Russian Sklifosovsky Journal "Emergency Medical Care"
“N.V. Sklifosovsky Research Institute for Emergency Medicine”
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Experience with the Use of Anti-Shock Cannulated Screws in Severe Pelvic Injuries
Background. In the structure of combined trauma, pelvic bone fractures occupy a significant part. Pelvic injuries are accompanied by the highest frequency of fatal outcomes than other injuries of the musculoskeletal system. The method of surgical treatment of pelvic bone fractures using cannulated screws is widely known among surgeons around the world and is successfully used for various categories of injuries. In some situations, this method is more advantageous in terms of restoring the stability of the pelvic ring, allows achieving greater interfragmentary compression, plays a significant role in stopping bleeding and serves as an effective anti-shock measure. Aim of study. To propose a new approach and prove its effectiveness in the treatment of victims with severe combined pelvic trauma in the acute period of injury, consisting of the use of cannulated screws for minimally invasive immersion fixation of unstable pelvic ring injuries. Materials and Methods. The article analyzes the treatment outcomes of 139 patients with unstable pelvic ring injuries treated in the I.I. Dzhanelidze St. Petersburg Research Institute of Emergency Care (level 1 trauma center) from 2016 to 2024, with signs of traumatic shock and ongoing intrapelvic bleeding. The patients underwent fixation of multiple pelvic bone fractures with cannulated screws upon admission to the anti-shock operating room. The following parameters were selected to assess the severity of the patients’ condition and the effectiveness of anti-shock measures: systolic blood pressure, body temperature, hemoglobin, red blood cell, hematocrit, platelet levels, coagulogram parameters (activated partial thromboplastin time, prothrombin time, prothrombin index, fibrinogen, international normalized ratio) and blood acid-base balance (pH, lactate, base deficit, and calcium ion concentration). In the group of patients under consideration, various combinations of sacroiliac screw placement were used: unilateral and bilateral placement, insertion into the body of S1 and (or) S2 vertebrae; and screws were installed in the supra-acetabular bone corridor (LC2 screws). The anterior pelvic half-ring was fixed both by immersion structures and by external fixation devices (combined osteosynthesis). Dependent samples were formed and indications were analyzed upon admission to the trauma center and 12 hours after surgery. Results. Early minimally invasive fixation of unstable pelvic ring injuries with cannulated screws contributed to the cessation of intrapelvic bleeding, which was statistically significantly confirmed by the results of a comparative analysis of clinical and laboratory parameters. Thus, there was stabilization of hemodynamic parameters (systolic blood pressure increased from 90 to 120 mmHg, p<0.05), positive dynamics of changes in hemoglobin levels (increase from 69 to 89 g/l, p><0.05), improvement of acid-base balance and tissue perfusion (increase in pH from 7.292 to 7.382; restoration of base deficit from -4.05 to -0.9 mmol/l; decrease in lactate levels from 3.4 to 2.05 mmol/l, p><0.05), as well as normalization of blood coagulation system parameters (increase in the prothrombin index according to Quick from 71 to 81%; increase in the level of ionized calcium from 0.74 to 0.89 mmol/l, p><0.05). Additional methods of surgical hemostasis (extraperitoneal tamponade, angioembolization ) were used only in a limited number (13.5%) of victims with severe combined pelvic trauma. The immediate treatment results (mortality, complications, bed-day in intensive care and trauma center ) corresponded to the literature data, while in all discharged victims verticalization was achieved within 4 to 2 weeks after pelvic immersion fixation. CONCLUSION Early minimally invasive fixation of pelvic bone fractures with cannulated immersion screws in severe combined pelvic trauma is a safe and highly effective therapeutic measure that helps to finally stop intrapelvic bleeding, relieve traumatic shock, and improve hemodynamics and tissue perfusion. Minimally invasive fixation of unstable pelvic injuries with cannulated screws located at the level of the sacroiliac joints and supraacetabular corridor (LC 2 screw) is an effective way to combat shock in these patients. The achieved clinical results indicate the advisability of using this technique in the acute period of traumatic disease and are consistent with modern literature data on this issue. Keywords: unstable pelvic ring injuries, pelvic bone fracture, sacroiliac screws, minimally invasive osteosynthesis, traumatic shock, polytrauma> < 0.05), positive dynamics of changes in hemoglobin levels (increase from 69 to 89 g/l, p < 0.05), improvement of acid-base balance and tissue perfusion (increase in pH from 7.292 to 7.382; restoration of base deficit from -4.05 to -0.9 mmol/l; decrease in lactate levels from 3.4 to 2.05 mmol/l,p < 0.05), as well as normalization of blood coagulation system parameters (increase in the prothrombin index according to Quick from 71 to 81%; increase in the level of ionized calcium from 0.74 to 0.89 mmol/l, p < 0.05). Additional methods of surgical hemostasis (extraperitoneal tamponade, angioembolization ) were used only in a limited number (13.5%) of victims with severe combined pelvic trauma. The immediate treatment results (mortality, complications, bed-day in intensive care and trauma center ) corresponded to the literature data, while in all discharged victims verticalization was achieved within 4 to 2 weeks after pelvic immersion fixation. Conclusion. Early minimally invasive fixation of pelvic bone fractures with cannulated immersion screws in severe combined pelvic trauma is a safe and highly effective therapeutic measure that helps to finally stop intrapelvic bleeding, relieve traumatic shock, and improve hemodynamics and tissue perfusion. Minimally invasive fixation of unstable pelvic injuries with cannulated screws located at the level of the sacroiliac joints and supraacetabular corridor (LC 2 screw) is an effective way to combat shock in these patients. The achieved clinical results indicate the advisability of using this technique in the acute period of traumatic disease and are consistent with modern literature data on this issue.
Comparative Effectiveness of Small Bowel Decompression Methods in Patients with Benign Small Bowel Obstruction: Results of a Multicenter Non-Randomized Controlled Retrospective Study
Introduction. The success of treatment of patients with acute intestinal obstruction is determined by many factors, including the correction of intra-abdominal hypertension and endotoxicosis by performing intraoperative decompression of the small intestine. Aim of Study. Evaluation of the effectiveness and safety of small intestinal decompression methods in patients with benign forms of small bowel obstruction. Material and Methods. The present work was conducted as a multicenter cohort retrospective study, including the analysis of treatment outcomes of 397 patients operated on for benign forms of intestinal obstruction, who underwent one of three types of intestinal decompression intraoperatively: placement of a gastric tube, intubation of the initial sections of the small intestine, and total intubation of the intestine. The study groups did not demonstrate significant differences in the main clinical, laboratory parameters, causes of intestinal obstruction, and intraoperative findings. Significant differences were revealed when comparing the degree of intestinal dilation and the resection nature of the intervention, that influenced both the choice of decompression method and, probably, the outcome of treatment - these parameters were taken into account as confounders. Conclusion. Carrying out total nasogastrointestinal intubation for decompressive purposes in patients with benign forms of intestinal obstruction was associated with the highest mortality (22.3% versus 7.0% in the group with nasogastric tubes, and 13.3% in the group with short intestinal tubes, p<0.001) even in the context of the comparative predominance of resection interventions in this group of patients. As for the other methods of intraoperative intestinal decompression, the data obtained do not allow us to make an unambiguous choice between the installation of a nasogastric tube or intubation of the initial parts of the small intestine, since when taking into account the main confounders, no significant differences in the studied outcomes were found in these groups of patients. Keywords: acute intestinal obstruction, nasogastric tube, nasointestinal tube, intestinal decompression> < 0.001) even in the context of the comparative predominance of resection interventions in this group of patients. As for the other methods of intraoperative intestinal decompression, the data obtained do not allow us to make an unambiguous choice between the installation of a nasogastric tube or intubation of the initial parts of the small intestine, since when taking into account the main confounders, no significant differences in the studied outcomes were found in these groups of patients.
Biomarkers for Predicting the Use of Selective Hemosorption of Lipopolysaccharides in Sepsis and Septic Shock
Abstract. Sepsis and septic shock are one of the most life-threatening complications with high mortality, reaching 70% in the presence of endotoxemia. Extracorporeal removal of lipopolysaccharides (LPS) can improve treatment outcomes. Aim. To evaluate the effectiveness of a group of biomarkers for predicting the use of selective hemosorption of lipopolysaccharides in patients with sepsis and septic shock. Material and Methods. The study included 22 patients (12 men and 10 women) who were treated at the N.V. Sklifosovsky Research Institute for Emergency Medicine from April 2022 to November 2023. Patients were examined within 72 hours after the development of sepsis. In the case of sepsis or septic shock, with an endotoxin activity assay (EAA) ≥0.6, 11 patients underwent LPS-selective hemoperfusion (LPS-HP) procedures. The values before hemoperfusion were analyzed in Group 1 (11 points), if LPS-HP was not used — in Group 2 (22 points). Results. The concentration of β-hydroxymyristic acid (β-HMA) in healthy volunteers was 2.95 (1.52; 5.08) ng/ml, and in patients with sepsis and septic shock 7.44 (4.50; 15.68) ng/ml (p=0.0001). The level of EAA was higher in Group 1 (0.780) compared to Group 2 (0.425), p=0.019. Differences were found between Groups 1 and 2 in the level of CRP: 290.0 and 166.5 mg/l, respectively (p=0.016). The percentage of lymphocytes (CD95+) was lower in Group 1 compared to Group 2: 24.8 and 44.2%, respectively (p=0.04). The SOFA score significantly correlated with the β-HMA level, the Spearman correlation coefficient r was 0.386, a moderate correlation was found between the β-HMA level and IL-6 (r=0.638), EAA and CRP (r=0.485), a negative correlation of CD 95+ lymphocytes with the level of IL-6 and CRP. Conclusion. 1. The β-HMA level in patients with sepsis and septic shock is 2.5 times higher than the values in healthy volunteers (p=0.0001). In the ROC analysis, AUC was 0.817 (95% CI 0.702; 0.933, p=0.0001), the cutoff point was 3.26 ng/ml. 2. Using the threshold values EAA≥0.6 c.u. allowed us to identify patients requiring LPS-selective hemoperfusion with statistically significant differences in the level of endotoxin activity (p=0.019) and CRP (p=0.016). At the same time, in the high EAA group, there was a tendency for an increase in the absolute value of the LPS level tested by β-HMA, the SOFA score was 13 points, compared with 9.5 points in the low EAA group. 3. In the high EAA group, a decrease in CD 95+ lymphocytes was established (p=0.033), which, together with a tendency towards lower values of HLA-DR expression on monocytes, may indicate the development of immunoparalysis and immune system dysregulation in these patients. 4. The β-HMA level correlated with the severity of organ dysfunction according to the SOFA score and IL-6 levels. EAA positively correlates with the level of CRP, and negatively correlates with IL-6. A positive correlation of IL-6 with CRP and a negative correlation with the level of CD 95+ lymphocytes were established. CRP negatively correlated with CD 95+ lymphocytes.
New Markers for Determining the Severity of Intoxication in Patients with Complicated Forms of Acute Appendicitis
Background. Acute destructive appendicitis has been and remains the most important factor in the mortality structure of surgical patients with bacterial abdominal infection. Among the factors significant for diagnostics are the severity of intoxication The markers include the iron-containing protein lactoferrin (LF) and its positively charged fragment, lactoferricin (LFC). The Aim of Study. To study the relationship between serum levels of LF and LFC and the severity of endotoxicosis in patients with various forms of acute destructive appendicitis. Material and Methods. In blood serum samples of 45 patients with destructive forms of appendicitis of varying severity after laparoscopic or laparotomic The concentrations of Lf protein and Lfc peptide were studied after appendectomy. Results. When studying the levels of LF and LFC in patients with acute destructive appendicitis, it was found that their levels differ from the figures in donors by 3 times for both LF and LFC. Conclusion. 1. In acute complicated appendicitis, including that complicated by peritonitis, a statistically significant increase in the concentration of lactoferrin protein and lactoferricin peptide relative to the norm is observed in the blood serum, and in peritoneal exudate. 2. In patients with acute destructive appendicitis, lactoferrin levels in peritoneal exudate statistically significantly exceed serum levels of the same patients by 3–4 times, and lactoferricin levels in parallel samples do not differ from each other. 3. According to the data obtained in the work, the levels of LF and LFC after laparoscopic appendectomy are not statistically significantly different from levels after laparotomy appendectomy and depend only on the severity of the patient’s condition.
An Algorithm for Analyzing Computed Tomography Images in Case of Suspected Strangulation in Adhesive Intestinal Obstruction
Introduction. Adhesive intestinal obstruction is responsible for up to 2.4% of all laparotomies. The choice of patient management strategy directly depends on whether there are indications (including CT findings) of intestinal obstruction and/or ischemia of the intestinal wall. The Aim of Our Study. Identification of CT signs that are reliably associated with ischemic intestinal changes, and CT predictors of irreversible intestinal changes that may require surgical resection. Material and Methods. The study used 53 retrospective CT scans of the abdomen with intravenous contrast enhancement, performed at the time of admission on patients undergoing surgery for adhesive obstruction. These scans were evaluated for the following signs: the presence of the “beak” sign in the transition zones, the thickness of the intestinal wall, a decrease in contrast of the intestinal wall, local edema of mesenteric tissue, the presence of “closed-loop” obstruction, a small-bowel faeces sign, and the “fat-notch” sign. Results. The study found that a thickened intestinal wall, a prominent “beak” at two adjacent points, the presence of a “closed loop” obstruction, and poor contrast between the intestinal wall and a small-bowel faeces sign were all independent predictors of the need for intestinal resection. Based on the obtained results, an algorithm for visual assessment of the intestine on CT of abdominal organs in patients with adhesive intestinal obstruction was proposed. Conclusion. Using the method of computed tomography with intravenous contrast enhancement and visual analysis of the obtained tomograms according to the proposed algorithm, it is possible to detect signs of strangulation and adhesive intestinal obstruction with sensitivity of 69%, specificity of 97%, and accuracy of 88%.
The FOUR vs Glasgow Scale for Monitoring the Transition from Acute to Chronic Impairment of Consciousness in the ICU
Introduction. Management of a patient with chronic disorders of consciousness (DOC) requires establishing a correct diagnosis, dynamic assessment, intensive care, and scientifically based prognosis. It is also important to monitor the recovery from coma and the development of chronic DOC. The Glasgow Coma Scale (GCS), a “gold standard” that has been widely used in research and clinical practice for 50 years, has a number of obvious significant drawbacks: brainstem reflexes, eye movements or complex motor responses in patients with altered consciousness are not assessed, which precludes the possibility of reliably assessing the condition of a patient with subtentorial damage and in the state of DOC. In this regard, the FOUR scale has been added to the GCS in recent years, which has the advantages of greater sensitivity to the neurological status in patients with acute cerebral insufficiency (ACI); and due to the high prognostic value of the scale in patients with an unfavorable outcome, it has prospects for continued use in patients with DOC. Aim of the Study was to study the sensitivity and specificity of the FOUR scale as clinical metrics for assessing chronic DOC. Material and Methods. This work is a continuation of the study: “FOUR scale as specific clinimetric in intensive care and rehabilitation of patients with acute cerebral insufficiency — FOURACI”. The study cohort included 33 patients over 18 years of age with acute cerebral insufficiency, with further recovery from coma and formation of chronic disorders of consciousness. Results. FOUR scale has high correlation with CRS-R (p<0.0001, Spearman correlation coefficient r=0.8946), high sensitivity and specificity in predicting outcomes (AUC=0.936). CONCLUSION The high proven correlation with the CRS-R reference standard allows the FOUR scale to be used as an alternative of GCS tool at the time of coma recovery and chronic disorders of consciousness formation. And in case of insufficient experience and/or negative dynamics of the patient’s condition, FOUR can be used as an auxiliary, simpler and less time-consuming scale for dynamic assessment of consciousness. Keywords: GCS, coma, chronic disorders of consciousness, FOUR, CRS-R, Coma Recovery Scale (revised))> < 0.0001, Spearman correlation coefficient r=0.8946), high sensitivity and specificity in predicting outcomes (AUC=0.936). Conclusion. The high proven correlation with the CRS-R reference standard allows the FOUR scale to be used as an alternative of GCS tool at the time of coma recovery and chronic disorders of consciousness formation. And in case of insufficient experience and/or negative dynamics of the patient’s condition, FOUR can be used as an auxiliary, simpler and less time-consuming scale for dynamic assessment of consciousness.
Effect of Cardiac Resynchronization Therapy on Reverse Left Ventricular Remodeling in Patients with Functional Class II Heart Failure
Introduction. Implantation of a cardioverter-defibrillator reduces the risk of sudden cardiac death caused by the development of ventricular tachycardia (VT) and ventricular fibrillation (VF) of the heart, but implantation of this device does not improve the function of the left ventricle (LV). Modern implantable cardioverter-defibrillators (ICD) with endocardial electrodes allow for optimal treatment of cardiac arrhythmias in heart failure (HF) due to the function of electrical cardiac pacing. Cardiac resynchronization therapy (CRT) is aimed at synchronizing contractions of the opposite walls of the LV, which leads to an improvement in the inotropic function of the heart, and subsequently to reverse remodeling of the LV geometry. The obtained results of the study made it possible to determine whether there was an improvement in volume changes, cardiac function and shock rate when using CRT in combination with an ICD (CRT-D) in patients with HF accompanied by LV dysfunction and a wide QRS complex. Aim of Study. To assess whether CRT in combination with ICD has an effect on LV reverse remodeling in patients with functional class (FC) II HF. Material and Methods. A total of 35 patients with a wide QRS complex >130 ms were included in the study: 15 patients in the CRT-D group and 20 with ICD. The obtained results of the study were interpreted one year after the start of treatment in all patients. Changes in the volumes and contractility of the ventricles of the heart were analyzed in both groups. An assessment was made of the dependence of these changes on the results of treatment in subsequent years. Results. In patients in the CRT-D group, compared with the ICD group, there was an improvement in the LV end-diastolic volume index (-18.7 vs. 8.6 ml/m2), LV end-systolic volume index (-22.5 vs. 5.2 ml/m2), LV ejection fraction (13.2 vs. 0.4%), left atrial volume index (-16.8 vs. 2.7 ml/m2), and pulmonary artery systolic pressure (-11.4 vs. 1.4 mmHg), p<0.05 for all parameters. The improvement in LV functional parameters 1 year after treatment was reflected in a decrease in mortality and recurrence of HF in these patients in the long-term period (13% in the CRT-D group vs. 50% in the ICD group, p><0.05). During the first year of observation, one to two shocks for VT/VF were administered in two patients with CRT-D and three patients with an implanted ICD. During the subsequent threeyear observation period, the defibrillation function was activated in two more patients in the CRT-D group and in two patients with an implanted ICD. CONCLUSION Cardiac resynchronization therapy combined with an implantable cardioverter -defibrillator improves cardiac performance in patients with class II heart failure. Our study demonstrated a decrease in end-diastolic volume, end-systolic volume, left atrial volume, an increase in left ventricular ejection fraction, and an improvement in right ventricular function in patients treated with combined cardiac resynchronization therapy and an implantable cardioverter -defibrillator compared with those treated with an implantable cardioverter -defibrillator alone. These results were consistent with improved outcomes, and outcomes at 1 year were directly related to the degree of improvement in ventricular volumes and function. Keywords: cardiac resynchronization therapy, left ventricular remodeling, heart failure> < 0.05 for all parameters. The improvement in LV functional parameters 1 year after treatment was reflected in a decrease in mortality and recurrence of HF in these patients in the long-term period (13% in the CRT-D group vs. 50% in the ICD group, p < 0.05). During the first year of observation, one to two shocks for VT/VF were administered in two patients with CRT-D and three patients with an implanted ICD. During the subsequent three-year observation period, the defibrillation function was activated in two more patients in the CRT-D group and in two patients with an implanted ICD. Conclusion. Cardiac resynchronization therapy combined with an implantable cardioverter -defibrillator improves cardiac performance in patients with class II heart failure. Our study demonstrated a decrease in end-diastolic volume, end-systolic volume, left atrial volume, an increase in left ventricular ejection fraction, and an improvement in right ventricular function in patients treated with combined cardiac resynchronization therapy and an implantable cardioverter -defibrillator compared with those treated with an implantable cardioverter-defibrillator alone. These results were consistent with improved outcomes, and outcomes at 1 year were directly related to the degree of improvement in ventricular volumes and function.
Types of Surgical Interventions Performed for Various Neck Injuries in Civilian Medical Facilities in the Context of a Localized Military Conflict
Relevance. Despite a sufficiently large number of works, the number of patients with neck wounds does not decrease due to unfavorable criminal situation and the presence of localized military conflicts. The Aim of the Study. To analyze the main types of surgical interventions performed for various neck wounds in a civilian medical institution in the conditions of localized military conflicts. Materials and Methods. The study is based on a retrospective analysis of the treatment of 214 patients with various neck injuries who were treated at the surgical ward of City Hospital № 9 in Grozny, Chechnya, from 1991 to 2000. All patients were divided into two groups: 129 were in the group with gunshot wounds and 112 were in the group with stab wounds to the neck. The mean age was 35 ± 5 years, with males predominating (78%). Results. It was found that in 25 (19,3%) cases, operations were performed under local anesthesia, and in 45% of this number anesthesia was given. When anesthesia was performed, in the majority of cases - 84% - there was tracheal intubation, in the rest - intravenous anesthesia was used. The main types of operations performed on the wounded in the neck were typical tracheostomy without laryngeal and tracheal suture in 26,3%; atypical tracheostomy without laryngeal and tracheal suture in 16,2%; laryngeal and tracheal suture with tracheostomy in 13,1%; and diagnostic revision of the internal structures of the neck, which was performed in 12,4% of cases. In addition, thoracotomy was performed in 10.8% of observations, in which, most often, suturing of esophageal wounds was performed. Conclusion. The conducted study confirmed the list of the main types of operations that surgeons resort to in the treatment of patients with gunshot wounds to the neck, admitted to a medical institution in an emergency in the conditions of a localized military conflict. Those operations include typical tracheostomy without laryngeal and tracheal suture; atypical tracheostomy without laryngeal and tracheal suture; laryngeal or tracheal suture with tracheostomy; and diagnostic revision of the internal structures of the neck.
Effectiveness of Safety Control in Surgical Care for Patients with Abdominal Sepsis
Relevance. Improving surgical outcomes in patients with abdominal sepsis, including enhancing the quality and safety of care by preventing diagnostic and treatment-related errors, remains a top priority in emergency medicine. Aim of the Study. To perform a comparative clinical analysis of the effectiveness of surgical safety control based on the implementation of an improved checklist titled “Preventive Measures Checklist for Defects in Surgical Care for Abdominal Sepsis”. Material and Methods. This retrospective and prospective controlled clinical study included 49 patients with abdominal sepsis resulting from secondary postoperative diffuse purulent peritonitis. The patients received comprehensive treatment programs that involved different approaches to controlling and preventing surgical care defects. In the comparison group A (31 patients), the improved checklist was used retrospectively by analyzing primary medical records to identify previously occurred defects in surgical care. In the main group B (18 patients), the same checklist was applied prospectively during the actual surgical care process. Results. The controlled comparative clinical study demonstrated a statistically significant reduction in the number of surgical care defects, the severity of endogenous intoxication, the incidence of postoperative complications, and the duration of hospital stay in patients with abdominal sepsis when the improved checklist was integrated into the treatment protocol. Conclusion. Prospective application of the improved surgical safety checklist significantly reduced the frequency of documentation errors from 38.7–67.7% to 11.1–0% (p<0.05); diagnostic errors from 80.6% to 0% (p><0.05); preoperative and intraoperative management errors from 19.4–74.2% to 16.7–0% (p><0.05); and postoperative care errors from 6.5–83.9% to 11.1–0% (p><0.05). > < 0.05); diagnostic errors from 80.6% to 0% (p < 0.05); preoperative and intraoperative management errors from 19.4–74.2% to 16.7–0% (p < 0.05); and postoperative care errors from 6.5–83.9% to 11.1–0% (p < 0.05). The effectiveness of the improved surgical safety checklist is further evidenced by a significant decrease in serum markers of endogenous intoxication (p < 0.05), increased bioelectrical activity of the small intestine (p < 0.05), and reduced postoperative complications — including intra-abdominal abscesses (from 45.2% to 11.1%, p=0.05), eventrations (from 35.5% to 0%, p=0.03), and pulmonary complications (from 61.3% to 11.1%, p=0.05). The length of hospital stay among survivors also decreased significantly from 39.3±2.1 to 22.5±1.1 days (p=0.002).
Threshold Levels of Monocyte Chemoattractant-1 for Determining Phenotypes of Children with Cerebral Palsy
Aim of the Study. To establish threshold levels of monocyte chemoattractant -1 for determining phenotypes in children with cerebral palsy (CP). Material and Methods. The work was carried out in the period from 2018 to 2022 at the Department of Faculty Pediatrics of the Federal State Budgetary Educational Institution of Higher Education Astrakhan State Medical University of the Ministry of Health of the Russian Federation, State Budgetary Healthcare Institution of the Astrakhan Region N.N. Silishcheva Regional Children’s Clinical Hospital, and State Autonomous Institution of the Astrakhan Region Astrakhan Regional Children’s Clinical Center Rus. The study involved 128 children with different clinical forms of cerebral palsy. The level of monocyte chemoattractant1 was determined by enzyme immunoassay using a diagnostic reagent kit from Vector-Best (Novosibirsk). Statistical analysis was performed using IBM SPSS Statistics 26.0 (USA). Results and Discussion Based on the conducted examination, two phenotypes of children with cerebral palsy were distinguished. Among children of the first phenotype, higher concentrations of monocyte chemoattractant-1 in the blood serum were revealed. Thus, in patients of the first phenotype it was 2.1 (1.63; 2.99) pg/ml, which was statistically significantly (p<0.001) higher than in children of the second phenotype, 1.71 (1.44; 2.06) pg/ml. Using ROC analysis, the threshold level of monocyte chemoattractant-1 for determining belonging to the first or second phenotype was identified. It was 1.89 pg/ml. If the values exceed the specified one, the patient can be attributed to the first phenotype, with lower or equal values — to the second phenotype. CONCLUSION As a result of the conducted studies, a threshold level of MCP-1 was identified, amounting to 1.89 pg/ml. In patients of the first phenotype, possessing the most unfavorable prognostic characteristics, the values of monocyte chemoattractant-1 are higher than the specified indicator, which allows for the organization of rehabilitation measures at an earlier date. Keywords: cerebral palsy, monocyte chemoattractant, comorbid pathology> < 0.001) higher than in children of the second phenotype, 1.71 (1.44; 2.06) pg/ml. Using ROC analysis, the threshold level of monocyte chemoattractant-1 for determining belonging to the first or second phenotype was identified. It was 1.89 pg/ml. If the values exceed the specified one, the patient can be attributed to the first phenotype, with lower or equal values — to the second phenotype. Conclusion. As a result of the conducted studies, a threshold level of MCP-1 was identified, amounting to 1.89 pg/ml. In patients of the first phenotype, possessing the most unfavorable prognostic characteristics, the values of monocyte chemoattractant-1 are higher than the specified indicator, which allows for the organization of rehabilitation measures at an earlier date.
Ultrasound Diagnosis of Acute Mesenteric Ischemia
Relevance. Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate despite advances in diagnosis and treatment methods. There is a perception in the scientific community that the use of ultrasound to assess mesenteric vascular status is not sufficiently informative, and does not provide a complete picture of intestinal wall perfusion. The Aim of the Study. To evaluate the effectiveness of ultrasound in diagnosis and its impact on treatment outcomes in patients with acute mesenteric ischemia. Material and Methods. The work is based on the retrospective study of the results of examination and treatment of 36 patients with mesenteric ischemia at the N.V. Sklifosovsky Research Institute for Emergency Medicine for the period of 2022–2024. To assess the reliability of ultrasound data in diagnosing intestinal wall blood supply disorders in AMI with the results of the intraoperative picture, comparative information content with multispiral computed tomography (MSCT), all patients included in the retrospective study were divided into two groups: Group No. 1 — patients who underwent ultrasound examination by a physician with more than 10 years of experience; Group No. 2 — patients who underwent ultrasound examination by a specialist with less than 10 years of experience. Results. In diagnosis of ischemic changes of the intestinal wall in acute intestinal failure (AIF), the MSCT method showed a sensitivity of 80% [60–90%], specificity of 81% [51–96%], which did not statistically significantly differ from the sensitivity and specificity of ultrasound in Group No. 1 (p=0.598 and p=0.572, respectively). In the diagnosis of intestinal wall necrosis in AIF, the MSCT method showed a sensitivity of 50% [2–95%], specificity of 95% [91–100%], which did not statistically significantly differ from the sensitivity and specificity of ultrasound in Group No. 2 (p=1.000 and p=0.411, respectively). The sensitivity of the ultrasound method in Group No. 2 was significantly lower than in Group No. 1 and MSCT (p=0.318). Conclusion. The obtained data indicate that ultrasound is a more preferable method of diagnosis, especially in conditions of limited resources or the need for examination of non-transportable patients, patients with multiple organ failure. The key factor determining the quality of diagnosis when using the ultrasound method is the high qualification of sonographers.
ST-segment Elevation Myocardial Infarction. Study Data
Relevance. Kardiovascular diseases remain the leading cause of disability and mortality among people of all ages, not only in Russia, but also in other developed countries. Death from myocardial infarction occurs from its complications. The creation of vascular centers in the Russian Federation, as well as the use of modern technologies for the provision of specialized care for acute coronary syndrome (ACS) have clearly led to a decrease in cases of complicated myocardial infarction and mortality rates from them in general. At the same time, the still fairly frequent occurrence of these life-threatening conditions requires further efforts to improve the quality of their diagnosis and treatment. Aim of Study. To study the course of complicated myocardial infarction (MI) and assess the frequency of its early and late complications. Material and Methods. The study included 2,172 patients who were treated in the emergency cardiology department for patients with MI of the N.V. Sklifosovsky Research Institute for Emergency Medicine for the period from 2011 to 2021 with complicated MI. This cohort accounted for 79% of the total number of hospitalized patients (n=2,741) during the specified observation period. All patients underwent the necessary diagnostic methods and received treatment at a modern level. Results. The article presents information on the treatment outcomes of patients with complicated MI for the period from 2011 to 2021. The frequency of various MI complications was analyzed, taking into account the modern approach to providing specialized care to patients with ACS within the regional vascular center. As a result of the study, complications in acute myocardial infarction, their frequency of development were studied and algorithms for optimizing the modern approach to diagnosis, prevention and treatment of these complications were developed. The study noted a statistically significant decrease in the frequency of such complications by 1.5–15 times in most cases, especially early post-infarction angina, left ventricular aneurysm formation, mechanical myocardial damage (myocardial ruptures), as well as the development of Dressler syndrome. Conclusion. It has been established that as specialized care for patients with acute coronary syndrome with ST segment elevation improves within the framework of the network of vascular centers, a decrease in the number of complications at different stages of the disease and mortality in general is observed. However, complications such as cardiogenic shock and heart failure dictate the need for further study and development of modern methods for their prevention and treatment.
The Level of Emotional Dysadaptation in Patients with Cerebral Meningiomas at the Stage of Preparation for Stereotactic Radiosurgery
Relevance. Stereotactic radiosurgery is the method of choice for asymptomatic cerebral meningiomas of small size. The psychoemotional state of patients diagnosed with cerebral meningioma for whom indications for stereotactic radiosurgery have been determined is poorly understood. The study of a real traumatic situation, the assessment of the level of emotional maladaptation of patients and the identification of factors contributing to its development are an important task for clinical psychology and neurosurgery. The Aim of Study. To assess the level of emotional maladaptation in patients with cerebral meningiomas at the stage of preparation for stereotactic radiosurgery. Material and Methods. The sample consisted of 57 patients aged 30 to 85 years with cerebral meningiomas. Psychological diagnostics was performed before stereotactic radiosurgery at the Radiosurgery Center of the N.V. Sklifosovsky Research Institute of Joint Venture. The following techniques were used: Holland’s modified “Distress Thermometer” technique, PCL-5, Beck depression scale, Spielberger-Khanin anxiety scale. Computer processing of the results was carried out in IBM SPSS Statistics 23. Results. A high level of situational anxiety was revealed on the eve of stereotactic radiosurgery in 32% and personal anxiety in 42% of patients. Symptoms of depression of varying severity were detected in 44% of patients. Moderate severity of symptoms of post-traumatic stress disorder in 19%, high in 4%. A high level of situational anxiety on the eve of surgery is twice as common in young patients as in the elderly (44% versus 22% in the elderly). Conclusion. In patients with cerebral meningioma, at the stage of preparation for stereotactic radiosurgery, manifestations of emotional maladaptation are noted, expressed by symptoms of depression, post-traumatic stress disorder, high levels of subjectively perceived stress, situational and personal anxiety. The subjective assessment of the level of perceived stress and situational anxiety on the eve of stereotactic radiosurgery is influenced by the age of patients.
Mechanical Circulatory Support in Patients with End-Stage Heart Failure: a Literature Review (Part 1)
Chronic heart failure (CHF) is a progressive and irreversible syndrome that develops against the background of structural and functional disorders of the heart. It is accompanied by a decrease in cardiac output, pressure overload and a high level of hospitalizations, which makes CHF one of the key medical and social problems of our time. In recent decades, the prevalence of CHF has been steadily increasing, especially among the elderly population, which is associated with an increase in life expectancy and an improvement in the quality of medical care. According to forecasts, by 2050 the number of patients will increase by 50-60% compared to 2010. The terminal stage of CHF is characterized by an extremely unfavorable prognosis: survival does not exceed 25-30%. Heart transplantation (HT) remains the only radical treatment method that can significantly improve survival and quality of life. However, the shortage of donor organs and the growing number of patients necessitate the use of mechanical circulatory support (MCS) as a temporary or long-term alternative. MPC systems act as a “bridge” to transplantation, allowing for hemodynamic stabilization and organ function support before surgery. The most common short-term support technologies are extracorporeal membrane oxygenation (ECMO), intra-aortic balloon pump (IABP), and temporary axial pumps (Impella, TandemHeart). ECMO provides both respiratory and hemodynamic support, but is associated with a high risk of complications and relatively low survival. IABP is the most accessible method, improving coronary perfusion, but provides limited support. Impella devices demonstrate higher efficiency, unloading the left ventricle and improving systemic hemodynamics, while being characterized by fewer complications. TandemHeart provides a comparable effect, but requires a more complex installation technique. The choice of MPC method depends on the patient’s condition, the severity of multiorgan dysfunction, the availability of equipment, and the qualifications of the specialists. Current research confirms that a combination of different devices (e.g., ECMO and Impella) can improve outcomes. Thus, mechanical circulatory support occupies a central place in the treatment of terminal heart failure in conditions of limited donor resources, allowing to gain time before transplantation and reduce mortality on the waiting list.
Perioperative Nutritional Support and Management of Patients with Proximal Femur Fractures with Senile Asthenia
Introduction. Due to the development of medical technologies, improvement of the quality of medical care, progress in the field of disease prevention and lifestyle changes, the average life expectancy is constantly increasing. With age, bones become more fragile and prone to fractures; most often the proximal femur is damaged. Femoral fractures occur, as a rule, due to a fall on a flat surface, and mainly in people over the age of 60 years. It should be borne in mind that proper nutrition is one of the key components of treatment and recovery of the body. Patients in hospital may experience various digestive and appetite problems or have additional nutritional needs. Poor nutrition and insufficient protein intake can be a particularly important risk factor for hip fracture, and is often considered to be the cause of a high incidence of fracture complications in the elderly. Among various general geriatric pathologies, sarcopenia syndrome has attracted special attention in recent years, because its development leads to deterioration in the quality of life, and increases the risk of falls and complications after injury. Perioperative nutritional support plays an important role in the recovery of patients with senile asthenia and fractures of the proximal femur. A comprehensive multidisciplinary approach to the treatment of patients with senile asthenia and fractures of the proximal femur restores ability of self-care and limb support, raises the vitality and improves psychological state of the patient. The Aim of the review is to determine the role of perioperative nutritional support in the management of patients with fractures of the proximal femur and concomitant sarcopenia. Material and Methods. To write this review, we used the following electronic databases of scientific literature: PubMed, Cochrane Library, eLibrary, and Cyberleninka. The papers published in the period from January 1995 to May 2024 on the influence of sarcopenia on the incidence of postoperative complications, mortality rate and overall survival in elderly patients with fractures of the proximal femur were considered. Thanks to the review, it was indicated that so far there is no single view on a comprehensive multidisciplinary approach to the treatment of those patients, who should be carefully examined in order to identify nutritional deficiencies. There is also no complete perioperative algorithm in the available literature; and the issue of medical and social rehabilitation of this complex category of patients has not been resolved. Conclusion. There is a need to create such an algorithm that includes methods for screening and diagnosing nutritional insufficiency in elderly patients with fractures of the proximal femur.
Possibilities of Using Artificial Intelligence Technologies in Prehospital Trauma Care
The use of artificial intelligence in the prehospital stage of trauma care is feasible and has great potential. Artificial intelligence technologies can reduce the time of emergency medical care, make objective decisions on triage, evacuation and treatment of victims, facilitate coordination of actions and optimal distribution of rescue services resources in peacetime, emergency situations and combat operations. Artificial intelligence algorithms using computer vision, natural language processing and mobile wireless sensor systems expand the capabilities of remote search and remote medical triage of victims. Artificial intelligence systems developed on the basis of machine learning algorithms significantly outperform traditional triage tools in the accuracy of identifying victims with severe trauma who require emergency surgery and intensive care. Artificial intelligence can reduce the number of errors, but does not replace the professional experience of a specialist providing prehospital care, and only provides an additional tool to support decision making. Further exploration of the potential for using artificial intelligence technologies in real-world prehospital trauma care settings is needed.
On the Issue of Automation of Electronic Documentation in the Anesthesiology and Resuscitation Service
Abstract. The current stage of healthcare development is characterized by the widespread introduction of medical information systems with the unification of technological processes and a complete transition to electronic document management; one of the most important components of which is the automatic maintenance of electronic medical records. However, today, real practice is facing a number of challenges and problems, the solution of which is becoming a top priority. The Aim of the Study. was to analyze the current state of digitalization of the anesthesiology and resuscitation (A&R) services in the country’s medical institutions towards the introduction of automated document management. Material and Methods. An expert assessment of the digitalization of A&R services (departments) of 235 multidisciplinary hospitals was conducted, including the evaluation of its level, leading components and their structure in the overall sample. Information from a multicenter questionnaire study approved by the Federation of Anaesthesiologists and Reanimatologists of Russia was used. Results. The study showed that the functionality of the medical information system in each particular hospital differs depending on the developer and the technical capabilities of the hospital itself. The study revealed that electronic document management in the field of A&R, including fully automated ones, is currently fraught with a number of problems (barriers), including technical difficulties, the need for staff training, issues of confidentiality and data security. Conclusions. Automated electronic document management requires a comprehensive solution to issues of hardware and software, connection of special equipment, and personnel training. In addition, the successful integration of electronic A&R records into medical practice requires active cooperation from all stakeholders: medical staff, IT specialists, medical institution administration, and health authorities.
Development of an Approach to Assessing the Feasibility of Implementing Options for Improvement within the Framework of the Organizational Development System of a Multidisciplinary Hospital
At the current stage of healthcare development, one of the most important factors for the success of medical organizations is the presence of an effectively functioning system of organizational development. The paper presents an organizational and methodological approach developed by the authors to substantiate the feasibility of implementing blitz and cross-structural proposals for development as the most important element of the system of organizational development of medical and diagnostic processes of a medical institution. The presented approach includes algorithms and organizational schemes for making appropriate decisions, as well as approaches to quantitative, including cost, assessment of typical effects from the implementation of relevant projects. The paper also presents the results of testing the organizational and methodological approach, conducted on the basis of proposals for improving the N.V. Sklifosovsky Research Institute of Emergency Medicine of the Moscow Health Department, which confirmed its applicability and efficiency.
Regional Model of Mass Training of the Population in First Aid
Despite the process of improving the regulatory framework and methodological foundations of first aid training, the practical implementation of these initiatives faces a number of serious obstacles. The purpose of the study is to analyze the possibilities of developing mass training of the population in first aid techniques at the regional level. The research methods used were content analysis of the regulatory and legislative framework, sociological and analytical methods. In the Ryazan region in 2022-2024, monitoring of first aid skills among specialists of educational, healthcare and social support institutions was organized through the Google electronic survey service Forms, according to the results these specialists noted the lack of confidence in the correctness of the actions taken when performing first aid manipulations. Monitoring showed the initial level of first aid skills among respondents and made it possible to develop ways to introduce and implement a first aid training methodology. Based on the analysis of the monitoring and current regulatory legal acts, the regional program of the Ryazan region “First Aid for Everyone” for 2024-2026 and programs for training the population in first aid techniques were developed, according to which 39,328 residents of the Ryazan region were trained, which is 3.6% of the total population of the Ryazan region. A large proportion of students were residents of the territories most remote from the regional center. The training of first aid teachers and instructors was carried out from among pedagogical and medical workers on the basis of the regional medical university, which ensured a high-quality personnel, material, technical and methodological base for training. The choice of this contingent of students in combination with the presented training base provided an opportunity for the subsequent transmission of the acquired competencies to wide sections of the population.
Experience of a Multidisciplinary Hospital in Implementing Organizational Development Measures Using Artificial Intelligence Technologies
Relevance. Currently, an essential factor in the success of medical organizations is the presence of an effective system of organizational development, which provides for the use of modern technologies in the implementation of various improvement initiatives. From the standpoint of organizational development, there is great potential for the analysis and prevention of various undesirable events in a medical organization, including patient falls. This task is currently one of the most pressing, both in terms of optimizing the treatment and diagnostic process and in the economic aspect. The paper presents the experience of the N.V. Sklifosovsky Research Institute for Emergency Medicine of the Department of Health of Moscow in using artificial intelligence technologies to reduce the risks of undesirable events associated with a patient’s stay in a hospital (in particular, patient falls), and, as a result, to reduce the time of a patient’s stay in a hospital and the costs of his treatment. The paper also considers the impact of the use of artificial intelligence technologies on the possibility of reducing the workload of nursing staff. Aim of Study. To study the trend in the number of cases of adverse events associated with the stay of patients (in particular, patient falls) when using artificial intelligence technologies for their analysis, and to determine the potential economic efficiency of using artificial intelligence in the management of adverse events for the emergency hospital complex (EHC) of a multidisciplinary hospital. Material and Methods. An analysis of 34,876 cases of patient stay in the emergency and diagnostic departments of the N. V. Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health for the purpose of identifying cases of adverse events (patient falls). The obtained data were examined in their economic and social aspects using statistical methods. Results. Based on the results of the analysis of data obtained using artificial intelligence technologies, a trend was identified for the occurrence of adverse events associated with the stay of patients in the hospital (patient falls) on the territory of the emergency hospital complex. As a result of the development and implementation of a number of organizational measures, the identified trend was leveled. A medical and social portrait of a patient at risk of falling was compiled, which, in turn, also contributed to improving the statistics of adverse events. Conclusions. Artificial intelligence is not only an effective tool in the management of adverse events, but also improves the quality of the treatment and diagnostic process as a whole.
Assessment of Financial Performance Indicators of Emergency Medical Services Before and After Merging into a Single Legal Entity
Abstract. In the Russian Federation, organizational models of emergency medical services (hereinafter referred to as EMS) vary depending on the region. In some regions, single legal entities have been created, in others — centralized dispatch services, and in a number of cases, substations remain part of district hospitals without functional integration. The Aim of the Study. Assessment of the economic effect of the unification of emergency medical services into single legal entities using the example of five regions: Belgorod, Kursk, Kirov, Tula and Orenburg regions. Research Objectives. Analyze financial indicators before and after the merger for the following regions: Belgorod Region, Kursk Region, Kirov Region, Tula Region, Orenburg Region. Material And Methods. The study used the mathematical-statistical method and the economic analysis method. The analysis was based on official statistical data for the period from 2021 to 2023 for the following regions: Belgorod Region, Kursk Region, Kirov Region, Tula Region, Orenburg Region. Results. The study used the mathematical-statistical method and the economic analysis method. The analysis used official statistical data for 2021–2023, as well as mathematical-statistical and economic analysis methods. Conclusion. The creation of a unified emergency medical service in the constituent entities of the Russian Federation has a positive impact on the financial and economic performance of a medical organization.
A Hybrid Treatment for a Giant Subclavian Artery Aneurysm
Surgical treatment of aneurysms of the is a serious clinical challenge due to the complexity of surgical treatment. The method of hybrid surgical treatment using temporary balloon occlusion of the brachiocephalic trunk is the most optimal in open surgery, which optimizes the conditions for surgical intervention, minimizes the risks of intraoperative complications and affects the treatment outcomes. Patient M., 62 years old, was admitted to the vascular surgery department of the State Budgetary Healthcare Institution prof. S.V. Ochapovsky Research Institute — Regional Clinical Hospital No. 1 in June 2024 year with complaints of chest and spine pain of a girdle nature. Multispiral computed tomography with intravenous contrast revealed: aortic dissection type III B according to DeBakey - Belov, aneurysm of the right anterior aortic aneurysm. A hybrid surgical intervention was performed. The patient was offered a two-stage surgical treatment: thoracic aortic endoprosthetics with stent-graft implantation, resection of the aneurysm of the thoracic aorta and its prosthetic replacement. After implantation stent graft during CT dynamics in the early postoperative period revealed signs of endoleak stent graft Type I B. After 11 days, a repeat thoracic aortic endoprosthesis was performed with stent graft implantation. The endoleak was isolated. After 5 months, the patient underwent the second stage of treatment in the volume resection of the aneurysm of the cerebral artery, which, due to the anatomical features of the aneurysm of the cerebral artery, was performed using a hybrid method. The duration of the surgical intervention was 190 minutes. The anastomosis formation time was 20 minutes, and the occlusion time was 55 minutes. The volume of intraoperative blood loss was about 50 ml. The patient was extubated 10 minutes after the end of the operation on the operating table and transferred to the intensive care unit. The postoperative period was uneventful. On the 3rd and On the day after the operation the patient was activated and transferred to the general ward from the intensive care unit. On the 7th day the patient was discharged from the hospital in satisfactory condition.
The Path ˝Between Scylla and Charybdis˝ in the Non-Operative Management of Blunt Splenic Injuries (Using the Example of Three Clinical Cases)
Abstract. Non-operative management of blunt splenic injuries in hemodynamically stable patients is accompanied by fewer complications and low mortality. At the same time, it is very important to select patients correctly and dynamically monitor their condition for timely treatment correction. Aim of the Study. was to demonstrate three possible scenarios for the development of the situation when choosing the initially non-operative management of patients with combined blunt splenic injuries. Material And Methods. The clinical observations of three patients with combined blunt splenic injuries who were treated at the 3rd-level trauma center of the Volgograd City Clinical Emergency Hospital No. 25 in 2024 are presented. The initially planned non-operative management was supplemented or transformed in two cases. Results. Non-operative management of blunt splenic injuries is the method of choice in hemodynamically stable patients in the absence of other indications for surgery and the possibility of careful dynamic monitoring. Conclusion. Proper selection of patients with splenic injuries for non-operative management and their dynamic monitoring, supplemented by angioembolization, if necessary, make it possible in most cases to achieve success, which is accompanied by fewer complications and low mortality. With the development of hemodynamic instability and an increase in hemoperitoneum, a laparotomy splenectomy is the surgery of choice.
Use of Veno-Arterial Extracorporeal Membrane Oxygenation in Methadone Poisoning
ABSTRACT. Poisoning with opioids, including methadone, occupies one of the leading positions in the structure of acute chemical poisonings with narcotic drugs. Often, these poisonings cause severe complications, which in some cases result in death. Traditional approaches to the treatment of these patients are in most cases limited and may be ineffective in the development of serious complications, such as refractory cardiogenic shock or acute respiratory distress syndrome; against this background, ECMO can serve not only as a method of supporting vital functions, but also as a means correction of metabolic disorders, providing optimal conditions for the body. An additional aspect that highlights the relevance of ECMO for methadone poisoning is the increasing availability of this technique in clinical practice and its potential for use in settings where other treatment methods have failed. The purpose of this work is to demonstrate the first experience of using extracorporeal membrane oxygenation in severe methadone poisoning. Results. Patient Sh., 27 years old, was found by the Emergency Medical Service (EMT) at home. At the time of examination, emergency medical services specialists examined the patient (GCS 3 points, bradypnea, hypotension, hypothermia), tracheal intubation was performed to ensure airway patency, and vasopressor support with norepinephrine was initiated. The patient was urgently taken to the intensive care unit, where effective circulatory arrest occurred, refractory to the ongoing intensive therapy, and therefore a specialized EMS ECMO team was called and VA ECMO was initiated. The patient was hospitalized in the intensive care unit of the regional vascular center (ICU RSC) of the N.V. Sklifosovsky Research Institute for Emergency Medicine, where the clinical diagnosis of “methadone poisoning” was established. Alcohol intoxication” (according to ICD-10 T40.3). Against the background of combined intensive therapy, restoration of cardiorespiratory function was noted, which made it possible to wean the VA ECMO system on the 4th day. On the 20th day (from the moment of hospitalization in the hospital), the patient in a stable somatic status was discharged from the N.V. Sklifosovsky Research Institute for Emergency Medicine. Conclusion. The observation we presented shows the effectiveness and feasibility of using VA ECMO in the development of refractory cardiogenic shock in methadone poisoning.