Brain death diagnosis (BDD) remains a challenge for anesthesiologists and intensive care physicians despite existing regulatory frameworks. Objective. To evaluate the frequency of BDD procedure and identify factors limiting its implementation in a multidisciplinary hospital setting. Materials and Methods. A single-center retrospective study was conducted including 698 patients by total sampling. Of these, 98 (14 %) had brain injury and were selected for further analysis. From this cohort, patients who died within 15 days of hospital admission (N = 61) were identified. A subgroup of patients with a Glasgow Coma Scale (GCS) score of 3–5 was then selected (N = 38). For comparison, a literature search was performed in PubMed using the query «brain death criteria» and in eLibrary.ru using the keywords «brain death diagnosis». Results. BDD was initiated in 12 (31.6 %) cases within the GCS 3–5 subgroup, with brain death confirmed in 8 (21.1 %) patients, including 5 (63 %) women and 3 (37 %) men. Complete BDD procedures were performedin 6 (75 %) patients with non-traumatic intracerebral hemorrhage (ICH), 1 with non-traumatic subarachnoid hemorrhageь (SAH), and 1 with traumatic brain injury (TBI) (12.5 % each). The median patient age was 59 [43; 65] years, the median GCS score was 3 [3; 3], and the median FOUR score was 0 [0; 0]. Median hospital length of stay was 1.5 [1; 2.5] days, and median intensive care unit (ICU) stay was 1 [1; 2] day. Conclusion. Insufficient pupil diameter (5 mm) is a limiting factor for the performance of BDD procedures in grade III coma patients.

The pandemic of coronavirus infection COVID-19 (Coronavirus Disease 2019), caused by a new strain of coronavirus SARSCoV-2 (severe acute respiratory syndrome coronavirus 2), has caused high mortality worldwide. The clinical manifestations of COVID-19 are nonspecific. Diagnostics includes clinical, laboratory and radiological data. The importance of introducing information systems into medical practice in order to improve the quality of medical care is noted. It is stated that the development of medical artificial intelligence is associated with the development of artificial intelligence programs designed to help the clinic in making a diagnosis, prescribing treatment, as well as predicting the outcome of the disease. Such systems include artificial neural networks, fuzzy expert systems, and hybrid intelligent systems. The article analyzes data from a number of studies on the use of artificial intelligence for diagnosing COVID-19, predicting the risk of mortality and studying risk factors for severe course and lethal outcome in various groups. Using clusters of predictors, models have been developed to predict mortality and understand the relationship of various characteristics and diseases with mortality from COVID-19. The article also summarizes the key factors that worsen the prognosis for COVID-19. Scales for detecting or predicting the development of COVID-19-induced “cytokine storm” are marked as a separate item.

ЦЕЛЬ ИССЛЕДОВАНИЯ Анализ результатов проведения искусственной вентиляции легких у пациентов с пневмонией, возникшей на фоне тяжелого течения новой коронавирусной инфекции (COVID-19), осложненной острым респираторным дистресс-синдромом. МАТЕРИАЛ И МЕТОДЫ В основу работы положены результаты одноцентрового обсервационного исследования. Проанализированы результаты проведения искусственной вентиляции легких (ИВЛ) у 60 пациентов (медиана возраста 63 [54; 74] года) с тяжелой и крайне тяжелой формами COVID-19, осложненной острым респираторным дистресс-синдромом. Все пациенты распределены в две группы: 1-я группа — 14 пациентов с благоприятным исходом; 2-я группа — 46 пациентов с неблагоприятным исходом. Всем пациентам осуществляли комплексную терапию, включая респираторную поддержку, согласно российским рекомендациям по лечению коронавирусной инфекции COVID-19 и острого респираторного дистресс-синдрома. Тяжесть состояния оценивали по шкале SAPS II, степень выраженности органных дисфункций — по шкале SOFA, тяжесть острого респираторного дистресс-синдрома — по шкале LIS. Оценку механических свойств легких проводили на основании регистрируемых в карте ИВЛ параметров: F, Vt, MV, PIP, PEEP, СРАР. Динамическую оценку газообмена осуществляли путем постоянного мониторинга SpO2, PetCO2, плетизмографии и по данным газового анализа. Данные регистрировали в карте ИВЛ с последующим расчетом некоторых показателей: FiO2, PaO2, PaCO2, pH, PaO2/FiO2. Осуществлен динамический мониторинг следующих тестов: лейкоциты, лимфоциты, тромбоциты, С-реактивный белок. Исследования проводили на определенных этапах респираторной поддержки: 1-е сутки (I этап), 3-и сутки (II этап), 5-е сутки (III этап), 10-е сутки (IV этап), 14-е сутки (V этап), а у пациентов с неблагоприятным исходом — в претерминальном периоде (VI этап). Фиксировали длительность респираторной поддержки, пребывания в отделении анестезиологии и реанимации, в условиях стационара, осложнения и показатели летальности (на 28-е сутки) в целом массиве исследуемых пациентов. РЕЗУЛЬТАТЫ У пациентов с острой гипоксемической дыхательной недостаточностью, вызванной тяжелыми и крайне тяжелыми формами COVID-19, независимо от исхода заболевания (благоприятный или неблагоприятный) наблюдается выраженное повреждение легких в виде острого респираторного дистресс-синдрома (оценка по шкале LIS >2,5 балла); имеется только тенденция к меньшей тяжести повреждения легких по шкале LIS у пациентов с благоприятным исходом по сравнению с пациентами с неблагоприятным исходом. Для обеспечения достаточной оксигенации (PaO2≥80 мм рт.ст.) в процессе ИВЛ при неблагоприятном исходе (по сравнению с благоприятным) используются статистически значимо бóльшие уровни РЕЕР, тогда как остальные ключевые параметры респираторной поддержки (Vt, F, MV, PIP) являются сопоставимыми. При тяжелых и крайне тяжелых формах COVID-19 и неблагоприятном исходе наблюдаются значительно более выраженные расстройства газообмена (по PaO2/FiO2), которые не удается корригировать, несмотря на проведение интенсивного лечения, включая ИВЛ. В претерминальном периоде (по сравнению с этапом начала ИВЛ) оценка по шкале LIS увеличивалась с 2,8 до 3,8 балла, что говорит о прогрессировании острого респираторного дистресс-синдрома, а расстройства кислородного статуса были очень выраженными (PaO2/FiO2 92,1 мм рт.ст.), но не достигали уровня запредельной гипоксемии (PaO2/FiO2<75 мм рт.ст.). ЗАКЛЮЧЕНИЕ Полученные результаты свидетельствуют о том, что искусственная вентиляция легких у пациентов с тяжелыми и крайне тяжелыми формами новой коронавирусной инфекции оказалась эффективной в 23,3%. Однако данное исследование имеет определенные ограничения, связанные с его одноцентровым типом, отсутствием патогенетического лечения (эффективной противовирусной терапии), разными версиями временных методических рекомендаций по лечению коронавирусной инфекции COVID-19, на основе которых проводилась интенсивная терапия данной категории пациентов.

Modern high-technology methods for ischemic stroke treatment (systemic thrombolysis, mechanical thrombectomy, thrombaspiration, stenting of cerebral arteries) can improve the rehabilitation potential and survival of patients. Important tasks here are selection for reperfusion and its performance on the greatest possible number of peracute patients. Mechanical thrombectomy combined with systemic thrombolysis is the most effective reperfusion strategy in the therapeutic window, but the availability of endovascular methods is limited to highly specialized centres. One way to solve this problem is to organize effective logistics with stroke patients, which will provide high-tech care for patients living far from large treatment centers due to regulated interaction between institutions at different levels. The aim of the study was to improve emergency interaction related to transfer of peracute stroke patients from primary vascular units and district hospitals of the Krasnoyarsk region to Krasnoyarsk Regional Vascular Center for thrombectomy.

Introducrion. Due to the peculiarities of the Krasnoyarsk krai (a huge territory, low population density, different levels of health development in the districts, personnel shortage), there is a need to increase the availability and quality of medical care to district patients. For this purpose, since 2016, the Regional telemedicine system has started functioning online monitoring for patients with severe pneumonia, which provides full-fledged curation of patients from all over the region.Objective. To evaluate the results of RTS monitoring of patients with severe pneumonia.Materials and methods. 770 cases of severe community-acquired pneumonia registered in RTS from 2016 to 2018 were analyzed. Statistical data processing was performed using variational statistics using the “Excel-7” software package. For all values, the minimum significance level (p) of 0.05 was taken into account.Results. The risk factor for severe flow was male. Among comorbid diseases, cardiovascular and bronchopulmonary diseases, diabetes, alcoholism and HIV infection prevailed. The lack of flu vaccination in 97% of patients increased the number of deaths by 4.5 times. The greatest need for consultation arose in the Central district hospitals of low capacity. The majority of patients are registered in the system on the first day of hospitalization and are consulted by a pulmonologist of the Regional clinical hospital within 2 hours. Air ambulance of the Regional clinical hospital evacuated 174 patients, the need for flights decreased by 3.5 times. The main mistakes of district hospitals in the management of patients were the irrational selection of antibacterial drugs, the volume of detoxification therapy, the late start of antiviral therapy and ventilators, and the lack of prescription of anticoagulants.Conclusions. Along with the presence of comorbidities, the outcome of the EAP is affected by the quality of medical care, which depends on the professional training of medical workers, continuity in the work of regional medical institutions and air ambulance, which causes difficulties, given the specifics of the region. RTS allows you to solve this problem at minimal cost.

Background. Provided stronger demands of people towards healthcare systems, changes in the legal framework and increasing competition, medical institutions are seeking new approaches and mechanisms for improving comfort of medical care services. Navigation support as part of the visualisation system in a medical unit should comply with certain standards of colour design and its comfortable presentation to patients.Objectives. To formulate basic principles for effective colour navigation support in medical facilities using best national and foreign practices of colour design for navigation and visualisation solutions in healthcare.Мethods. Relevant publications were mined in Scopus, Web of Science, MedLine, the Cochrane Library, Elibrary and PubMed. Search depth by time was limited to 10 years. Main keyword queries were «lean production» [«бережливое производство»], «lean healthcare» [«бережливое здравоохранение»], «lean medicine», «navigation» [«навигация»], «visualization» [«визуализация»], «бережливая поликлиника», «квалиметрия». The obtained data were interpreted using legal, historical, descriptive analytical methods, content analysis.Results. Colour solutions in the Russian healthcare system are implemented in a variety of ways to support data visualisation. As part of a visual and tactile navigation system, the colour solutions serve to highlight individual navigation objects, pattern space, order and structure navigation elements, emphasise and manage relevant textual information. Incorrect colour navigation support can lead to wastes of lean principles in the main, auxiliary and maintenance processes in a medical facility. The Russian federal legislation does not currently regulate colour solutions for visualisation support in medical institutions.Conclusion. Colour solutions being part of navigation support systems should be regulated by federal and regional legal acts to allow qualimetric assessment and improvement of navigation and visual systems in medical facilities. A high-quality design of navigation support requires detailed information about the managed institution.

Introduction . Severe community-acquired pneumonia is one of the most important medical problems due to its prevalence and high mortality. A total of 705 lethal cases with severe community-acquired pneumonia for 2014-2017 were analyzed on the Krasnoyarsk territory. Aim . To determine the risk factors for the development of deaths in severe community-acquired pneumonia in the Krasnoyarsk territory over a given period. Results . When analyzing patients with severe community-acquired pneumonia, the prevalence of men was found – 461 cases, the average age of the patients was 62 years old. After analyzing patients’ adherence to smoking, injecting drug use, alcohol abuse, it was found out that 180 patients smoked (25.53±1.64%), 177 (25.1±1.6%) patients abused alcohol, 58 injected drugs (8.2±1.0%). In 75.18±1.63% cases, bilateral lung lesions were recorded. Almost half (53.76%) of patients had comorbidities: chronic diseases of the cardiovascular system in 30.21%, chronic lung diseases in 15.46%, diabetes in 8.79%, chronic viral hepatitis and liver cirrhosis 4.54%, HIV infection in 6.81%. In patients aged 18-44 years, HIV infection, chronic viral hepatitis, and liver cirrhosis were more common. Starting at the age of 45, chronic diseases of the cardiovascular system were more frequently recorded. As a result of the analysis of patient management, it was found out that along with an underestimation of the severity of the condition, antibiotic therapy, which corresponds to the clinical guidelines, was prescribed only in 53% of cases. Conclusion . It is important in the supervision of patients with severe community-acquired pneumonia to assess all risk factors, as well as analyze the comorbidities which will lead to the correct choice of therapy in accordance with clinical guidelines.

ОПЫТ РАБОТЫ КАБИНЕТА ПО ПРОФИЛАКТИКЕ ИНСУЛЬТА В КРАЕВОЙ КЛИНИЧЕСКОЙ БОЛЬНИЦЕ Г. КРАСНОЯРСКАИ

The article describes peculiarities of community-acquired pneumonia on a background of non-epidemic influenza in 218 patients in the period from 2009 to 2016 at the age from 18 to 85 years. The diagnosis of community-acquired pneumonia was verified based on clinical and epidemiological data at the time of admission; radiological and laboratory diagnostic methods. Criteria of severity were: a degree of respiratory failure, severity of the intoxication syndrome, the amount of inflammatory infiltration, presence of complications, decompensation of co-morbidities. Pneumonia on a on the 6th day from onset of disease in women aged 21 to 49 years with premorbid background (overweight, obesity, hypertension, COPD, chronic pyelonephritis). The main clinical manifestations are: acute onset, fever at 38–41 °C, sore throat and pain at swallowing, chest pain, shortness of breath, cyanosis of the skin, decreased breath sounds auscultation. Community-acquired pneumonia on a background of non-epidemic influenza is characterized by unilateral lesion, predominantly in the right lung. Changes in the hemogram depended on the time of admission: leukopenia is diagnosed in the first days of the disease, with a later admission to hospital was dominated by leukocytosis, and thrombocytopenia, on the contrary, was identified at late admission to the inpatient hospital.

The aim of the study was to investigate efficacy of specific prevention of pneumococcal infection in high-risk group patients living at Krasnoyarsk krai. Methods. The study involved 12,080 patients with a high risk of pneumococcal infection including patients with chronic lung diseases, chronic heart failure (CHF) and diabetes mellitus. A special questionnaire was developed which included medical history for the previous 1 year and for 1 year after the vaccination. Results. CHF was diagnosed in 41.08% of patients, diabetes was diagnosed in 28.44%, chronic lung diseases were diagnosed in 30.07%; 2.4% of patients had pneumonia. PCV13 vaccine (Prevenar 13) was used in 9,986 patients (82.67%) including 5,070 patients (41.97%) vaccinated against flu and pneumococcus simultaneously. PPV23 (Pneumo-23) vaccine was used in 1,967 patients (16.28%) including 1,181 patients (9.83%) vaccinated against flu and pneumococcus simultaneously. Due to the broad-scale vaccination against pneumococcal infection, exacerbation rate reduced trice, number of hospitalisations related to exacerbations reduced by 11.5 times, morbidity of pneumonia reduced by 4.8 times, morbidity of acute respiratory infections and flu reduced by 6.6 times. Conclusion. The results confirmed high efficacy and safety of 13-valent conjugate pneumococcal vaccine and 23-valent polysaccharide pneumococcal vaccine. The vaccination allowed reducing morbidity of respiratory infection and decrease number of hospitalisations due to exacerbations of chronic diseases.

Цель исследования. Провести оценку результатов лечения пациентов, оперированных открытым способом в острейшем периоде субарахноидального кровоизлияния в зависимости от скорости кровотока по интрацеребральным артериям. Материалы и методы. Проведена оценка результатов лечения 17 пациентов, оперированных по поводу разорвавшихся артериальных аневризм головного мозга в острейшем периоде субарахноидального кровоизлияния в зависимости от тяжести исходного состояния. Пациенты были разделены на 2 группы в зависимости от тяжести ангиоспазма: I группа 10 пациентов, у которых по данным ТКДГ скорость кровотока по СМА на 3-5-е сутки была менее 120 см/с (10 наблюдений в возрасте 50,1±8,3 лет); II группа 7 пациентов, у которых на 3-5-е сутки от момента развития САК скорости кровотока по СМА были более 120 см/с (в возрасте 55,7±6,5 лет). Оценивались:уровень угнетения сознания и степень тяжести САК по шкалам (GCS, Hunt-Hess, Fisher) на момент поступления больного; уровень конечного неврологического дефицита по расширенной шкале исходов Глазго (GOS extended); а также проводился мониторинг скоростей мозгового кровотока методом ТКДГ. Результаты. Установлено, что при развитии ангиоспазма с повышением скоростей более 120 см/с уже при поступлении имеется статистически значимая большая скорость кровотока по интрацеребральным артериям, несущим причинную аневризму; а также наблюдается ранее и большее нарастание скоростей кровотока, что соответствует более выраженному ангиоспазму. Определено, что первичная оценка по шкалам Hunt-Hess, Fischer, GCS отражает большую тяжесть САК в группе с повышением скорости кровотока по интрацеребральным артериям. Заключение. Установлено, что неблагоприятные исходы САК (смерть тяжелая инвалидизация) характерны для больных с развитием ангиоспазма.

Objective. The aim of this prospective randomized study was to assess the impact of renal artery denervation on patients with refractory AF and drug resistant hypertension, for whom pulmonary vein isolation (PVI) was recommended. Methods. Patients with symptomatic paroxysmal or persistent AF refractory to ≥2 antiarrhythmic drugs and drug-resistant hypertension (systolic blood pressure >160 mm Hg despite triple drug therapy) were eligible for enrolment. 50 consenting patients were randomized to PVI only (n = 25) or PVI with renal artery denervation (n = 25). All patients were followed during 18 months to assess sinus rhythm stability and to monitor blood pressure changes. Results. Out of 25, 16 (64%) patients treated with PVI and renal denervation versus 6 (24%) of the 25 patients in the PVI-only group (p=0.004, log-rank test) were AF-free at 18-month post ablation follow-up. At the end of follow-up, significant reductions in systolic (–27±4 mm Hg) and diastolic blood pressure (–11±2 mm Hg) were observed in patients treated with PVI with renal denervation, with no significant changes in the PVI only group. Conclusion. Renal artery denervation combined with PVI reduces AF recurrence and systolic/diastolic blood pressure, as compared with conventional AF ablation, in patients with drug-resistant hypertension and AF.

Objective. The aim of this prospective randomized study was to assess the impact of renal artery denervation on patients with refractory AF and drug resistant hypertension, for whom pulmonary vein isolation (PVI) was recommended.Methods. Patients with symptomatic paroxysmal or persistent AF refractory to ≥2 antiarrhythmic drugs and drug-resistant hypertension (systolic blood pressure >160 mm Hg despite triple drug therapy) were eligible for enrolment. 50 consenting patients were randomized to PVI only (n = 25) or PVI with renal artery denervation (n = 25). All patients were followed during 18 months to assess sinus rhythm stability and to monitor blood pressure changes.Results. Out of 25, 16 (64%) patients treated with PVI and renal denervation versus 6 (24%) of the 25 patients in the PVI-only group (p=0.004, log-rank test) were AF-free at 18-month post ablation follow-up. At the end of follow-up, significant reductions in systolic (–27±4 mm Hg) and diastolic blood pressure (–11±2 mm Hg) were observed in patients treated with PVI with renal denervation, with no significant changes in the PVI only group. Conclusion. Renal artery denervation combined with PVI reduces AF recurrence and systolic/diastolic blood pressure, as compared with conventional AF ablation, in patients with drug-resistant hypertension and AF.

Objective. The aim of this study was to assess the impact of RD in conjunction with pulmonary vein isolation (PVI) on patients with atrial fibrillation (AF) and moderate resistant or severe resistant hypertension.Methods. The data for this study were obtained from two different prospective randomized trials and evaluated by means of meta-analysis. Patients with paroxysmal or persistent AF and moderate resistant hypertension (BP ≥140/90 mm Hg and <160/100 mm Hg; n = 60) or resistant hypertension (≥160/100 mm Hg; second study; n = 50) were randomized to PVI or PVI with RD groups and followed up during 18 months. Results. Each group had 55 patients. At 18-months, 35 (63.6%) of the 55 PVI with RD group patients were AF-free vs 22 (40%) of the 55 patients in the PVI-only group (p = 0.013; log-rank test). In patients with severe hypertension, 16 (64%) of the 25 PVI with RD group patients vs 6 (24%) of the 25 PVI-only group patients were AF-free (p = 0.004; log-rank test). For moderate hypertension, the differences were less dramatic: 16 (53.3%) of 30 vs 19 (63.3%) of 30 when RD was added (p = 0.43). Superior efficacy of adding RD was most apparent in persistent AF and resistant hypertension (probability risk 0.24 95%, confidence interval 0.08–0.69, p = 0.012). Conclusion. RD improves the outcomes of PVI, especially in patients with persistent AF and resistant hypertension.

КГБУЗ Краевая клиническая больница, г