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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.

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.

Postoperative respiratory failure is a most common complication and a main cause of postoperative death. The lung opening maneuver is a most effective method of respiratory therapy for this syndrome.Objective. To evaluate the impact of recruiting maneuver on gas exchange parameters, the biomechanical properties of the lung, and hemodynamic parameters. To determine whether the lung opening maneuver can be fully performed in patients undergoing cardiac surgery.Materials and methods. The study covered 19 patients aged 53 to 70 years who had postoperative failure. The indication for the recruiting maneuver was a decrease in the oxygenation index below 250 mm Hg during assisted ventilation (AV) with FiO2>0.5, an inspiratory-expira-tory phase ratio of 1:1 to 3:1, and a positive end-expiratory pressure of 5—10 cm H2O.Results. A decrease in the oxygenation index to 139±36 mm Hg was observed before the recruiting maneuver was applied. Cd;n. averaged 41.1±8.4 ml/cm H2O. After use of the recruiting maneuver, there were increases in the oxygenation index up to 371±121 mm Hg and in Cd;n. up to 64.3±10 ml/cm H2O in all the patients. When the recruiting maneuver was employed, 14 patients were observed to have elevated blood pressures corrected with a vasopressor. One patient developed pneumothorax that was drained in proper time.Conclusion. The application of the lung opening maneuver leads to a considerable improvement of gas exchange parameters and lung mechanical properties.

Objective: to provide a rationale for the efficiency of sevoflurane-induced cardiac preconditioning (CPC), by assessing the pattern of recovery of heart rate and by estimating troponin I levels and changes in NT-proBNP concentrations in patients undergoing aortocoronary bypass surgery (ACBS) under extracorporeal circulation (EC). Subjects and methods. Sixty patients aged 60.6±8 years (M±&) were examined after elective ACBS using EC and divided into two groups of 30 patients each: 1) inhalation induction and maintenance of anesthesia (IIMA) with sevoflurane and fentanyl, with CPC being simulated; 2) total intravenous anesthesia (TIA) with propofol and fentanyl. Inhalation induction of sevoflurane anesthesia was performed in the IIMA group. Ten minutes before aortic ligation, the dose of the anesthetic was increased up to 2 MAC for CPC. Inhaled anesthetics were not used in the TIA group. The authors assessed the pattern of cardiac performance recovery and estimated the level of NT-proBNP 24 and 48 hours after tracheal intubation and that of troponin I following 24 hours of the intubation. Results. Defibrillation was required in one patient from the TIA group who developed ventricular fibrillation. The baseline levels of NT-proBNP were comparable in both groups. Following 24 hours, its level was more than thrice higher in the TIA group than that in the IIMA one (p

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

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.

Objective: to study the effect of sevoflurane on functional recovery in animals after clinical death. Materials and methods. Experiments were carried out on male albino rats. The cardiac vascular fascicle was ligated to simulate temporary circulatory arrest. Its time was 10 minutes. Clinical death was modeled in the animals anesthetized with sevoflurane or chloral hydrate. The functional state of resuscitated animals was evaluated from the time of recovery of effective cardiac performance, spontaneous breathing, corneal reflex, and neurological deficit scores. Their elevated plus-maze behavior was examined. Results. The rats anesthetized with chloral hydrate, unlike those anesthetized with sevoflurane, showed an earlier recovery of spontaneous external breathing and corneal reflex and, in succeeding 2 days following resuscitation, less neurological deficit scores. In addition to a prompter recovery of central nervous system functions on postresuscitation day 4, the sevoflurane-anesthetized rats had a greater gain in body weight for its value on the day of clinical death modeling than the chloral hydrate-anesthetized rats. A study of their behavioral activity showed that the resuscitated rats of both groups differed from false-operated ones in a trend towards reduced number of executions, which is indicative of the higher level of rat phobic state in the postresuscitation period. No differences were observed between the groups of the resuscitated animals in all the indicators examined. Conclusion. Ten-minute clinical death modeling in sevoflurane-anesthetized rats accelerates neurological recovery and improves their general state as compared to chloral hydrate-anesthetized rats. At the same time, both anesthesia modes stop the development of the higher level of phobic state seen in the rats in the postresuscitation period. The findings do not preclude the involvement of the preconditioning properties of sevoflurane in the postresuscitation processes of brain functional recovery. Key words: circulatory arrest, sevoflurane.

The paper describes a rare case of successful surgical treatment for mitral insufficiency due to heart valvular apparatus damage in the acute period of severe concomitant injury. Prosthetic mitral valve replacement was done on day 3 after injury. The patient was switched to spontaneous breathing on day 7 postoperatively and transferred to a surgical unit on day 11. Timely diagnosis, a comprehensive therapeutic approach, active surgical policy, the availability of up-to-date medical equipment, and the presence of high-quality physicians allowed severe cardiopulmonary insufficiency to be eliminated and the patient was discharged from hospital in a satisfactory state on day 25 after injury. Key words: severe concomitant injury, blunt chest injury, mitral valve damage, cardiac surgery.

This paper is the second part of an overview dealing with experimental and clinical studies in ischemic and pharmacological preconditioning. It considers the possibilities of practically using the available knowledge on the mechanisms of preconditioning, the interaction of agents from different groups in exhibiting the protective effects of inhaled anesthetics in anesthesiology and resuscitation. Data are given on the efficacy of the discussed processes in different organs and tissues. The possibility of using opioids and other biologically active substances that are likely to have a protective effect against hypoxia is discussed separately. The problems of remote preconditioning and post-conditioning are touched upon. The available data on the impact of choosing an anesthetic mode on the course of immediate and long-term postoperative periods and mortality rates are analyzed; the problem of the old heart is discussed. It is concluded that studies dealing with the problems of pre- and postconditioning are urgent and of great scientific and practical value. Key words: ischemic preconditioning, pharmacological preconditioning, anesthetic preconditioning, postconditioning.

The review article deals with the problem of ischemic preconditioning, the universal physiological mechanism of cell protection from hypoxia. Preconditioning is the term used to describe a phenomenon of the enhanced tolerance of a cell to a damaging factor due to its preliminary effects of stressful stimuli. The article describes the phenomenon of ischemic preconditioning and summarizes the results of a study of the possible mechanisms of this effect in organs and tissues. It discusses the key role of the enzyme glycogen synthase 3fl in the regulation of the mitochondrial pore and that of the latter in the protection of a cell from hypoxia. Experimental data are given on the testing of different drugs as pharmacological agents that initiate/inhibit preconditioning. Reasons for the selective efficacy of some antihypoxants and antioxidants are analyzed in the context of the ischemic preconditioning theory. Conventional anesthetics and analgesics as potential inductors or inhibitors of the process in question are discussed. Key words: ischemic preconditioning, hypoxia, anesthetics, cyto-protection.

Objective: to study the hemodynamic effects of sevoflurane during the induction of anesthesia in elderly patients at high risk for cardiac events. Subjects and methods. This study enrolled 32 patients who had a left ventricular ejection fraction of

Objective: to evaluate the efficiency of a recruiting maneuver (RM) and adjustment of positive end-expiratory pressure (PEEP) in patients with early acute respiratory distress syndrome (ARDS). Subjects and methods. The study enrolled 16 patients (14 men and 2 women) aged 46 to 78 years (range 62±5.6 years) with ARDS of various genesis. RM was made, by stepwisely increasing PEEP and inspiratory pressure under the control of dynamic lung compliance and hemodynamic parameters. The values of blood gas composition and hemodynamics were determined during the study. Results. RM caused an increase in oxygenation index (OI) from 153.5±48.3 to 348.5±53.2 mm Hg. Oxygenation values returned to the baseline levels 30—40 min after the PEEP was set at the closure point of +2 cm H2O. If the set PEEP was 8—10 cm H2O higher than the objective, the effect of RM was retained for as long as 24 hours. When RM was performed using the maximum pressure of 50—60 cm H2O, the cardiac index (CI) was lower in all the patients and 30—50% of the baseline values were achieved in all cases, which required the optimization of cardiotonic therapy. The time of this pronounced reduction in cardiac output with RM was not longer than 5 min. After RM, during mechanical ventilation with 18—26 cm H2O PEEP, the CI did not practically differ from the baseline values (3.31±0.41 and 3.37±0.36 l/min/m2, respectively), though the dopamine dose required to maintain normal hemodynamics was somewhat higher (7.5±2.3 and 6.3±2.6 ^g/kg/min). Conclusion. Analysis of the given cases suggests that RM is highly effective in patients at the early stages of acute lung injury. The duration of RM effects may depend on the set PEEP level in individual cases. Setting PEEP at a level of +2—4 cm H2O fails to prevent repeated alveolar derecruitment in a number of patients. In these cases, it is expedient to individually adjust PEEP levels, by taking into account the long-term changes in OI and Cdyn. In this situation, PEEP may be set at a level of +8—10 cm H2O or at the maximum level that causes no hemodynamic disorders. Key words: acute respiratory distress syndrome, recruiting maneuver, alveolar derecruitment, positive end-expiratory pressure.