With the development of clinical pathophysiology, the basic concepts of maintaining fluid homeostasis of the body in normal and critical conditions were revised, and the negative effects of infusion therapy at all stages of its use were studied. Therefore, in the intensive care of shock, the main clinical questions are: when to start fluid therapy, when to stop active fluid therapy, when to start fluid removal from the body, and when to stop fluid de-resuscitation. Thus, in order to implement the principle of personalized treatment, it is important to determine not only the ‘tolerance’ of infusion therapy, but also the ‘sensitivity’ to the infusion of a particular patient – the ability to maintain hemodynamics without the risk of fluid overload. Evaluation of routine clinical, instrumental and laboratory indicators of the state of macro- and microcirculation does not provide an opportunity to accurately answer these questions. Modern sonographic methods for monitoring central and peripheral cardiohemodynamics, ‘venous excess’ using Doppler and extended focus echocardiography allow us to assess the ‘tolerance of infusion therapy’. The implementation of this new direction will increase the efficiency and safety of infusion therapy and improve the outcomes of the critically ill patients’ treatment.

This article presents the Moscow Botkin Hospital experience of using combination of general and superficial cervical plexus regional anesthesia during carotid endarterectomy performed in patients in the acute period of atherothrombotic genesis ischemic stroke. The result of reliable antinociceptive protection of the body from the activation of the sympatho-adrenal system against the background of surgical manipulations was the prevention of episodes of critical hypertension and ensuring normalization of systemic hemodynamics. By reducing the need for opioids, patients’ awakening is accelerated, and their time in the operating room is minimized. In addition, the time of necessary observation in the intensive care unit and the need for anesthesia at the immediate postoperative period, is also reduced. The above factors, as well as a multidisciplinary approach to the patient, allowed not only to provide reliable prevention of recurrent vascular incidents in the acute period of ischemic stroke, but also to improve the neurological outcomes.

Infusion therapy is an important component of many diseases treatment – and one of the main methods of intensive care for intensive care patients. Active infusion therapy using different infusion media, large volumes and high rates of intravenous fluid is especially relevant in critical patients, the most severe of which remains patients with septic shock. For more than two centuries of clinical use, infusion therapy has gone through a long evolutionary path and has become more effective and safer. However, like any drug, infusion therapy (in general and specific infusion media) has a number of side effects, especially when used excessively. Therefore, in recent years, the use of infusion therapy is considered as the appointment of any drug, taking into account indications, contraindications, methods of administration, dosing, duration, deescalation. This made it possible to identify the main stages of infusion therapy of critical conditions and shock: intensive infusion therapy (rapid administration of a large fluid volume), optimization of infusion therapy (reduction of the rate and volume of infusion), stabilization of the patient and minimization of infusion, de-resuscitation – removal of excess fluid from the body. With the development of clinical pathophysiology, the basic concepts of maintaining fluid homeostasis of the body in normal and critical conditions were revised, and the negative effects of infusion therapy at all stages of its use were studied. Therefore, in the intensive care of shock, the main clinical questions are: when to start fluid therapy, when to stop active fluid therapy, when to start fluid removal from the body, and when to stop fluid de-resuscitation. Thus, in order to implement the principle of personalized treatment, it is important to determine not only the «tolerance» of infusion therapy, but also the «sensitivity» to the infusion of a particular patient – the ability to maintain hemodynamics without the risk of fluid overload. Evaluation of routine clinical, instrumental and laboratory indicators of the state of macro- and microcirculation does not provide an opportunity to accurately answer these questions. Modern sonographic methods for monitoring central and peripheral cardiohemodynamics, ‘venous excess’ using Doppler and extended focus echocardiography allow us to assess the ‘tolerance of infusion therapy’. The implementation of this new direction will increase the efficiency and safety of infusion therapy and improve the outcomes of the critically ill patients’ treatment.

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.

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.

Encephalitis with antibodies to glutamate NMDA receptors (anti-NMDA receptor encephalitis, ANRE) is a relatively common form of autoimmune encephalitis. Clinical symptoms at onset are similar to the symptoms of exacerbation of schizophrenia, such that these patients are often hospitalized in psychiatric institutions. Considering the high lethality of this condition, and also its potential curability, detection of ANRE is an important clinical task. We present here the first laboratory confirmed case of ANRE in the Russian literature. Difficulties preventing the prompt resolution of the condition are presented, along with criteria for its diagnosis and a treatment algorithm.

Anti-NMDA-R encephalitis is a relatively frequent form of autoimmune encephalitis. Initial clinical features of anti-NMDA-R encephalitis resemble those of schizophrenia exacerbation which resulted in hospitalization of patients to mental care facilities. Taking into account high lethality and potential curability, detection of this condition is an important clinical problem. The authors describe a case report of encephalitis with NMDA-R antibodies. This report is the first in the domestic literature. The difficulties of timely diagnosis, diagnostic criteria and treatment algorithm are presented.

The researcher's opinions about myocardial and brain anesthetic preconditioning efficiency are yet contradictive. In addition, the anesthetic neuroprotection phenomenon is poorly investigated. In this study the authors attempted to evaluate the efficiency of myocardial and central nervous system (CNS) protection by using a modified method of volatile induction and maintenance of anesthesia (VIMA) based on pulse-like sevoflurane dosing that excludes propofol usage. Ninety CABG patients aged 45-75 years were included in the study group (VIMA) and underwent volatile induction with sevoflurane and anesthetic preconditioning (2 MAC) for 10 min before aortic cross-clamping, with ataralgesia used during CPB. The control group patients (TIVA) received propofol and fentanyl, no inhalation anesthetics were applied. Preoperative concentrations of NTpro-BNP were comparable. There was no significant rise of NTpro-BNP concentration in the VIMA group during the postoperative period. In the TIVA group NTpro-BNP concentrations were 3.8 and 4.8 times as much as the baseline values at 24 and 48 postoperative hours respectively (р<0.05). 17 patients in the VIMA group needed dopamine infusion during 24 postoperative hours, this number was 1.7 times less than that in the TIVA group (23 patients) (р<0.05). VIMA patients had 2-fold lower troponin T concentration in 24 hours after surgery (р<0.01). Significant differences in protein S100B concentrations were observed only during the postoperative period. No significant differences in cognitive functions of the patients from both groups were identified before surgery. On postoperative day 2 MMSE scale count was significantly lower in TIVA patients (20.843.73) in comparison with VI-MA patients (23.364.34) (р<0.05). Thus, the modified VIMA technique with sevoflurane has a greater neuroprotective potential during CABG with CPB and provides better preservation of myocardium structural integrity and cardiac performance than fentanyl/4propofol-based TIVA would do.

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<0.05). By the end of 2 days, the concentration of NT-proBNP continued to rise (up to 480% of the baseline level) in the TIA group and returned to the preoperative values in the IIMA group (p=0.05). Twenty-four hours after tracheal intubation the level of troponin I was insignificantly higher in the TIA group than that in the IIMA group (p=0.1). Conclusion. Sevoflurane has cardioprotective properties in preventing and/or reducing the degree of heart failure after ACBS using EC. There is a need to continue the study in increased cohort to provide evidence that sevoflurane-induced CPC can lower cardiomyocyte damage due to ischemia/perfusion. Key words: anesthetic preconditioning, sevoflurane, NT-proBNP, troponin I, heart failure.

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

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.

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.

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.