case of hyperhydration and by eliminating inflammation mediators. The present study demonstrated a favorable impact of hemodiafiltration on ventilation oxygen status of patients with acute lung injuries, which was confirmed by positive changes in blood oxygen pressure, intrapulmonary shunt, alveolar-arterial oxygen difference, etc. Changes in oxygen transport corresponded to those in patients with sepsis and shock without hemodiafiltration.

Relationship between alteration of body position and parameters of central hemodynamics and oxygen status were studied in patients with severe blunt chest injury. Use of position tests in this patient population helped detect disorders in the central hemodynamics, oxygen transport and consumption. Argument increase of volumetric loading promoted an increase in oxygen delivery.

Permanent hemodiafiltration (PHDF) as a method for treating patients with sepsis and multiple organ failure (MOF) corrects the severity of generalized inflammatory reaction, which is caused by hyperproduction of bioactive substances. Cytokines can be eliminated from circulation by 2 methods of kidney-replacing therapy: convection and adsorption on hemofilter membrane. Despite the slight adsorption clearance, our results indicate that experimental data not always correspond to the clinical situation. Pronounced cytokinemia persists in patients with sepsis and MOF during PHDF. In addition to correction of the main hemostasis parameters, kidney-replacing therapy eliminates an appreciable amount of TNF-alpha and other proinflammatory cytokines. Estimation of TNF-alpha balance indicates its good adsorption on the surface of hemodiafilter membrane.

High-volume hemodiafiltration is a new approach to the treatment of critical patients with generalized inflammatory reaction and multiple organ failure. Increase of the liquid exchange during the procedure is fraught with the development of secondary metabolic disorders in cases when lactate-based buffer is used (with high amounts of lactate). This study was undertaken to evaluate the consequences for the acid-base balance in patients with hypoxia and circulatory failure. Twelve patients (6 men and 6 women) with APACHE II score 25 were examined. The major treatment modality was continuous hemodiafiltration. The results indicate that lactate-buffered solutions can be used in critical patients, because they do not cause a notable increase in the blood lactate levels due to its good utilization. Moreover, it is associated with correction of disorders in acid-base balance. No negative clinical consequences were observed after using lactate anion in high concentrations as the major buffer compound.

Nine patients (8 men and 1 woman) were treated. Sepsis was diagnosed in 7 of them. All patients were subjected to forced ventilation of the lungs, 6 were in need of inotropic support. The severity of clinical status was 31 +/- 0.8 according to APACHE II score. One patient survived. The main method of substitute renal therapy (SRT) was permanent hemofiltration with spontaneous arteriovenous perfusion. The results indicate manifest depletion of the complement system augmenting with the progress of multiple organ failure (MOF). Extracorporeal perfusion in SRT had no additional negative effects on the complement system damaged by disease. Nonselective penetration of individual complement fractions into the filtrate in the course of perfusion was noted. Therefore, the complement system is severely damaged in patients with MOF; it can modulate the SRT because of penetration of its individual fractions.

Reanimatology is a science dealing with prevention and correction of severe homeostasis disorders, nonspecific reactions of the organism to disease, injury, wounding, with general regularities of vital functions fading in the course of dying and their recovery after resuscitation. Five main sections of reanimatology are formulated: resuscitation, intensive care, anesthesiology, urgent medicine, and medicine of disasters. Specialization in reanimatology is determined by methods of treatment. Four trends are distinguished among the pressing problems of reanimatology: fundamental studies, development of methods for prevention and treatment of critical, terminal, and post-reanimation states, ethical and legal problems, and management. Results of recent studies are presented and prospects for the future are discussed.