Vol 47, No 3 (2019)

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Particulars of the perioperative management of patients with end stage renal disease during hip and knee replacement arthroplasty

Petrova E.N., Polushin Y.S., Shlyk I.V., Tsed A.N.


The world prevalence of chronic kidney disease (CKD) stages 1 to 5 ranges from 11.7 to 15.1%. Incidence of fractures in patients with CKD stage 5 is 5-fold higher than that in the general population, which is related to mineral metabolism disorders, secondary hyperparathyroidism, and osteoporosis. By damaging multiple organs and systems, CKD triggers a whole pathological cascade. There are hematopoietic abnormalities, cell lineages, direct toxic effect on blood cell elements, with simultaneously increased risk of bleeding and a high and extremely high risk of thrombi formation and thromboembolic complications. Calcium and phosphorus metabolism disorders lead to calcification and mineralization of vasculature, myocardium and heart valves; progressive renal dysfunction affects the course of heart and vessel diseases, aggravating their clinical manifestations. Cardiovascular disorders become the main cause of death of such patients, and the development of pulmonary hypertension is associated with increased morbidity and mortality. At the same time, protein and energy deficiencies do occur, with disturbance of the acid-base balance, water and electrolyte balance; uremic toxins exert unhealthy effects on the gastrointestinal tract. Various extra-renal pathologies, specific pharmacokinetics, regimen and frequency of renal replacement therapy needed to maintain an adequate volume status make it necessary to thoroughly prepare the patients for surgery and define special requirement to perioperative management in arthroplasty. Currently, there are no guidelines on the perioperative management of this patient category. In this review article we consider specifics and particulars of preoperative, intraoperative and postoperative management of the end stage CKD patients during knee and hip replacement arthroplasties.

Almanac of Clinical Medicine. 2019;47(3):251-265
pages 251-265 views

Gestational sleep apnea. The association between pregnancy and preeclampsia with obstructive sleep apnea syndrome

Kalachin K.A., Pyregov A.V., Shmakov R.G.


Preeclampsia (PE) continues to be one of the main reasons of maternal mortality even in countries with a high level of medical care. Current PE treatment can be etiological and symptomatic. Therefore, active investigation into etiology and pathogenesis of this pregnancy complication is on the way. Identification of new pathways in PE is of vital importance because it could provide clues to pathogenesis-related treatment and consequent reduction in mortality. It is especially in the mainstream nowadays, when leading world perinatal institutions have focused on prolongation of pregnancy in early onset PE (EPE) to improve neonatal outcomes. Obstructive sleep apnea (OSA) syndrome and early small airway obstruction have been proposed as pathophysiological pathways of PE. In this review article we present the association between pregnancy and sleep-related breathing dysfunction, as well as between OSA and hypertensive disorders of pregnancy. Common mechanisms for arterial hypertension in PE and OSA have been proposed, and additional potential treatment approaches are discussed aimed at pregnancy prolongation in EPE. We have formulated unresolved issues related to studies of obstructive sleep apnea in pregnancy in general and in PE patients in particular.
Almanac of Clinical Medicine. 2019;47(3):266-275
pages 266-275 views

Low cardiac output syndrome in cardiac surgery

Merekin D.N., Lomivorotov V.V., Efremov S.M., Kirov M.Y., Lomivorotov V.N.


Low cardiac output syndrome is one of the most common and serious complications in cardiac surgery and is associated with increased morbidity and mortality. Several prognostic features have been recognized, including preoperative, intraoperative risk factors and laboratory predictors. The pathophysiologic mechanisms of low cardiac output syndrome are not limited by ventricular systolic dysfunction only, diastolic dysfunction and valvular abnormalities also contribute to low cardiac output syndrome development. There is a broad spectrum of monitoring techniques during cardiac surgery, all of them are different in their invasiveness and reliability. Goal-directed hemodynamic therapy should be based on the most informative and accurate monitoring methods and its goal is to optimize the balance between oxygen delivery and consumption. Treatment of low cardiac output syndrome is intended to increase tissue oxygen delivery and prevent organ dysfunction providing adequate hemodynamic support. The first line of low cardiac output syndrome therapy, to be initiated as soon as the volume status is optimized, is the use of inotropes, vasopressors and vasodilators to improve contractility, preload and afterload. In the most severe cases the need of mechanical support might take place, including intra-aortic balloon pump, ventricular assist devices and extracorporeal membrane oxygenation.

Almanac of Clinical Medicine. 2019;47(3):276-297
pages 276-297 views


The method of inhalation analgesia with sevoflurane during spontaneous delivery

Upriamova E.Y., Shifman E.M., Krasnopol'skiy V.I., Ovezov A.M., Novikova S.V., Bocharova I.I., El'chaninova A.G.


Background: The search for methods for protection against delivery and labor pains has led to resumption of studies of non-invasive, safe and effective labor analgesia and inhalational anesthesia that could be used both separately and in combination with other methods. Recent research has demonstrated the highest efficacy of sevoflurane for analgesia of spontaneous delivery.

Aim: To develop an optimized and effective method of inhalational analgesia with sevoflurane for spontaneous delivery.

Materials and methods: We have performed a prospective study of the efficacy of inhalational sevoflurane for analgesia of spontaneous delivery. Thirty three obstetric patients were given sevoflurane-oxygen mixture according to a specially designed technique. The pain intensity was assessed with a visual analogous scale (VAS), sedation level, with Ramsay scale and Richmond Agitation-Sedation Scale (RASS).

Results: The mean duration of inhalational anesthesia was 92.1±28 minutes [60–180']. There were no refusals and no switching to another type of analgesia. After induction of analgesia with Funding sevoflurane, there was a significant decrease of pain intensity by VAS by 34.9% from the baseline level (p = 0.00003); the pain was assessed as “moderate”. This trend was maintained throughout the whole exposure period.

Conclusion: The results obtained confirm the possibility to use the proposed method of inhalational analgesia with sevoflurane to ensure effective analgesia in obstetric patients during delivery and labor.

Almanac of Clinical Medicine. 2019;47(3):196-203
pages 196-203 views

The clinical decision support system for sepsis as an important part of the medical and economic component of a hospital

Gorban V.I., Bakhtin M.Y., Shchegolev A.V., Lobanova Y.V.


Aim: To evaluate an impact of a clinical decision support system (CDSS) in the clinical practice of a hospital on the quality and costs of treatment of patients with severe sepsis and septic shock.

Materials and methods: We performed a retrospective analysis of the database in the medical information system qMS (SP.ARM, Russia, St. Petersburg) from 2015 to 2017 on 37,997 patients. In the first study period from January 2015 to June 2016, we analyzed the results of the conventional treatment regimen. From May to June 2016, the CDSS module was implemented into the qMS and the personnel was trained correspondingly. The data collected during the second study period mirrored the results of sepsis treatment with the use of CDSS. We assessed the average number of in-hospital days, duration of stay in the intensive care unit, number of septic shock cases, mortality, and treatment costs.

Results: The diagnosis of sepsis was confirmed in 67 patients: in 1.4‰ (27/18,792) before the CDSS was implemented versus 2.1‰ (40/19,205) after the CDSS implementation (p < 0.01). It was found that the use of CDSS integrated into the hospital medical information system reduced the number of cases of septic shock development (p < 0.05). Lethality decreased by 10%. The sepsis-associated mortality showed a non-significant trend to decrease by 10% (p < 0.1). The implementation of the CDSS incorporated into the qMS helped to reduce the number of septic shock cases from 26% (7/27) to 7.5% (3/40) (p < 0.05). There was also a trend towards reduced duration of stay in intensive care unit, as well as towards decreased costs of sepsis treatment by 13% and efferent (extra-corporeal) treatments by 29%; however, the differences were not significant.

Conclusion: The CDSS implementation for electronic monitoring of the patient's condition and changes in his/hers parameters allowed for an earlier diagnosis of sepsis. We identified some prerequisites for more rational utilization of medical resources, mainly due to early, targeted treatment of patients with severe sepsis and septic shock; however, additional studies are necessary.

Almanac of Clinical Medicine. 2019;47(3):204-211
pages 204-211 views

On the possibility to increase sensitivity of diagnostic tests for fixed pulmonary hypertension in heart transplant candidates

Bortsova M.A., Bautin A.E., Yakovlev A.S., Fedotov P.A., Sazonova Y.V., Marichev A.O., Tashkhanov D.M., Sukhova I.V., Vizer R.V., Moiseeva O.M., Sitnikova M.Y., Gordeev M.L.


Background: Fixed pulmonary hypertension (PH) in heart transplant candidates is a risk factor for right ventricular failure in the postoperative period and early mortality. Patients with fixed PH are not included in the waiting list. Thus, the correct assessment of the pulmonary circulation before the operation affects both clinical management and prognosis. Aim: To reduce the risk of incorrect patient non-inclusion to the waiting list by reduction of false negative test results for PH reversibility.

Materials and methods: Fourteen heart transplant candidates were included in this retrospective cohort single center study. Fixed PH with pulmonary vascular resistance (PVR) exceeding 3.5 Wood's units was found in all these patients using right heart catheterization and pulmonary vasoreactivity tests. Initially, these patients had not been put into the waiting list. Pulmonary catheterization was performed in the intensive care unit with a Swan-Ganz catheter and pre-pulmonary thermodilution technique. To perform pulmonary vasoreactivity tests, inhaled iloprost (n = 12) or nitric oxide (n = 2) were used. Subsequently all patients received levosimendan infusion at a dose of 12.5 (0.05–0.2) mg/kg/min, with repeated pulmonary artery catheterization and pulmonary vasoreactivity tests at 72 hours after the infusion. Pulmonary vasoreactivity tests results allowed 13 patients to be included into the waiting list. Heart transplantation was performed in 8 recipients, with postoperative assessment of their hemodynamic and clinical parameters. Data are presented as median [25th percentile; 75th percentile].

Results: After the levosimendan infusion, there was a decrease in the pulmonary artery mean pressure from 45 [36; 47] to 29.5 [23; 37] mm Hg (p < 0.01), and in PVR from 6.9 [4.9; 8.9] to 3.6 [2.9; 5.9] Wood's units (p <0.01). In 7 patients, PVR decreased to less than 3.5 Wood's units: the rest of the patients underwent pulmonary vasoreactivity tests. As a result, 13 of 14 patients showed reversible PH and were included into the waiting list. By the date of the manuscript submission, heart transplantation has been performed in 8 patients. Their PVR 6 hours after surgery was 2.2 [2; 3.1] Wood's units; there were no cases of fixed PH and right heart failure. There was a single death associated to a hemorrhagic stroke at day 6 after heart transplantation. The sensitivity of pre-operative pulmonary vasoreactivity tests with the use of levosimendan was 87.5%.

Conclusion: Levosimendan infusion may increase the sensitivity of the pulmonary vasoreactivity tests before patients' inclusion into the waiting list for heart transplantation.

Almanac of Clinical Medicine. 2019;47(3):212-220
pages 212-220 views

Is it possible to augment myocardial protection during cardiopulmonary bypass by administration of inhalational anesthetics?

Molchan N.S., Polushin Y.S., Zhloba A.A., Kobak A.E., Khryapa A.A.


Aim: To evaluate the possibility to augment myocardial protection with desflurane and sevoflurane by prolongation of their delivery into the oxygenator of the cardiopulmonary bypass (CPB) pump during surgical myocardial revascularization.

Materials and methods: This randomized prospective study included 75 patients with ischemic heart disease who underwent aortocoronary and mammary coronary bypass grafting with extracorporeal circulation from 2014 to 2017. The patients were allocated into the three study group by means of a  random number table generated by Statistica 10.0 software, depending on the anesthetic agent used: group 1, desflurane (n=30), group 2, sevoflurane (n=28), and group 3 (control), propofol (n=17). Desflurane and sevoflurane were delivered into the oxygenator during the artificial circulation. Hemodynamic parameters were assessed, such as cardiac index, total peripheral vascular resistance index, pulmonary artery wedge pressure. Changes in lactate, pyruvate, alanine, glutamate, glutamine, aspartate, asparagine, taurine, leucine, isoleucine and valine levels over time were assessed in blood taken from the heart coronary sinus before aortal clamping, before release of the clamp and after 30 minutes of reperfusion. During the first 24 hours post perfusion, we assessed the incidence of postperfusion heart failure (PPHF), duration of mechanical ventilation and duration of stay in the intensive care unit. Troponin I levels were measured at 12 and 24 hours after the intervention.

Results: There were no significant differences in the changes of the hemodynamic parameters over time in all the groups. The PPHF incidence and the course of the postoperative period were similar in all the groups. Irrespective on the type of the anesthesia, lactate and pyruvate levels increased during the CPB, with no significant differences between the groups, as well as the postoperative troponin I  levels at 12 and 24  hours after surgery. No differences between the groups were found for the changes of amino acid levels over time, except a  significant reduction of alanine levels during the aortal clamp in the group  3.

Conclusion: Prolongation of desflurane and sevoflurane delivery into the CPB pump oxygenator does not augment myocardial protection during myocardial revascularization surgery. 

Almanac of Clinical Medicine. 2019;47(3):221-227
pages 221-227 views

Synthetic leu-enkefalin analogue prevents activation of neutrophils induced by a bacterial component

Grebenchikov O.A., Shabanov A.K., Kosov A.A., Skripkin Y.V., Yavorovsky A.G., Likhvantsev V.V.


Background: Neutrophil activation is a  mandatory stage and a  sensitive marker of systemic inflammatory response. The development of this condition is associated with subsequent multiple organ failure which is the main indication for the patients stay in the intensive care unit. The search for drugs that could prevent the development of systemic inflammatory response and reduce mortality remains an urgent task of anesthesiology/resuscitation.

Aim: To study the anti-inflammatory effect of dalargin, a synthetic analogue of lei-enkephalin, on human neutrophils in vitro.

Materials and methods: The study was performed on blood neutrophils isolated from 5 healthy donors. A proportion of neutrophils were activated by 10 mkM formil-Met-Leu-Pro (fMLP) and 100 ng/mL lipopolysaccharide (LPS) with subsequent assessment of their activity by fluorescent antibodies to the degranulation markers CD11b and CD66b. Thereafter intact and activated neutrophils were treated with dalargin solution at concentrations of 50 and 100 mcg/mL.

Results: Dalargin at 100 mcg/mL reduced the expression of CD11b molecules on the surface of intact neutrophils by 5.5-fold (p=0.008). On the contrary, LPS at a  dose of 100  ng/mL increased the expression of the same molecules by 46% (p=0.08). The addition of dalargin at 50 mcg/mL to LPS-activated neutrophils reduced the expression of CD11b molecules (p=0.016). The addition of dalargin at 50  mcg/mL to fMLP-activated neutrophils significantly (p=0.008) reduced the expression of CD11b molecules and reversed their expression virtually to the level of the control. The addition of dalargin at 100  mcg/mL to neutrophils activated by fMLP at 10 mkM reduced the expression of CD11b on their surface to a level below the control by 23% (p=0.08).

Conclusion: Dalargin at the studied concentrations has an anti-inflammatory effect on both intact and pre-activated bacterial components of neutrophils, thus inhibiting the process of activation and degranulation in a dose-dependent manner. 

Almanac of Clinical Medicine. 2019;47(3):228-235
pages 228-235 views


Takotsubo syndrome after induction of general anesthesia: three clinical cases

Klimov A.A., Buldakov M.Y., Gritskevich M.V., Zabaluev D.A., Kamnev S.A., Malakhova A.A., Novikova E.V., Osokin Y.A., Subbotin V.V.


Takotsubo syndrome (stress-induced cardiomyopathy, or apical ballooning syndrome) is a  rare critical condition with approximate incidence of 0.00006% and relatively favorable prognosis. It is characterized by electrocardiographic signs of myocardial ischemia, as well as by severe left ventricular failure with intact coronary vessels. The literature on postoperative development of this disease is scarce. This paper presents three documented cases of takotsubo syndrome with favorable outcomes that developed just after the induction of general anesthesia.
Almanac of Clinical Medicine. 2019;47(3):236-243
pages 236-243 views

Anesthetic management during endocardial radiofrequency ablation of septal hypertrophy – a case report

Viesi J.H., Nigro Neto C., Valdigem B.P., Dornelles I.M., Passos S.C., Stahlschmidt A., Le Bihan D.C., Correia E.B.


Background: Hypertrophic cardiomyopathy (HCM) is a genetic disorder present in up to 1/500 individuals, about 20–30% of them presenting with hypertrophic obstructive cardiomyopathy (HOCM) due to left ventricle outflow tract obstruction. This is an important cause of sudden cardiac death. Endocardial radiofrequency ablation of septal hypertrophy (ERASH) might be an attractive treatment for HOCM, particularly in patients who do not respond to transcoronary alcohol septal ablation (TASA).

Aim: To describe technical aspects related to the procedure and anesthetic management of an ERASH case.

Case report: A 64-year-old woman with HOCM was scheduled for ERASH. She had worsening of dyspnea on exertion and generalized fatigue for the previous weeks after previous surgical myomectomy about 6 months ago. The anatomy was unfavorable for TASA and the patient was not willing to undergo another surgery. Preoperative transthoracic echocardiography (TTE) showed asymmetric mid-septal hypertrophy, systolic anterior motion with septal contact and left ventricular outflow tract maximum gradient of 68 mmHg at rest and 105 mmHg after the Valsalva maneuver. General anesthesia was performed. Pulse pressure variation, echocardiography parameters and passive leg raising test where used to guide fluid therapy. At the end of the procedure, analgesia was provided together with prophylaxis of nausea and vomiting. Extubation was uneventful and the patient was transported to the intensive care unit eupneic and hemodynamically stable. On the fourth postoperative day, TTE showed septal  hypocontractility and maximum gradient reduction of 33% at rest (68 mmHg to 45 mmHg) and 31% after the Valsalva maneuver (105 mmHg to 73 mmHg). The patient was discharged from hospital at the sixth postoperative day. One month later, she reported progressive improvement of symptoms and expressed satisfaction with the results.

Conclusion: Better understanding of the pathophysiology and natural history of HCM has enabled earlier diagnosis, as well as a more adequate therapeutic approach. Anesthesiologists should be aware of the pathophysiology of HOCM and must be prepared to anticipate the hemodynamic changes and cardiovascular instability that such patients may show perioperatively. ERASH is a promising therapeutic modality increasingly used for HOCM and anesthesiologists should become more familiar with it.

Almanac of Clinical Medicine. 2019;47(3):244-250
pages 244-250 views

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