АКТУАЛЬНОСТЬ: Разработка клинических, методических рекомендаций улучшает качество оказания медицинской помощи и снижает риск развития осложнений. ЦЕЛЬ ИССЛЕДОВАНИЯ: Провести анализ методических рекомендаций «Периоперационное ведение пациентов с ишемической болезнью сердца», «Периоперационное ведение пациентов с сопутствующей патологией клапанного аппарата сердца» и «Периоперационное ведение пациентов с сопутствующим ожирением» с помощью модифицированного метода Дельфи. МАТЕРИАЛЫ И МЕТОДЫ: Был использован модифицированный метод Дельфи с двумя раундами анкетирования для выработки единого мнения. Достижение согласия специалистов было проведено в три этапа: подготовительный этап, этап обсуждений и этап выработки консенсусного заключения. РЕЗУЛЬТАТЫ: При обсуждении методической рекомендации «Периоперационное ведение пациентов с ишемической болезнью сердца» достигнут консенсус по 35 из 37 положений и 7 из 8 критериев качества оказания медицинской помощи. Анализ методической рекомендации «Периоперационное ведение пациентов с сопутствующей патологией клапанного аппарата сердца» показал достижение согласия по 57 из 60 положений, а также по всем 13 критериям качества оказания медицинской помощи. Обсуждение методических рекомендаций «Периоперационное ведение пациентов с сопутствующим ожирением» показало достижение по 22 из 23 положений рекомендации и по всем 5 критериям качества. ВЫВОДЫ: Результаты модифицированного дельфийского анализа, полученные независимыми экспертами, будут полезными для соавторов обсуждаемых методических рекомендаций перед плановым пересмотром.

Therapy of chronic pain syndrome and adequate perioperative pain management during treatment of malignant neoplasms are important problems at the current stage of clinical medicine development. Currently, multimodal pain management is effectively applied through drugs of various pharmacological groups prescribed depending on pain intensity in accordance with a digital rating scale. Associated adverse events as well as impossibility of using peroral or transdermal forms in some cases, limit the use of opioid analgesics. High bioavailability and fast absorption of μ1-opioid receptor agonist tafalgin shown during preclinical studies, relatively favorable safety profile allowed to use this drug in oncological clinic.An experience of using tafalgin in treatment of pain syndrome in patients with malignant tumors at the “Lapino” clinical hospital since 2022 is presented. The effectiveness of the drug is evaluated, and its niche in multimodal pain management is determined.

Intravenous leiomyomatosis is a smooth muscle tumor of unclear malignant potential capable of intravascular growth with varying levels of intravascular advancement. The only radical treatment method is surgical intervention requiring quality preoperative preparation and determination of optimal surgical tactics taking into account the level of damage. A description of a clinical case of intravenous leiomyomatosis with intracardial growth is presented

INTRODUCTION: The development of clinical and methodological recommendations improves the quality of medical care and reduces the risk of complications. OBJECTIVE: To analyze the methodological recommendations “Perioperative management of patients with coronary heart disease”, “Perioperative management of patients with concomitant pathology of the valvular heart apparatus” and “Perioperative management of patients with concomitant morbid obesity” using the modified Delphi method. MATERIALS AND METHODS: A modified Delphi method was used with two rounds of questionnaires to develop a consensus. The agreement of specialists was reached in three stages: the preparatory stage, the discussion stage and the stage of developing a consensus conclusion. RESULTS: When discussing the methodological recommendation “Perioperative management of patients with coronary heart disease”, a consensus was reached on 35 out of 37 provisions and 7 out of 8 criteria for the quality of medical care. The analysis of the methodological recommendation “Perioperative management of patients with concomitant pathology of the valvular heart apparatus” showed that 57 out of 60 provisions, as well as all 13 criteria for the quality of medical care, were agreed upon. The discussion of the methodological recommendations “Perioperative management of patients with concomitant morbid obesity” showed that 22 of the 23 provisions of the recommendation and all 5 quality criteria were agreed upon. CONCLUSIONS: The results of the Delphic examination, obtained as a result of a detailed analysis by independent experts, will be useful for the co-authors of the discussed methodological recommendations before the planned revision.

Endoscopic trachea stenting is a pressing issue in modern endoscopy. This method is applied in various diseases including benign stenoses associated with complications after long-term mechanical ventilation, malignant stenoses (oncological diseases of the trachea itself, compression from outside by esophageal or mediastinal tumors), post-injury stenoses and developmental defects.Currently, a certain contingent of patients exists for whom trachea prosthesis and its bifurcation remain the only possible option for stepwise or final treatment. If the lower third of the trachea, bifurcation zone or the main bronchi are affected, the optimal technique is stenting with Y-shaped stents which provide maximal patency of the airways.

BACKGROUND: Regional anesthesia for aortocoronary bypass surgery have shown promise in achieving reduced perioperative pain, need for systemic opioids, and improved surgical outcomes. However, use of neuroaxial anesthesia in cardiac surgery remains controversial due to the lack of studies. Parasternal blockade is a simple, effective technique that can be applied after cardiac surgery. CLINICAL CASE DESCRIPTION: This is a clinical case presenting the performance of bilateral parasternal blockade in the III–IV intercostal space using the «Single Shot» technique for a patient who underwent aortocoronary bypass surgery. Advantages of this technique are its ease of implementation, safety, and most importantly, effective distribution of local anesthetic in the parasternal interfascial space. This results in blockade of the anterior cutaneous branches of intercostal nerves from T2 to T6 that innervate the surgical area. CONCLUSION: Parasternal blockade is a technically simple, affordable, and promising method for analgesia after aortocoronary bypass surgery. Multicenter studies are required to further evaluate the efficacy of parasternal blockade postcardiac surgery.

Chronic pain syndrome developing in patients with oncological diseases significantly decreases their quality of life which makes effective integrative analgetic therapy a pressing issue. Currently, drugs of various pharmaceutical groups are used for pain management and administered subsequentially in accordance with the pain intensity visual analogue scale. For moderate and severe pain syndrome, opioid analgesics are used which have side effects limiting their use in some cases. Trials showed that new highly specific μ1-opioid receptor agonist tafalgin is characterized by high bioavailability, fast absorption, biotransformation, absence of accumulation which makes its safety profile favorable. Pronounced analgesic effect of tafalgin, as well as ease of administration and absence of significant adverse events, allow to significantly improve the quality of life of patients with chronic pain syndrome.

Adequate postoperative pain management remains a challenge. We discuss pathophysiology of pain after cardiac surgery and describe in detail multimodal and regional anesthesia, their advantages and disadvantages.

The high efficacy of the currently used combined chemoradiotherapy for Hodgkin’s lymphoma not only significantly increased overall survival, but also made it possible for most patients to achieve the same quality of life as in a healthy population. at the same time, the problem of identifying late treatment complications, in particular cardiovascular the high efficacy of the currently used combined chemoradiotherapy for Hodgkin’s lymphoma not only significantly increased overall survival, but also made it possible for most patients to achieve the same quality of life as in a healthy population. at the same time, the problem of identifying late treatment complications, in particular cardiovascular diseases, remains an urgent problem, the timely diagnosis of which is an important task. the development of a second malignant neoplasm and the appointment of drug antitumor therapy with cardiotoxic agents necessitate a multidisciplinary approach. In the presented clinical observation, such tactics of patient management made it possible not only to timely identify late cardiovascular complications of Hodgkin’s lymphoma chemoradiotherapy, but also to conduct treatment for the second malignant disease with cardiotoxic agents with a positive antitumor effect.

This paper describes the first experience of the department in using an electronic infusion pump in order to optimize and select an adequate and safe method of permanent analgesia in cardiac surgery patients in the perioperative period. Two clinical cases of using an infusion pump for continuous anesthesia are also presented.

Severe chronic pain syndrome with high requirement for opioids is frequently complicated by opioid tolerance, hyperalgesia, and other side effects. Special complications occur during anesthesia for high-injury surgical interventions and in the postoperative period. Perioperative pain management in these patients requires planning, multimodal approach, combination methods, and prevention of complications including specific complications. This article describes a case of successful surgical treatment of pancreatic cancer in a patient with severe chronic pain syndrome, opioid tolerance, and hyperalgesia. Perioperative period was complicated by high requirement for epidural pain management and use of adjuvants, acute strangulating intestinal obstruction on day 6 of the postoperative period. The authors had to differentiate between pain syndrome and abstinence multiple times and encountered the problem of tachyphylaxis to local anesthetics. Due to thought-out and flexible system of combination multimodal pain management, pain syndrome was relieved, and the patient was discharged in satisfactory condition without the need for opioids.

Pulmonary arteriovenous malformations are a rare congenital pathology observed in 2–3 individuals per 10,000, and 10 % of cases are diagnosed in children in the first several years of life. Arteriovenous malformations are vascular abnormalities of the cardiovascular system presenting as pathological anastomoses (shunts) between the arterial and venous systems which leads to direct shunting of nonoxygenated blood from the arterial bed into the venous bed bypassing pulmonary capillary network. Frequently, diagnosis of pulmonary arteriovenous malformations is made in rather neglected cases. Pulmonary arteriovenous malformations is hard to diagnose and treat, therefore it requires special attention from surgeons and clinicians which prompted us to describe a clinical case of a young 27-year old male patient with signs of significant chronic hypoxia (saturation (SpO2 ) – 84–86 %, hemoglobin level – 185 g/L, erythrocyte count – 6.13 million/μL, hematocrit – 51.8 %; during examination: acrocyanosis, nail clubbing; complaints of vertigo, decreased tolerance of physical activity, breathlessness during physical activity). Computed tomography in the S8, S9 segments showed arteriovenous malformation, size about 70 × 70 mm. Patient underwent radical treatment in the form of right lower thoracoscopic lobectomy which led to an immediate increase in oxygen saturation (SpO2 ) to 99 %. This clinical example shows that surgical method of treatment is the most radical, and thoracoscopic intervention in a young patient significantly decreases the volume of injury and promotes quick recovery and return to active life.

Plasma cell leukemia (PCL) is a rare malignant plasma cell neoplasm with aggressive clinical progression, minimal response to therapy and unfavorable prognosis. Concomitant new coronavirus infection COVID-19 and its complications significantly worsen prognosis in patients with PCL. Currently, approaches to PCL therapy are not finalized, and regimens developed for multiple myeloma are used. In PCL, the most common clinical symptoms are renal failure and hypercalcinemia which are frequently observed in multiple myeloma. Therefore, use of proteasome inhibitor (bortezomib) with proven effectiveness in multiple myeloma, is justified. A clinical observation of a 64-year-old female patient who was hospitalized in poor physical condition with the new coronavirus infection COVID-19 is presented. During hospitalization, debut of PCL was suspected, and as soon as possible after diagnosis confirmation using vital indications, antitumor drug therapy was started with positive effect.

In current conditions, increased life expectancy led to increased cancer morbidity. Presence of pain syndrome with significant intensity caused development of numerous guidelines on its treatment. Currently, pain management is based on the stepwise multimodal approach of the World Health Organization. In our opinion, wide application of narcotic analgesics is a disadvantage of this method. This pharmaceutical group has a significant number of adverse effects including addiction, development of hyperalgesia, and potential effect of increased rate of cancer recurrence.The study objective is to optimize the stepwise approach by addition of continuous multimodal analgesia. We aim to develop the principles of complex approach to pain management including new combinations of pharmaceuticals of different modalities and new techniques of continuous safe administration using innovative devices.The article presents a prospective description of a series of clinical cases in which new combinations of pharmaceuticals were administered in the context of complex treatment of pain syndrome of significant intensity. Objective evaluation of pain syndrome was performed using the Numeric Rating Scale.Multimodal intravenous pain management using mobile devices administering a mixture of pharmaceuticals in conjunction with basic peroral therapy and widely accepted discrete stepwise approach of the World Health Organization showed first positive results. In our opinion, further studies will allow to 1) decrease the rate of chronic pain syndrome in oncological patients; 2) treat pain syndrome of almost any intensity with preserved quality of life.The first results are encouraging; they show satisfactory effectiveness of the method and its safety. It is necessary to continue studies to develop and standardize the intravenous mixture composition for pain management in the context of the main clinical syndromes determining pain.

Recently due to significant successes in drug therapy of malignant tumors, the question of quality of life of patients has become more important. Cyclical drug treatment implies intravenous infusion of antitumor agents. Complications associated with this type of therapy include phlebitis and extravasation and, in some cases, lead to full obliteration of vessel lumen and vast skin and hypoderm necrosis. Multiple venous punctions can with time lead to significant technical difficulties in accessing the vein and limit the continuation of therapy. This drives the necessity to search for rational approaches to patient safety during both outpatient and inpatient antitumor drug treatment. To solve this problem, fully implanted venous port systems were developed and implemented in clinical practice which provide organization of aseptic continuous venous access, as well as infusion pumps (for independent prolonged intravenous therapy). Use of these devices allows for continuity and cycling of treatment process, significantly improves patients' quality of life by not limiting daily activities.In the article we present our experience of using microinfusion single-use mechanical systems for antitumor drug therapy and relief of intense pain syndrome in patients with malignant disorders of hematopoietic tissue and solid tumors.

Myeloma is an oncological disease characterized by uncontrolled formation of plasma cells in the bone marrow leading to destruction of bone tissue and accompanied by anemia and kidney failure. Morbidity is 1–2 % among all malignant tumors. Specific antitumor therapy in conjunction with bone marrow transplant allows to achieve satisfactory long-term outcomes. It should be noted that during therapy various complications are quite common, as well as exacerbation of concomitant pathology which can transform into a competitive disease at any moment. A clinical observation of treatment of a patient with myeloma and diverticulosis of the colon complicated by acute diverticulitis with paracolic infiltrate formation is presented.

Perforation of a hollow organ with development of peritonitis is a known complication of lymphomas often occurring during diagnosis or therapy. Frequency of perforations of the gastrointestinal tract in patients with lymphomas is 9 %. Presence of a perforation complicates treatment and can worsen disease prognosis. A clinical case of a patient with diffuse large B-cell lymphoma complicated by surgical pathology and infection is presented: perforation of the transverse colon, fibrinous septic peritonitis were detected during a diagnostic procedure (prior to morphological verification of the diagnosis), and COVID-associated pneumonia developed later. The selected treatment tactics despite the volume of surgical intervention and presence of infectious complications allowed to achieve improvement of the patient’s condition.

Immune thrombocytopenia is an immunosuppressed acquired disease characterized by low platelet levels in peripheral blood and an increased risk of bleeding. This pathology deserves special attention in cases of patients who are scheduled for surgery, which undoubtedly requires careful preparation of the patient for surgery and a complete laboratory analysis, including a thromboelastogram.This article describes the clinical case of successful surgical treatment of a patient with immune thrombocytopenia.

21 clinical cases of abdominal cancer surgery in patients with concomitant myasthenia gravis are combined with the use of the “pharmacological duet” of rocuronium ‒ sugammadex and the mandatory monitoring of neuromuscular conduction. In all cases, surgery procedures were performed under combined anesthesia with sevoflurane and low-dose epidural ropivacaine + fentanyl + norepinephrine. In all cases, except one, when the mechanical ventilation was planned and determined by the severity of the operation, blood loss and hypothermia, it was possible to reliably restore the spontaneous breathing immediately after the end of the operation. The necessity of an individual approach to patients suffering from myasthenia gravis, due to the difference in its severity and degree of compensation, is clearly shown. It was especially emphasized that with subcompensated state, incomplete efficacy of sugammadex is possible and additional intravenous administration of anticholinesterase drugs may be required (2 cases). In addition, in severe myasthenia gravis, a discrepancy is possible between “safe” TOF = 90% and clinical signs of residual respiratory failure (1 case).

The current development of oncological surgery requires maximum possible radical interventions both for the patients with concurrent conditions and those with large tumors. In thoracic surgery, provision of the adequate surgical access by the anesthesiologist is crucial, and first of all, it requires the full collapse of the operated lung for the whole time of surgery. A chest tumor often results in the changes of the trachea and main bronchi anatomy, compression of their lumen, which can make lung separation difficult. Introduction of double lumen tube with an integrated video camera into clinical practice is aimed to provide easy and reliable separation and isolation of the lungs in case of pathological changes in the trachea and main bronchi without control bronchoscopy. The article analyses 17 cases when double lumen tubes with video monitoring were used for oncological thoracic surgeries, assesses the results and opportunities for their use in the patients with the changed anatomy of the tracheobronchial tree. Video monitoring provides safe and fast intubation of the left main bronchus reaching the required depth, reduces the time of preparation for surgery and its duration providing good working conditions for surgeons.