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Impaired microcirculation due to endothelial dysfunction in COVID-19 is considered to be the most important link in the pathogenesis of this disease. However, due to the complexity of its instrumental assessment in critically ill patients, the data available in the literature on specific manifestations of endothelial dysfunction are very contradictory.The objective: to determine the most characteristic capillaroscopic signs of microvascular disorders and to assess the state of microcirculation regulation in patients with severe COVID-19.Subjects and Methods. When admitted to the intensive care unit, 60 patients with COVID-19 and 12 patients with chronic cardiovascular pathology without COVID-19 (Comparison Group) were examined. All patients underwent microscopy of the microcirculatory bed of finger nail bed; the following parameters were assessed: diameters of the venous, arterial and transitional parts of capillaries, height of capillary loops, density of capillaries per 1 mm of the length of the perivascular zone, the average linear velocity of capillary blood flow (LVCBF), and thickness of the perivascular zone. The presence of avascular zones, the number of capillaries in the visualized field with circulating aggregates in the lumen, and the shape of capillaries were taken into account. In addition, an occlusion test using laser Doppler flowmetry was performed in 32 patients with COVID-19. The maximum post-occlusive increase in blood flow at the moment of cuff deflation was assessed, as well as changes in the mean value of post-occlusive blood flow relative to the baseline within 3 minutes after cuff deflation.Results. In 53 (88.3%) patients with COVID-19, abnormalities corresponding to chronic microcirculatory changes in the form of predominance of pathological capillary forms were detected. Microaggregates in the lumen of capillaries and decreased linear velocity of blood flow were revealed in 100% of cases. When comparing groups of patients with different outcomes, statistically significant differences were revealed between the LVCBF parameters (in the survivors - 354.35 ± 44.78 pm/sec, in the deceased - 278.4 ± 26.59 pm/sec), as well as between the values of the perivascular zones thickness (95.35 ± 15.96 microns versus 159.93 ± 19.90 microns). The results of the post-occlusion test revealed a significant difference between the groups in terms of the maximum post-occlusion gain (39.42 ± 3.85 BPU in the group with a favorable outcome, 27.69 ± 3.19 BPU in the group with an unfavorable outcome, 47.23 ± 1.78 BPU in the control group). In both groups, there was no increase in this parameter relative to the initial blood flow. At the same time, in the control group, the average index of post-occlusive blood flow was higher than the initial level.Conclusions. Acute microcirculation disorders with decreased linear velocity of capillary blood flow, circulation of aggregates, increased thickness of the perivascular zone were detected in all patients with severe COVID-19 but especially in those with unfavorable outcomes. Vascular tone regulation disorders were manifested by the absence of reactive hyperemia in response to acute ischemia, as well as a decrease in maximal flow-induced increase. These changes fit into the concept of endothelial dysfunction. Signs of chronic microcirculation disorders in most patients increase the risk of severe COVID-19.

Ferritin is one of the biomarkers requiring special attention; its blood level increases significantly especially in the severe course of COVID-19. Information on the effect of hyperferritinemia on the disease outcome is very contradictory as are the ideas about the causes of its development.The objective: to study the effect of hyperferritinemia on the disease outcome and analyse the possible causes of its development in severe COVID-19.Subjects and Methods. Data on 479 patients with severe course of coronavirus infection treated in intensive care units (ICU) were retrospectively analyzed. Of them, the proportion of patients with a favorable outcome (Group 1) was 51.0% (n = 241), and with an unfavorable outcome (Group 2) - 49.0% (n = 235). The following parameters were assessed: the levels of ferritin, C-reactive protein, fibrinogen, IL-6, IL-10, IL-18, procalcitonin, complement C5a, total, direct and indirect bilirubin, ALT, AST, and the blood level of lactate dehydrogenase (LDH). The changes of erythrocyte count and hemoglobin blood level were also monitored. In order to form a clear view of iron metabolism, free iron, transferrin, and myoglobin levels were assessed in several patients with high ferritin values (more than 1,500 pg/L).Results. In the unfavorable outcome, ferritin levels increase very significantly, reaching maximum by day 6 of patients' stay in ICU. The difference in the level of ferritin between the groups of survivors and deceased during this period is clear and significant (p = 0.0013). The association of ferritin values with the outcome is detected as early as day 1, but by day 4 it becomes highly significant (the cut-off point is 1,080 pg/l). No data have been obtained that would indicate the association of hyperferritinemia with impaired iron metabolism, the development of hepatic dysfunction, or cellular destruction. In contrast to survivors, those who died on day 6 had elevated IL-6 while C5a level remained unchanged. Conclusions. The rapid increase in ferritin blood levels to 1,000 pg/L or higher is an unfavorable prognostic sign indicating a high probability of a lethal outcome. When assessing genesis of hyperferritinemia in COVID-19, the crucial significance should be attributed to the cytokine storm rather than disorders of iron metabolism or hemotoxic effects of the virus. The persistent increase of ferritin level in blood during 4-6 days of stay in ICU should be considered as a reason to intensify anticytokine therapy.

Estimations of the frequency of acute kidney injury in SARS-CoV-2 (COVID-19) coronavirus disease are very diverse. The literature data is highly inconsistent and shows AKI ranging from 0.5 to 80%.The objective: to analyze the incidence of renal dysfunction in COVID-19 patients and assess the significance of systemic inflammation for its development.Subjects and methods: The analysis was performed basing on data of 3,806 patients with COVID-19 treated at the Pavlov State Medical University, 395 of them were admitted to the intensive care units (ICU). The criterion for establishing renal dysfunction (RD) is the increase in blood creatinine level above the upper limit of reference values (0.115 mmol/l). Patients with end-stage chronic kidney disease who needed to continue routine long-term dialysis were not included in the study. We analyzed the incidence of renal dysfunction, changes in blood levels of creatinine, urea, and electrolytes during 8 days. In addition, glomerular filtration rate, diuresis volume, levels of hematocrit, hemoglobin, LDH, CRP, ferritin, and procalcitonin were evaluated.Results. The frequency of RD among all patients was 19.0%, among patients in the ICU – 41.0%. In 79% and 81%, respectively, it was detected on the first day of hospitalization. The increase in the number of patients with RD and the aggravation of the existing dysfunction occurred after 6 days. At the initial stage of the disease, the manifestations of RD in most cases were not expressed even in those with an unfavorable course of the disease but the level of creatinine showed a weak but significant (p < 0.5) correlation with changes in CRP (r = 0.110), ferritin (r = 0.137), and procalcitonin (PCT, r = 0.418). The difference in the level of creatinine in patients with PСT level above and below 0.5 ng/ml was observed on the first day only; the value of this parameter returned to normal faster in the subgroup of patients whose procalcitonin level did not exceed 0.5 ng/ml.Conclusion. In case of the signs indicative of RD, it is advisable to distinguish between primary and secondary injury. In the first case, it is primarily due to systemic inflammation, in the second case it is caused by additional impact of other aggressive factors. This will make it possible to clarify the renal and non-renal indications for renal replacement therapy (RRT) in patients with COVID-19, and to evaluate the results adequately since the effectiveness of RRT at different stages of the disease cannot be the same.

The constant mutation of the virus and the complicated epidemiological situation in other countries keep the probability of a third wave of the pandemic in the Russian Federation fairly high. It is important to summarize the gained experience as fast as possible to use it appropriately once it is needed.The objective: to analyze the specific parameters of care for critically ill patients with the novel coronavirus infection in Pavlov Multidisciplinary Medical Center.Subjects and methods. This is a result-based report on the work performed by the Infection Center, which was deployed twice in Pavlov Multidisciplinary Medical Center (from 28.04.2020 to 03.08.2020 and from 01.11.2020 to 15.03.2021). Totally, 3,830 patients with SARS-CoV-2 were managed (1,680 patients during the first deployment and 2,150 patients during the second one). In the preparatory period, the operation of the emergency department based on the inpatient emergency medical department (EMD) had been simulated to clarify its staff structure and the procedure for admission, examination, and treatment of patients. Here we compare the organizational approaches during the first and second waves of the pandemic and present the characteristics of the demographic data of the treated patients, the incidence of certain complications, and outcomes.Results. The overall lethality in the Center made 6.2%. Despite the experience gained in the first wave, the results of treatment during the second wave (autumn-winter) did not improve (5.7% died in the first wave and 6.7% in the second one). Lethality in ICU and EMD was 40.0% and 49.6%, in ICU only – 38.5% and 46.9% respectively. A moderate lethality increase in ICU was due to the concentration of critically ill and most critically ill patients. There were 51.4% of patients with comorbidities and 53.5% were above 65 years of age. Refinement and differentiation of tasks performed by departments, simulation of the operation of the Center before opening made it possible to increase the throughput of the medical unit avoiding rush during admission and deterioration the quality of treatment.Conclusion. Certain aspects of the organization of medical care affect the performance of a multidisciplinary medical institution transformed into an infectious diseases hospital. The experience gained under such circumstances can be useful in other emergencies with a large number of victims and patients.

The use of high-adsorption membrane hemofiltration in COVID-19 positive patients to reduce the severity of a cytokine storm is clearly beneficial but at the same time, there are no certain procedures for its practical use.The objective:to study the change in the levels of IL-6 and IL-18 in response to prolonged (24-72 hours) high-adsorption membrane hemofiltration.Subjects and methods. We retrospectively analyzed the data on IL-6 and IL-18 levels and their changes in 69 patients who were COVID-19 positive and had different degrees of lung damage, they had received high-adsorption membrane hemofiltration during their stay at the intensive care unit. The extent of lung lesions was the following: 4 people had CT-2, 44 people had CT-3, and 21 patients had CT-4. 18 patients had an unfavorable outcome of the disease. High-adsorption membrane hemofiltration (Prismaflex) was used in the group of patients who had clinical signs of the rapid progression of the disease and also such laboratory findings as elevated values of C-reactive protein (above 100 mg/L), ferritin (more than 600 μg/L), and progression of lymphopenia. This intervention lasted for 24 hours at CT-2/3, and 48 hours at CT-4. The effluent dose was 30.0 ± 6.4 ml/kg/h. The levels of IL-6, IL-18, and procalcitonin were tested before and after the completion of the intervention, and the difference between their concentration before and after high-adsorption membrane hemofiltration was calculated. The potential association between received data (IL-6, IL-18, delta of IL-6, delta of IL-18) and degree of lung damage and outcomes was analyzed.Results.It was detected that the more the lungs were affected, the lower levels of IL-6 and IL-18 were and vice versa and this correlation was not associated with the use of tocilizumab (used in 44 people). The maximum decrease in the level of cytokines was observed in the group of patients with CT-2. There was a significant association between the delta of IL-6 (F = 6.69; p ≤ 0.05) and the outcome which was especially pronounced in people with a favorable outcome.Conclusion.As the inflammation progresses in the lungs, the levels of IL-6 and IL-18 decrease which may be a manifestation of the depletion of the cytokine storm. The use of prolonged high-adsorption membrane hemofiltration (24-48 h) allows reducing the level of cytokines. The delta value reflects a decrease in IL-6 concentration, it significantly correlates with the outcome which indicates the importance of using this method in a continuous mode.

Thrombophilia, as well as multiple organ dysfunction, are typical manifestations of the severe new coronavirus infection that closely resemble the clinical signs of catastrophic antiphospholipid syndrome (CAPS). The objective: to assess whether catastrophic antiphospholipid syndrome is an essential manifestation of severe forms of COVID-19.Subjects and methods. 45 patients diagnosed with the new coronavirus infection (SARS-CoV-2) and a severe course of viral pneumonia (more than 3 points on the NEWS score by the admission, CT 3-4, oxygenation index below 100, the need for at least high-flow oxygen therapy). They were assessed for the development of CAPS due to signs of progressing organ dysfunction despite the ongoing intensive therapy, suspected pulmonary embolism and progressing venous thrombosis of a lower extremity or subclavian vein. It was an essential provision that they should have no signs of bacterial infection (blood procalcitonin should be below 0.5 μg/l). The antiphospholipid syndrome was diagnosed based on the detection of antibodies to β-2-glycoprotein in the blood (A/t β-2-GP1 IgGAM, A/t β-2-GP1 IgM, A/t β-2-GP1 IgG) and to cardiolipin (A/t CL IgM , A/t CL IgG) by ELISA tests. The course of the disease was monitored using other routine clinical (temperature, complete blood and urine counts) tests and blood panel tests reflecting the severity of the systemic inflammatory response (ferritin, CRP, interleukins 6 and 18), and the state of the hemostatic, respiratory, circulatory, liver and kidney systems.Results. Antiphospholipid antibodies (aAPL) moderately exceeding the reference values were detected in 9 out of 45 patients (20%), mainly due to IgA and IgM isotypes to β-2-glycoprotein and IgM isotype to cardiolipin. The assessment of the antibody titer in 5 patients over time (after 7 days) revealed a decrease, but it did not affect the outcome (four of them died). In 36 patients, some traces of aAPL were found that did not reach the lower limit of the norm, despite the uniformity of the clinical signs and similarity of biochemical parameters reflecting the severity of organ disorders. The absence of antibodies did not prevent the development of thrombotic complications (thrombosis of large vessels and pulmonary embolism in 5 patients). There were no other manifestations often associated with CAPS (thrombocytopenia, hemolytic anemia, decreased fibrinogen concentration in the blood). Conclusion. Catastrophic antiphospholipid syndrome is not inevitable in severe COVID-19 cases, however, it can develop as one of the manifestations of thrombophilia that occurs in such patients.

Microcirculation disorders caused by thrombosis are the most important factor determining the pathogenesis of organ damage in severe COVID-19 including the absence of obvious macrohemodynamic instability. However, there are very few publications demonstrating the results of intravital visualization of changes in the microcirculation system in this disease.The objective: to assess the state of microcirculation in patients with viral pneumonia associated with COVID-19 using nail bed microscopy.Subjects and methods. Eleven patients with COVID-19 were examined; they were admitted to the intensive care unit due to progressing acute respiratory failure. Vital microscopy of the microcirculatory bloodstream in the fingers’ nail bed was performed by admission and over time. When assessing microcirculation, the presence of aggregates in the lumen of capillaries and avascular zones, and the linear velocity of blood flow were taken into account. The results were summarized taking with the outcome consideration (6 people recovered, 5 died). Results. Microcirculation disorders were objectively confirmed in all patients. In 100% of cases, microaggregates were detected in the capillary lumen. The values of the mean linear velocity of capillary blood flow turned out to be extremely variable. However, the values of the maximum linear velocities of capillary blood flow in the patients who subsequently died were significantly lower versus survivors (190 μm/sec (135.5; 237) and 387 μm/sec (329.3; 407.5), p = 0.018). The irregularity of blood flow in the visualized field was revealed: when the value of the maximum linear velocity in some capillaries was less than 180 µm/sec, in others, disturbances in the form of pendulum-like movement were already noted. Further slowing down of the blood flow velocity led to the development of stasis and the formation of avascular zones.Conclusion. Impaired microcirculation (decreased blood flow rate in the capillaries, the presence of microaggregates and a lower number of perfused capillaries in the form of avascular zones) develops in all patients with severe COVID-19.

Introduction.The conductance of goal-directed hemodynamic therapy is controversial due to the difficulty in its implementation in routine practice despite the significant number of studies and meta-analyses.Objective.To estimate the efficacy of a modified algorithm of goal-directed hemodynamic management in patients with colorectal cancer who undergo laparoscopic surgery based on non-invasive monitoring of cardiac output.Subjects and methods.A single-centered, randomized trial was conducted. The control group included 75 patients, while the goal-directed therapy (GDT) group included 72 patients. In the control group, hemodynamic management was based on mean arterial pressure and intraabdominal perfusion pressure. In addition, results of fluid responsiveness tests were considered in the GDT group. The suggested protocol efficacy was evaluated on the basis of frequency of critical incidents, shifts in acid-base balance and lactate concentration, infusion volume, vasopressor doses, the incidence of acute kidney injury, and other complications.Results.After anesthesia induction and according to the results of a modified, passive leg raising test, 67.1% of patients were considered responders and received 1250 (1000; 1500) ml of balanced crystalloids before carboxyperitoneum. The infusion differentiation test of hypotension cause was performed in 47 patients of the GDT group, 37% were considered responders, and others received vasopressors and/or inotropes. The use of the GDT protocol led to a decrease in total infusion volume and vasopressor doses. A lower frequency of critical incidents was recorded when the GDT protocol was used. In the GDT group, there were no signs of ischemia and increased frequency of complications (including acute kidney injury).Conclusions.Testing of fluid responsiveness and non-invasive cardiac output monitoring allows for the correction of hemodynamics during surgery. Goal-directed therapy in the intraoperative period allows different approaches to maintaining systemic and intraabdominal perfusion pressure, thus decreasing the total volume of infusion without increasing hypoperfusion risk.

The article is devoted to the issue of control over antibiotic resistance of the main pathogens causing nosocomial infections and presents the experience of introducing the antimicrobial therapy control system in a general hospital. The special emphasis is put on capabilities of information technologies used as a tool to support decision making about prescription or restriction of antibacterial drugs.

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.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective method to treat malignancy and some solid tumors which may be accompanied by life-threatening immune and infectious complications refractory to standard immunosuppressive and antibacterial therapy. According to literature data, fecal microbiota transplantation (FMT) may be applied to restore functional activity of microbiota and to overcome antibiotic resistance. Two clinical cases of FMT in critical ill patients who had developed acute graft-versus-host disease (aGvHD) of intestine after allo-HSCT are presented in the article. The aim of the study was to assess FMT efficiency and safety in immunocompromised critically ill patients. Results. Following FMT, a complete regress of aGvHD signs as well as reduction of systemic infectious process were registered, due to probable modulation of the immune response. In one patient, elimination from respiratory ways of carbapenemase-producing Klebsiella pneumoniae positive for NDM- and OXA-48- producing was noted, like as elimination of Pseudomonas aeruginosa synthesizing KRS-type carbapenemase. Conclusions. FMT may be considered an alternative approach to intestinal aGvHD treatment in critically ill patients after allo-HSCT.

Aim of studyTo study of the role of hydrochloric acid in the genesis of stress-induced gastric ulceration in patients with extensive burns.Material and methodsThe results of gastroscopy and endoscopic pH-metry of 30 young patients with extensive burns (19 male patients and 11 female patients). The acidity of the gastric contents was measured on day 1,7 and 14 after the trauma.ResultsIt was found that the early period of burn disease was followed by the pH growth in the acid-producing area of the stomach to 3.8–4.2 (p=0.002–0.020). This indicated that extensive burns provoked a significant decrease of hydrochloric acid production by parietal cells of the stomach. The restoration of the acid production occurred only 14 days after thermal injury and was not followed by the development of a hyperacid state. The frequency of erosive-ulcerative lesions detection in the gastric mucosa by the end of the first day after receiving burns was 83%, 87% on day 7, and 96% on day 14. In total, stress-induced lesions of the gastrointestinal mucosa were diagnosed in 26 of 30 patients with a shock-induced thermal injury. Consequently, in patients with burn shock the protective factors of the gastric mucosa were depressed so that a minimum amount of hydrochloric acid was sufficient to damage it.ConclusionInhibition of acidogenic function is typical for patients with burn disease. Hydrochloric acid does not play a leading role in the genesis of stressinduced ulceration in patients with severe thermal trauma.

The OBJECTIVE is to evaluate the results of introduction of the new method of preparation in patients with deep neck burns to the imposition of tracheostomy. MATERIAL AND METHODS. The study included 124 patients with extensive deep burns and inhalation injury. The method of treatment consisted of early (3–4 days from the moment of injury) necrectomy with simultaneous autodermoplasty in the projection of the anterior surface of the neck and torso on the area of 1–1.5% of the body surface. Tracheostomy was performed after graft engraftment. RESULTS. According to the proposed method, 20 patients were operated. 17 of them were subjected tracheostomy through the restored skin on 11.6±1.8 days. CONCLUSION. The method of the early recovery of th skin in the projection of tracheostomy in patients with deep burns of the neck allows to safely subject tracheostomy through the restored skin on 8–14 days from the moment of the burn.

The article describes the clinical case when malignant hyperthermia was diagnosed in the patients during the cardiac surgery. The patient had anesthesia with desflurane. The state of the patient was stabilized due to timely diagnostics and aggressive therapy with non-specific agents and cardiopulmonary bypass. The article presents different variants of clinical manifestations of this complication, ways of diagnostics and specific therapy.

In the patients staying in the intensive care wards, it is often necessary to differentiate the cause of systemic inflammatory response and multiple organ failure (infectious and no n-i nfectious cause), which is often impossible unless various biomarkers are used. The objective: to study the informativeness of presepsin versus traditional biomarkers (procalcitonin, C-r eactive protein), to find benefits and drawbacks of these biomarkers when investigating the nature of the systemic inflammatory response in critical states of various etiology. Subjects and methods. The retrospectiv e-p rospective study trail was conducted. 95 patients were included into the trial, they all were admitted to intensive care wards with symptoms of systemic inflammatory response and multiple organ failure, assessed as 2 and more SOFA scores and who had their levels of procalcitonin, presepsin and C-r eactive protein tested. In order to assess sensitivity and specificity of presepsin for diagnostics of infections in the patients with disorders of excretory function of the kidneys and those with neutropenia, and the patients after massive traumatic surgeries, the following categories of patients were prospectively included in the study: patients with chronic kidney disease receiving hemodialysis ( n = 17), those with oncohematological disorders ( n = 8), and patients undergoing cardiac surgery ( n = 20) with cardiopulmonary bypass and without it (of pump). Results. It was demonstrated that presepsin was more sensitive and specific for diagnostics of sepsis versus other investigated biomarkers. It was found out that in the patients with sepsis and disorders of excretory function of the kidneys, the level of presepsin ( IU 10 876 (2 030; 15 972) was nearly 8 times higher than in the patients receiving no substitutive renal therapy with hemodialysis Patients with neutropenia ( IU of white blood count ‒ 0.4 (0.3; 0.5) and infectious complications had the level of presepsin compatible with the one in the patients undergoing surgery with no neutropenia: IU of presepsin in the patients with local infection made 324 (191; 601) p g/m l, and in the patients with sepsis it made 3,176 (1,514‒4,837) p g/m l. During the per i-o perative period, the changes in the biomarkers level in the patients undergoing cardiac surgery demonstrated that their level significantly increases in 12 hours after surgery versus pr e-o perative level, despite the absence of the systemic infection. And the fold of procalcitonin increase (2 2-f old rise) was much higher versus presepsin ( 3-f old rise). The tendency to normalization of presepsin level was observed in 24 hours, the fact of cardiopulmonary bypass provided no significant impact on the changes in presepsin level. Conclusion. As an infection biomarker, presepsin possesses high sensitivity and specificity. It can be used for diagnostics of infection in the patients with neutropenia and without it. But it should be noted that its level can be increased in case of a critical state not related to the development of infectious complications. When interpreting the obtained clinical data it is important to understand which mechanisms can cause the elevation of its level in blood in a certain situation. For the most difficult cases, the most adequate result can be obtained when the levels of different biomarkers are tested simultaneously.

Goal: to demonstrate the rare case of transfusion-associated graft-versus-host disease (TA-GvHD) after transfusion of blood components. The cause of TA-GvHD is implantation of donor lymphocytes, contained in blood components, which is related to immunological HLA-homology between the donor and recipient, that does not eliminate the donor cells. Mortality makes 90-100%. 68 year old patient had planned surgery - aortocoronary bypass. In the post-operative period under pressure anemia three doses of unirradiated packed red blood cells were transfused. On the 17th day after transfusion the patient developed febrile fever and manifested erythematous cutaneous rush. On the 24th day after transfusion neutropenia developed. Evaluation results of allele discrimination of high-polymorphic markers confirmed the diagnosis of TA-GvHD. HLA-typing of the donor's and recipient's blood was done retrospectively. The donor was homozygous in five loci in low resolution and in loci of HLA-А*, HLA-В*, HLA-DRB1* he had the gene common with the patient. On the 34th day after the transfusion the patient died of infectious complications. X-ray or gamma-irradiation of blood components in order to inactivate the donor's viable T-lymphocytes is considered to be the only way to guarantee the prevention of TA-GvHD. Since there is no effective therapy for TA-GvHD, prevention of risk to develop the disease, strict indications to blood transfusions and capacity for early diagnosis become crucial.

Sepsis remains to be a global medical problem associated with high mortality level. Due to this, there is constant interest towards investigation of its pathogenesis and introduction of new management techniques. Current recommendations contain clear instructions for intensive care including substitutive renal therapy in case of renal dysfunction, however other methods of extracorporal detoxification including selective sorbtion of endotoxin are still being discussed. Goal: to demonstrate the opportunities of selective LPS-sorbtion in the combined therapy of those suffering from septic shock using a specific clinical case. Results: Immediately after selective hemosorption the patient with septic shock demonstrated the following positive changes: reduction of body temperature down to low-grade fever, stabilization of hemodynamic rates, reduction of noradrenaline dose from 0.2 to 0.05 mkg (kg ∙ min-1), reduction of lactate level from 2.3 to 1.7 mmol/L and improvement of respiratory function rates. The renal function improved against the background of stabilization of hemodymanic rates, thus serum creatinine reduced from 0.309 to 0.150 mmol/L. The substitutive renal therapy was fully stopped on the 9th day. The intensity of clinical manifestations of multi-organ dysfunction reduced from 10 to 4 according to SOFA score. Conclusion. Clinical follow-up demonstrated the positive experience of using selective LPS-sorbtion in the combined therapy of septic shock, caused by gram-negative bacteria. Express test for endotoxin activity level in the septic shock patients enhances the objectivity of choice of extracorporal hemocorrection methods.

Currently, the majority of colorectal surgeries is performed using laparoscopic and minimal invasive methods, providing the best outcomes in the soonest post-operative period and equal oncological safety when compared to traditional open surgeries. Data of the publications on the safety of laparoscopic surgeries in such patients are fairly contradictory. The objective of the study: to evaluate the impact of intra-operative intra-abdominal hypertension on the course of post-operative period in the patients undergoing surgery for colorectal cancer. Subjects and Methods. 48 patients who had surgeries for colorectal cancer were enrolled into the study. All patients were divided into 2 groups based on the course of post-operative period: with complications(no. 1, n = 36) and no complications during the post-operative period (no. 2, n = 12). The analysis included the data of invasive monitoring of arterial blood pressure, blood gases and acid-base balance of arterial and venous blood, blood lactate level, frequency of critical incidents. The patients who had laparoscopic surgeries had their level of intra-abdominal pressure recorded and intra-abdominal perfusion pressure calculated. The statistic analysis was performed using the software of SPSS 20.0 IBM. In order to define the significance of differences between the groups, paired non-parametric Mann-Whitney test was used. Differences were considered valid with p < 0.05. Chi-square method was used to evaluate the differences between categorical values. Results. It was found out that two and more episodes of systolic blood pressure drop during surgery significantly increased the risk of post-operative complications (χ2 test with Yates' correction of 4.636, p = 0.001; OR 24.0, RR 8.6, 95% CI 2.002–7.981). The patients with complicated post-operative period had a significantly higher level of lactate, venoarterial differences of pСО2, more severe base deficit versus the comparison group. When laparoscopic methods were used, these differences were even more significant. When performing correlation analysis the significant association was detected between the levels of intra-abdominal pressure and lactate, BE and ΔpCO2 in 60 minutes after pneumoperitoneum and desufflation, which indirectly confirmed the impact of the increased intra-abdominal pressure on development of intra-abdominal hypoperfusion. Conclusion. Ischemic and reperfusion damage, developed during the intra-operative period, is one of the pathogenetic stages of development of post-operative complications in the patients who had surgeries for colorectal cancer. One of the risk factors promoting its development is a decrease of arterial blood pressure during the intra-operative period for more than 20% out of the initial letter as well as intra-abdominal hypertension, caused by the increase in intra-abdominal pressure during laparoscopic pressures.

A new federal model of in-patient medical care funding provides payment for treatment basing on the average costs estimated when evaluating "completed cases" of certain diseases grouped together due to their similarity and types of the provided medical care (CSG system). The lack of differentiation does not allow full reimbursement of expenses of in-patient units occurring during treatment of the severely ill in the intensive care wards. Goal: to estimate risks of financial losses of units providing medical care to the patients with high chances of a complicated course of the disease when medical care is reimbursed within the system described above (CSG system) and to propose improvement of this system. Results. The article presents the results of joint work of the experts from Organizational Economic Committee of the Association of Anesthesiologists and Intensive Care Physicians and workers of St. Petersburg Regional Fund of Mandatory Medical Insurance aimed at the improvement of the medical care funding system based on the so-called clinical statistic groups (CSG). It was suggested splitting up certain clinical statistic groups into subgroups considering the need of patients in the intensive care and its content. The coefficients reflecting the content of costs were calculated for the identified subgroups. The offered approach was piloted during the project in St. Petersburg through estimating costs for a completed case in parallel with estimation as per the existing method of reimbursement related to medical economic standards. The obtained results proved that the offered approach allowed achieving better differentiation due to re-distribution of funds from less severely ill patients who required no treatment in the intensive care departments to the more severely ill. The data were submitted to Center of Expertise and Monitoring of Medical Care Quality in order to prepare suggestions to amend guidelines on medical care reimbursement by the Russian Ministry of Health. Conclusion. The article describes specific practical outcomes – the model was developed to be introduced for reimbursement of the in-patient care as per CSG system within mandatory medical insurance.

Portal venous gas is a relatively rare case in clinical practice. Initially, the development of portal venous gas was associated with the life-threatening intra-abdominal disorder, which as a rule required emergency surgery. Introduction of new achievements in diagnostics resulted in the more frequent registration of portal venous gas in various abdominal disorders and after invasive surgery. A large volume of gas can result in the portal obstruction with development of portal hypertension and portal-systemic anastomoses. Gas can migrate from portal vein into system venous blood flow through liver or portal-systemic anastomoses in case of no abnormality, and cause pulmonary gaseous embolism which can be followed by arterial embolism. The article presents the clinical case of the patient suffering from pancreatic gland tumor, in whom portal venous gas followed by arterial embolism was detected in the post-operative period.

Procalcitonin is an important marker used in the clinical practice for sepsis diagnostics. However the increase of its concentration can be registered in the early post-traumatic period with no obvious nidus of infection. Goal: to clarify the value of procalcitonin as a biomarker in those with concurrent trauma. Methods. 76 those injured were examined and divided into subgroups depending on the severity of trauma (ISS < 20 and ISS > 20 scores) and outcome (favorable, unfavorable, with infectious complications and no infectious complications). The changes in procalcitonin level in the subgroups were compared with intensity of the systemic response to the injury through changes in IL-6, IL-8, IL-10, CD14, HLA-DR, secretory immunoglobulin A. Blood was collected upon admission to hospital, in 12 hours, on the 1st, 3rd, 7th and 10th days. Results. It has been found out that in case of concurrent trauma the procalcitonin level in blood increased immediately and it was especially intensively expressed in severe trauma (ISS > 20 scores). During first 24 hours it was tens times above the normal and it remained above the normal during the post-traumatic period. And these changes were not related to a generalized infection. During all period of follow up the changes in procalcitonin level coincided with changes in the systemic inflammatory response and anti-inflammatory and pro-inflammatory cytokines though with a certain delay. Procalcitonin level did not increase repeatedly every time as nidus of infection manifested, it occurred more often in those with lethal outcome. High procalcitonin level in the acute post-traumatic period indicated higher chances of septic complications development on the 7-10th day. Conclusion. Along with the role of procalcitonin as an infection marker, changes in its concentration in the early post-traumatic period can be considered as a laboratory sign of the intensity of systemic response to the injury.

The colon microflora was investigated by PCR method in real time before and after planned operation in 38 patients with colon cancer. A multifactor analysis showed absence of statistically significant dependence of revealed changes in microflora from sex, age of patients, volume and method of surgery, presence of tumor stenosis and infiltrate. An anaerobic imbalance was often registrated in postoperative period, especially after antibiotic prophylaxis and therapy. Clostridium difficile and Clostridium perfringens were often detected in patients with tumor of the right part of colon (p

The article describes the clinical case of reperfusional syndrome after caesarean section in the new mother with giant liver tumor which manifested through development of multi-organ dysfunction with hemodynamic disorders, acute respiratory distress syndrome, and acute liver lesion. This clinical case confirms the hypothesis that reperfusion syndrome can complicate the course of pregnancy and post-delivery period and shows that the issue of intra-abdominal hypertension in the pregnant requires further investigation.

Patients with colorectal cancer in the perioperative period, revealed pronounced changes of microbiocenosis of colon, which is characterized by changes in the quantitative and qualitative composition of microflora. It showed a significant inhibition of anaerobic microbial component mainly bifidobacteria and lactobacilli. As a result, saprophytic microbes multiply with highly resistant to drugs, acquire pathogenic properties. The most prominent representative of such microorganisms is a pathogenic strain of Clostridium difficile, often provokes the development of pseudomembranous colitis. Depending on the degree of dysbiosis held various schemes of conservative therapy, and in severe dysbiotic changes, including pronounced diarrhea associated Clostridium dificile -fecal transplantation.

We report a case of mixed phenotype cardiomyopathy (non-compaction cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy), associated with DSP genetic variant. The sudden cardiac death was the first and only symptom.

To reduce the incidence of gastrointestinal bleeding in patients with advanced burns by developing a prophylactic algorithm.The study consisted of retrospective group of 488 patients with thermal burns grade II-III over 20% of body surface area and prospective group of 135 patients with a similar thermal trauma. Standard clinical and laboratory examination was applied. Instrumental survey included fibrogastroduodenoscopy, endoscopic pH-metry and invasive volumetric monitoring (PICCO plus). Statistical processing was carried out with Microsoft Office Excel 2007 and IBM SPSS 20.0.New algorithm significantly decreased incidence of gastrointestinal bleeding (p0.001) and mortality rate (p=0.006) in patients with advanced burns.Цель исследования - снизить частоту развития желудочно-кишечных кровотечений у пациентов с обширными ожогами путем применения разработанного профилактического алгоритма. Материал и методы. Исследование состояло из ретроспективной части, в которую вошли результаты лечения 488 пострадавших с термическими ожогами II-III степени на площади более 20% поверхности тела, и проспективной части, в которую включены 135 пациентов с аналогичной по тяжести термической травмой. В ходе исследования использовались стандартные клинические и лабораторные методы. В объем инструментальных исследований вошли фиброгастродуоденоскопия, эндоскопическая pH-метрия и инвазивный волюметрический мониторинг (PICCO plus). Статистическую обработку данных проводили с помощью программ Microsoft Office Excel 2007 и IBM SPSS 20.0. Вывод. Внедрение разработанного алгоритма позволило свести к минимуму частоту развития желудочно-кишечных кровотечений (p0,001) и снизить летальность (p=0,006) в группе пациентов с обширными ожогами.