Russian Sklifosovsky Journal "Emergency Medical Care"
“N.V. Sklifosovsky Research Institute for Emergency Medicine”
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Intraoperative Neurophysiological Monitoring in Cerebral Aneurysms Surgery
Introduction The effectiveness of surgical treatment for cerebral aneurysms is due to the improvement of surgical and anesthetic methods that allow for the exclusion of aneurysms from the blood flow. An important condition for the safe isolation and clipping of an aneurysm is the temporary shutdown of blood flow in the artery, in particular, temporary clipping (TC) of the artery carrying the aneurysm. Intraoperative neurophysiological monitoring (IONM) was proposed to predict ischemic complications in the treatment for intracranial aneurysms using TC. However, data on the results of using IONM in clipping cerebral aneurysms are contradictory. The aim of the study was to evaluate the effectiveness of intraoperative neuromonitoring in the surgical treatment for cerebral aneurysms. Material and methods The examination and surgical treatment of 93 patients with cerebral aneurysms was performed; patients were divided into 2 groups: Group 1 (no IONM) — 48 patients who underwent open clipping of the aneurysm without the use of intraoperative neuromonitoring (control group); Group 2 (IONM) — 45 patients who underwent IONM during surgical treatment for cerebral aneurysms in the internal carotid artery and middle cerebral artery. The treatment outcomes were assessed by the indicators of the radicality of exclusion of the aneurysm from the blood flow, functional outcomes - by the Glasgow Outcome Scale and the Rankin scale. During IONM, transcranial electrical stimulation (TES) was performed, with the impulse being delivered through the bones of the skull from electrodes located on the scalp surface, and motor evoked potentials (MEP) were recorded, direct electrical stimulation of the cerebral cortex (DES-MEP) was performed using a strip electrode laid along the precentral gyrus. After isolating the parent vessel, TC was performed in order to dissect the aneurysm from the surrounding tissues. Results It was found that the use of IONM during blood flow interruption in surgical treatment for cerebral aneurysms was accompanied by a decrease (compared to the group of patients without neuromonitoring) in the number of cases of temporary clipping by 33%, an increase in the total duration of TC by 25%, a decrease in the number of reperfusions by 50%, a decrease in the total duration of reperfusions by 3 times, a decrease in the duration of one ТC session by 10%, and a decrease in the volumetric blood flow through the carrier arteries by 18.1%. At the same time, no significant intergroup differences in systemic hemodynamic parameters were observed. Also, during IONM, there was no decrease in the amplitude of the MEP-TES in 93.3% of patients, the amplitude of evoked potentials did not change in 77.8–91.2% of patients, while the course of the operation changed in 33.3% of patients. In the early postoperative period, in patients who underwent IONM during TC performance, the proportion of patients with a Glasgow Coma Scale score of 14–15 points was 51% higher, and with a score of 9–13 points 8.8 times lower (than in the group without IONM), speech disorders were detected 2.5 times less often, the presence of cerebral ischemia zones was noted 1.8 times less often. Conclusion Thanks to the feedback provided by the use of IONM in real time, the surgeon can always immediately respond to the development of structural damage to the brain, which in turn helps prevent neurological disorders during surgical treatment of cerebral aneurysms. The use of IONM during open clipping of aneurysms allows increasing the number of excellent treatment outcomes by 44%.
Damage Control Tactics for Personalized Surgical Treatment of Patients with Deep Burns
Relevance The optimal timing of surgical treatment for deep burns has not been definitively established. Extensive interventions in unstable patients risk worsening their condition due to the “second strike” principle, while delaying surgery can lead to infectious complications. An individualized approach based on an integrated assessment of the prognosis of the injury outcome and the patient’s current condition is required. Aim of the study To evaluate the effectiveness of an algorithm for selecting surgical treatment tactics based on an integrated assessment of the revised Frank Index, the probability of favorable outcome (PFO), and the SOFA score in patients with deep burns. Material and methods This single-center retrospective-prospective cohort study included 320 patients with deep burns. A retrospective (n=213, treated in 2019–2022) and prospective (n=107, treated in 2023–2025) groups were formed. In the prospective group, treatment tactics were determined using the following algorithm: early surgical treatment was performed with PFO ≥50% and SOFA <4 points; with PFO <50% and a SOFA score ≥4, radical surgery was postponed. Results Using the algorithm allowed us to differentiate surgical tactics. In patients with PFO ≥50%, the time to first necretomy was reduced from 12 (9; 16) to 10 (8; 13) days (p=0.001), and the time to first autologous skin grafting was reduced from 23 (16; 27) to 20 (17; 22) days (p<0.001). In patients with PFO <50%, the use of the algorithm resulted in a delay in the initial intervention (the necretomy time increased from 10 (6; 13) to 12 (10; 15) days, p=0.016) and a reduction in mortality from 40% to 6% (p=0.010). Conclusion The algorithm implementing damage control principles in burn trauma is an effective tool for personalizing surgical tactics. Its use allows for shorter surgical timing in stable patients and lower mortality by justifiably delaying surgical intervention in critically ill patients.
Randomized Clinical Trial of the Effectiveness of Thoracotomy Wound Management for the Prevention of Infectious Complications and Additional Anesthesia
Relevance Thoracotomy is a widely used method of access to the chest, however, its use is associated with a high risk of surgical site infections. According to the World Health Organization, infectious complications are the most common problem in surgical practice. They can significantly worsen the patients’ condition after surgery, increase the length of their hospital stay and create significant financial difficulties for the healthcare system. The proposed method of thoracotomy wound management can significantly reduce the incidence of unwanted postoperative infections, which, in turn, will reduce the burden on the healthcare system. The aim of the study To evaluate the effectiveness of the proposed method of thoracotomy wound management after anatomical lung resections, in order to prevent infection after surgery and additional anesthesia by comparative analysis with the control group. Material and methods The study was conducted on the basis of the Department of Thoracic Oncology Surgery of the Regional Clinical Oncological Dispensary, Ulyanovsk, Russia. The analysis included 63 patients at high and medium risk of developing surgical site infections (SSIs), who were divided into two groups of 32 and 31 people. Group 1 (32 patients) was the control group, group 2 (31 patients) were patients who underwent the developed method of complex thoracotomy wound management. All the patients underwent elective thoracotomy for anatomical lung resection (lobectomy or segmentectomy) in the period from 06/15/2023 to 11/18/2024. The characteristics of the studied patients were evaluated according to a single developed protocol. Results The incidence of SSIs in the control group was 28.1% (9/32), while in the group where preventive management of the postoperative wound was performed, this indicator was 6.5% (2/31), p=0.043. When performing a one-factor statistical analysis of the postoperative parameters of the studied groups of patients, statistically significant indicators were determined: the pain visual analog scale on day 1 (p=0.006), neutrophil-lymphocyte ratio on day 1 (p=0.003), platelet-lymphocyte ratio on day 1 (p=0.039); cortisol level on day 1 day (p=0.004) and day 5 (p=0.017); forced expiratory volume in 1 second and vital capacity for 1 day after surgery (p=0.038) and (p=0.027), respectively, forced vital capacity for 1 day after surgery (p=0.033). Conclusions The application of the developed technique for the management of postoperative thoracotomy wounds reduces the development of infectious complications in patients with moderate and high risk of surgical site infections, and also provides adequate anesthesia.
Characteristics of Abdominal Gunshot Wounds in Civilian Populations Using Modern Firearms
Relevance In the post-war period, both firearms and their delivery methods have undergone significant advancements. These developments have led to changes in the nature of injuries, including those sustained by civilian populations. The aim of the study To conduct a comparative analysis of the characteristics of abdominal gunshot wounds among civilian patients resulting from the use of modern firearms during two military campaigns. Material and methods The study included 100 civilian patients with gunshot wounds. The main group consisted of 50 patients injured during the special military operation; the comparison group included 50 patients injured during the Chechen campaign. Of the total participants, 67 (67%) were male and 33 (33%) were female. The mean age was 35±6 years. Results The study revealed that, under current conditions, civilian patients predominantly sustain shrapnel and multiple abdominal injuries involving damage to both parenchymatous and hollow organs, which contributes to the development of peritonitis. According to literature data, the incidence of complications in peritonitis is 43.8%, with a mortality rate of 4.9%. However, our findings indicate significantly higher complication rates in the main group (42%) compared to the comparison group (28%), while mortality was lower in the main group (18%) than in the comparison group (34%). This discrepancy may be attributed to more severe shrapnel injuries characteristic of modern warfare—such as those caused by unmanned aerial vehicles (UAVs)—which intensify the severity of peritonitis and complicate treatment compared to the Chechen campaign period, where injuries primarily resulted from automatic firearms. According to our data, patients in the main group exhibited a predominance of more severe forms of peritonitis, leading to complications observed in 26% of cases and a mortality rate of 9%. Conclusion Abdominal gunshot wounds in civilian patients in the current era are characterized by multiple shrapnel injuries, the development of severe peritonitis, and high rates of complications.
Application of Helium-Oxygen Mixture Improves Postoperative Outcomes in Cancer Patients with COPD
Introduction Cancer remains one of the most significant global problems of our time, having a complex impact on demographic, medical, and economic systems. According to the International Agency for Research on Cancer, more than 20 million cases of cancer were registered in 2022, and lung cancer was detected most often among all malignant diseases in the world. In Russia, more than 60,000 first-detected cases of lung cancer are registered annually. The Aim of our study Improving treatment outcomes in patients undergoing lung cancer surgery with concomitant chronic obstructive pulmonary disease (COPD) thanks to preoperative preparation with a helium-oxygen mixture. Material and methods The study was carried out on the clinical base of the Perm Regional Clinical Hospital in the departments of thoracic surgery, thoracoabdominal oncology, pulmonology, intensive care. All patients were divided into two groups depending on the method of preoperative period management: 1. study group, where in addition to preoperative preparation, inhalation of a breathing helium-oxygen gas mixture (Heliox, 70% helium and 30% oxygen) was used during the preoperative period of 5–7 days (He group); 2. control or historical control group, formed on the basis of accepted protocols of preparation of patients for planned surgical interventions for lung cancer with concomitant COPD (group C). Results In our study, postoperative respiratory failure in the He group was significantly less frequent than in the historical control group, which could not but affect the reduction in the duration of postoperative ventilatory support and pulmonary complications. The innovative management of the perioperative period resulted in a decrease in the duration of patients’ stay in the ICU and, as a consequence, had a positive effect on the duration of hospitalization in general. Conclusion Helium-oxygen mixture improves postoperative outcomes in lung cancer patients with concomitant COPD.
Biomarkers of Systemic Inflammation in Assessing the Efficacy of Extracorporeal Hemocorrection in the Treatment of Abdominal Sepsis
Introduction Biomarkers such as procalcitonin (PCT), C-reactive protein (CRP), presepsin (PSP), and interleukin-6 (IL-6) are closely associated with systemic inflammation. The results of their testing were analyzed to determine the benefits of early use of extracorporeal hemocorrection (ECHC) in the treatment of abdominal sepsis. The Aim of the study was to analyze the results of simultaneous testing of PCT, CRP, PSP, and IL-6 biomarkers; to investigate the association between initial blood biomarker levels and disease outcome; to determine whether this relationship differed when using ECHC in the treatment of abdominal sepsis. Hypothesis tested the early use of ECHC in the treatment of abdominal sepsis has a survival advantage. Study design prospective cohor Material and methods Method description. Blood samples were taken at two time points — on the first postoperative day and after 5 days of intensive care — to determine systemic inflammation biomarkers. We analyzed the association between initial blood biomarker levels and outcome, as well as their dynamics after 5 days of intensive care. Sample characteristics. The study included 113 patients aged 23 to 90 years who underwent emergency laparotomy due to disseminated peritonitis and abdominal sepsis. The gender distribution was 67 men and 46 women. In 50 cases (group 1), ECHC was performed early; in 63 cases (group 2), ECHC was not used. Results Baseline PCT and PSP levels were statistically significantly and strongly associated with disease outcome; the relationship was direct for a negative outcome and inverse for a positive one. For each unit (mcg/ml) of PCT, the chance of survival decreased by 0.016 times (OR=0.984; 95% CI 0.974–0.994) and by 25.7 times over the entire range of values (OR=0.0389; 95% CI 0.0049–0.3050). For each unit (pg/mL) of PSP, the odds of a favorable outcome decreased by 1.00046 times (OR=0.99954; 95% CI 0.99919–0.99988) and by 117.6 times across the entire range (OR=0.0085; 95% CI 0.0002–0.2982). AUC 0.762; 95% CI 0.670–0.855 and 0.776; 95% CI 0.682–0.870. Early use of ECHC increased survival in patients with high baseline PCT and PSP levels. With standard sepsis therapy, the chances of survival were 1.040 times lower for each unit of PCT and 1.0006 times lower for each unit of PSP; 2387 times lower across the range of PCT values and 1.5 times lower across the range of PSP values compared to the use of ECHC in treatment. The use of ECHC allowed the survival of patients with higher initial levels of PCT (Me 29.4 (11.0–71.4) ng/ml versus Me 4.9 (2.1–10.5) ng/ml, p=0.000001) and PSP (Me 891 (504; 1686) pg/ml versus 386 (200; 848), p=0.007) compared to patients in whose treatment ECHC was not used. Unlike PCT, CRP, and IL-6, elevated PSP levels did not decrease with ECHC (p=0.38), while with standard sepsis therapy, the decrease was statistically significant (p<0.001). Conducting ECHC presumably contributes to maintaining elevated blood PSP levels. The emergence of a highly statistically significant positive moderate correlation between IL-6 and PCT, PSP, CRP (p=0.001, p=0.00008, p=0.0003), as well as APACHE II and SOFA scores (p=0.000007 and p=0.000006) after treatment using ECG, and the absence of similar correlations in the standard therapy group at both testing points, may indicate a positive effect of ECHC in stabilizing intercellular relationships and synchronizing adaptive mechanisms. Baseline CRP levels were not associated with outcome. Conclusion Of the four biomarkers tested, procalcitonin best predicted the effectiveness of extracorporeal hemocorrection in the treatment of abdominal sepsis. The study revealed an unusual effect of extracorporeal hemocorrection on presepsin. A highly statistically significant positive association was observed between interleukin-6 and procalcitonin, presepsin, C-reactive protein, and APACHE II and SOFA scores after treatment with extracorporeal hemocorrection.
Antimicrobial Activity Study of New Samples of Polymeric Surgical Membranes
Background Currently, the increasing resistance of microorganisms to antimicrobial drugs reduces the effectiveness of the treatment for purulent-inflammatory processes. In this regard, innovative strategies and products based on polymer materials for local application are required in order to prevent or reduce the risk of surgical site infections. The aim of the study was to compare the antimicrobial activity of new samples of polymer surgical membranes developed by the authors in an in vitro experiment. Material and methods The study materials used were new samples of multicomponent polymer membranes developed on the basis of the laboratory of experimental surgery and oncology of the Kursk State Medical University (5 groups differing in the addition/absence of antibacterial agents), and the ElastoPOB® implantable biopolymer membrane (manufactured by BIOMIR Servis JSC, Russia). Inhibition of growth zones of test strains of aerobic and facultative-aerobic microorganisms was evaluated. The data obtained during the study were statistically processed using descriptive and variational statistics (Me [25; 75]). Significance was determined by the Kruskal-Wallis test (p≤0.05). Results The most pronounced antimicrobial activity, inhibiting the growth of all five microbial cultures, was observed in the study of polymer membranes No. 4 (Levofloxacin in the 3rd layer) and No. 2 (Levofloxacin in the 1st layer). Statistically significant differences were found when comparing microbial growth inhibition zones among the following study groups: No. 1 and No. 2 (p=0.009), No. 1 and No. 4 (p=0.0001), No. 2 and No. 5 (p=0.043), No. 2 and No. 6 (p=0.0001), No. 3 and No. 6 (p=0.002). Conclusion The study demonstrated that the new polymer membrane samples clearly exhibit antimicrobial activity. This is explained by the fact that sodium carboxymethyl cellulose (Na-CMC), which forms the basis of surgical polymer membranes, itself possesses some antimicrobial activity. At the same time, the addition of a broad-spectrum antibiotic during the polymer membrane manufacturing process to the base (third) or surface (first) layer will determine the intensity of local antimicrobial action (slowing down culture growth).
Use of Inhaled Nitric Oxide as Part of Combination Therapy for Symptomatic Cerebral Vasospasm in Patients in the Acute Period After Rupture of Cerebral Aneurysms
Introduction Symptomatic cerebral vasospasm (CVS) is one of the most severe complications of subarachnoid hemorrhage (SAH) due to ruptured cerebral aneurysms, leading to delayed cerebral ischemia. The pathogenesis of CVS is associated, among other factors, with a deficiency of the endothelial vasorelaxant factor — nitric oxide (NO). Administration of inhaled NO can replenish this deficit and help reduce the severity of CVS; however, clinical data remain limited. Aim To evaluate the feasibility of inhaled nitric oxide (iNO) therapy in patients with signs of symptomatic vasospasm in the acute period of non-traumatic SAH caused by ruptured cerebral aneurysms. Material and methods A case series was carried out involving 9 patients (5 women, 4 men; aged 35–74 years) admitted to the N.V. Sklifosovsky Research Institute for Emergency Medicine in 2022–2024 during the hyperacute period after cerebral aneurysm rupture. The main inclusion criterion was the development of symptomatic CVS resistant to standard therapy (calcium channel blockers, induced hypertension) for at least 1 hour. All the patients underwent microsurgical aneurysm clipping. Inhalation of NO was performed via a face mask using a “Tianox” device at a concentration of 55–80 ppm with FiO₂ 21% until regression of symptoms. Clinical neurological status, jugular venous oximetry, markers of oxidative stress (malondialdehyde (MDA), total antioxidant status (TAS)) and endogenous vascular regulation (nitric oxide metabolites (NOx), angiotensin-converting enzyme (ACE)), video-EEG monitoring and CT perfusion data were assessed. Results Inhalation therapy resulted in regression of symptomatic CVS in 8 of 9 patients, including complete neurological recovery in 5 patients. The mean time to symptom regression ranged from 3 to 21 hours. In 2 patients, premature discontinuation of therapy led to symptom recurrence, requiring resumption of inhalations. CT perfusion on day 7 revealed reversible focal cerebral perfusion deficits in 4 patients. No adverse effects (methemoglobinemia >3.5%, hypotension, toxic NO₂ concentrations) were recorded. Mortality (n=2) was due to extracranial complications. Conclusion Inhaled NO therapy in SAH patients with symptomatic CVS on spontaneous breathing is safe and potentially effective for rapid regression of neurological symptoms and improvement of cerebral perfusion.
The Place of Minimally Invasive Technologies in the Treatment of Patients with Blunt Abdominal Trauma: a Systematic Review and Meta-Analysis for 2016–2024. Secondary Control Points (Continued)
Introduction The development of minimally invasive technologies in medicine is fast, but their role and place in surgery of blunt abdominal trauma have not yet been definitively determined. The aim of the study to compare the effectiveness of various treatment options (non-operative with percutaneous or transluminal methods, laparoscopic, robot-assisted and laparotomic) in patients with blunt abdominal trauma. Material and methods A systematic literature search was conducted in accordance with the recommendations of PRISMA (2020) and AMSTAR (2017). The analysis of non-randomized studies from January 1, 2016, and randomized ones — without time limits, to September 10, 2024 from the electronic databases eLibrary, PubMed, Cochrane library was carried out. Results Laparoscopic and laparotomic interventions do not differ in the frequency of missed injuries. The conversion rate is 23.6-36.73%. As for percutaneous, transluminal and robotic methods, there is insufficient data for meta-analysis. Conclusion Laparoscopy is a safe technique for the treatment of hemodynamically stable patients with blunt abdominal trauma. To obtain data of a higher Level of Evidence and Grade of Recommendations, it is necessary to further conduct systematic reviews and meta-analyses based on randomized clinical trials.
Features of Orthotic Management in Patients with Thoracic and Lumbar Spine Fractures
Orthotic therapy represents a key component of conservative management for thoracic and lumbar spine injuries, aimed at stabilizing the affected spinal segment, reducing pain, and preventing deformity progression. This article examines contemporary approaches to selecting and applying orthopedic braces in patients with different fracture types. Special emphasis is placed on clinical and biomechanical studies, duration of brace wear, and the impact of orthoses on restoring mobility and improving patients’ quality of life. Based on clinical observations and literature review, the study provides recommendations for optimizing orthotic therapy according to clinical presentation and rehabilitation stage.
Modern Concepts on Classification, Diagnosis and Treatment of Wounds
The problem of the wound healing process remains relevant and significant. The analysis of modern approaches to classification, principles of diagnosis and treatment tactics of patients with wounds in freely available literature on eLibrary, Scopus, Web of Science databases was carried out. The basis of wound management is surgical treatment, which should be supplemented by the use of methods of physical impact and local conservative treatment, which includes, first of all, drugs that potentiate the processes of wound cleansing and stimulate reparation. Complex wound treatment is based on understanding the classification of wounds, stages of wound healing, knowledge of the volume and localization of damage, blood supply, temperature and humidity of tissues, acidity of wound discharge, type of pathogen, severity of the patient’s condition, indications and contraindications for the use of various methods, medications and their combinations, and includes a variety of approaches. But, despite the many proposed drugs, devices and methods, questions about the optimal wound management remain open. The development of accessible and inexpensive methods and drugs for local treatment of wounds is promising, as it was many years ago.
The “Step-Up” Approach in the Treatment of Patients with Severe Acute Pancreatitis
The aim was to improve treatment outcomes in patients with necrotizing pancreatitis through accurate topographic diagnosis of the pathological process and the selection of the optimal, personalized treatment strategy (depending on the disease phase), with a focus on minimally invasive treatment methods. Material and Methods A retrospective analysis was conducted on the treatment outcomes of 328 patients with necrotizing pancreatitis who were admitted to the surgical department of the S.P. Botkin Moscow Multidisciplinary Scientific and Clinical Center from 2021 to 2024. Conclusion The use of minimally invasive techniques within the framework of the “step-up” approach is an effective method in the treatment of patients with severe acute pancreatitis, which allows for a reduction in the number of postoperative complications as well as in the aggressiveness of surgical interventions.
Thoracostomy in the Surgical Treatment of Patients with Pleural Empyema and Upper Gastrointestinal Fistulas
Pleural empyema with upper gastrointestinal fistulas is a rare pathology in thoracic surgery. A comprehensive treatment approach includes not only debridement of the purulent lesion in the pleural cavity, but also interventions to promote fistula healing. The method for fistula repair and healing is selected individually, based on the specific clinical situation and etiology. Thoracostomy is an effective treatment method that allows for adequate pleural cavity debridement and, when combined with local negative pressure, creates conditions conducive to fistula healing.
Outcomes of Patients with Acute Mesenteric Ischemia Treated in Two Large Multidisciplinary Third-Level Hospitals of the Ryazan Region
Abstract Acute mesenteric ischemia is still a complex unresolved problem in surgery, as evidenced by the high mortality rates and postoperative complications in this cohort of patients. The aim of the study was to evaluate outcomes of patients with acute mesenteric ischemia (AMI) treated in two hospitals – Regional Clinical Hospital and City Clinical Hospital of Emergency Medical Care – in the Ryazan region in 2022–2023. Material and methods A retrospective analysis of 53 medical records of patients undergoing surgery with a diagnosis of acute mesenteric ischemia (K55.0) was conducted. Results The average age of patients was 73.5 years (60.3% women). The overall postoperative survival rate was 52.8% (n=27). Late hospitalization was noted: the average time from illness onset to admission was 21 hours, only 11.3% of patients were admitted within the “therapeutic window” (up to 6 hours). The diagnosis was correctly established upon admission in only 50.8% of cases, and intraoperatively in 46.6% of patients. Prehospital diagnosis was virtually nonexistent (2.6%). In the prehospital stage, AMI was most often masqueraded as acute intestinal obstruction (28.3%) and peritonitis (13.2%). The main risk factors were coronary heart disease (93.4%), hypertension (88.6%), and arrhythmia (75.4%). Bowel resection was performed in 52.8% of patients, primarily in the superior mesenteric artery (92.8%). Laboratory diagnostics were nonspecific, and ultrasound and radiography revealed only indirect signs of complications, without influencing early verification of thrombosis. Discussion The main problem remains late diagnosis and a lack of vigilance, leading to the development of irreversible intestinal necrosis. Early hospitalization (within 6 hours) and timely initiation of treatment are key factors for success. Conclusions Late presentation (over 6 hours) is the main cause of intestinal necrosis. Risk factor assessment should be the leading criterion in diagnosis. Early treatment increases the potential for organ-preserving interventions and improves the rehabilitation prognosis.
Production Factors Determining the Loyalty of Emergency Medical Personnel in a Large Industrial Center
The return of the able-bodied population to society is a national task. One of the key elements contributing to the achievement of this goal is the efficient and high-quality work of emergency medical services. Taking into account the annual increase in the number of people seeking emergency medical care, the importance of the service can be assessed as a key factor of national security. The staff’s loyalty to the organization has a decisive impact on the quality of emergency medical care. The level of goodwill of medical staff can reduce staff turnover. The study was conducted on the basis of the Nizhny Novgorod Ambulance Station and the Department of Public Health and Healthcare of the Privolzhsky Research Medical University. According to the questionnaire we developed, an anonymous survey was conducted of 521 employees (a solid sample), including 61 doctors, 364 paramedics and 96 ambulance drivers. Statistical and analytical research methods were used in the work. Statistical data processing was performed using the SPSS Statistics 26. The authors identify the main “pain points” of the professional activities of emergency medical personnel and outline ways to rationalize the use of the service’s resources. It is proposed to strengthen the legal protection of medical workers in the public health system by tightening liability for insults, harm to health, and bodily injury during working hours.
Modified Aortic Valve Reimplantation Using the “Kuban Cuff” Technique, Combined with Aortic Arch Replacement, Brachiocephalic Trunk and Left Common Carotid Artery Reconstruction for Acute DeBakey Type I Aortic Dissection
Acute DeBakey type I aortic dissection is a life-threatening condition requiring immediate surgical intervention. This article presents a clinical case of successful treatment of a patient with acute dissection of the ascending aorta and aortic arch involving the brachiocephalic trunk and left common carotid artery. We performed modified reimplantation of the aortic valve (AV) using the Kuban Cuff technique in combination with arch replacement and reconstruction of its branches. Patient, a 63-year-old male, was admitted with complaints of severe retrosternal pain and hypertension. The diagnosis of acute aortic dissection was confirmed by echocardiography and computed tomography. Surgical treatment included AV reimplantation using an Intergard Woven No. 32 vascular graft, replacement of the aortic arch, the brachiocephalic trunk, and the left common carotid artery. The postoperative period was uneventful, with the patient successfully extubated and sinus rhythm restored with medication. On the 5th postoperative day, the patient was transferred to a specialized department and discharged in satisfactory condition on the 12th day. The Kuban Cuff technique allowed for the effective preservation of the native aortic valve, reducing the risk of postoperative valve insufficiency and improving long-term outcomes. However, performing this surgery requires a high level of surgical expertise and careful patient selection. Thus, the proposed AV reimplantation technique combined with aortic arch replacement demonstrates its effectiveness and may be a promising approach in the surgical treatment for acute DeBakey type I aortic dissection.
Ventricular Free Wall Rupture as a Complication of Acute Myocardial Infarction: a Series of Favorable Outcome at the Regional Vascular Center that Operate Without On-Site Cardiac Surgery
Background Ventricular free wall rupture (FWR) is one of the most prognostically unfavorable complications of acute myocardial infarction (MI), requiring urgent cardiac surgery (CS). However, not all vascular centers in this country expand their services to include CS, and not all patients with mechanical complications have a hemodynamic condition that allows for transportation to a facility with such capabilities. Aim To identify and analyze cases of a favorable outcome of FWR as a acute MI complication in the Regional Vascular Center that operate without on-site CS. Material and methods All patients with FWR as a complication of MI who underwent inpatient treatment at the Regional Clinical Cardiology Dispensary, Ryazan, Russia, in 2021–2022 and survived at the end of the index hospitalization were consistently included. In total, 1,827 patients with the final clinical / pathoanatomic diagnosis of “MI with ST segment elevation on an electrocardiogram” were hospitalized during this period, three cases of a favorable outcome of FWR were registered among them. The anamnesis, clinical picture, results of FWR imaging confirmation, its treatment and catamnesis of these three patients (all men, aged from 49 to 86 years) are presented. Results In all the described cases, FWR occurred with the formation of pseudoaneurysm of the posterior left ventricle wall (posterior MI), a significant delay in medical care for MI (the time from the onset of pain to coronary angiography varied from 8 days to 30 days), and delayed FWR time (from 5 days to 1.5 months from MI onset). Surgical correction (delayed) was performed only in one case. The survival time in these cases is more than 2–3 years. Conclusions The survival of patients with MI complicated by FWR without CS is a rare favorable combination of circumstances related to the anatomy and physiology of the rupture (with the formation of pseudoaneurysm), rather than the quality of medical care.
Use of Veno-Arterial Extracorporeal Membrane Oxygenation in Takotsubo Syndrome Due to Methadone Poisoning
Background Opioid poisoning, including methadone, occupies one of the leading positions in the structure of acute chemical poisoning by narcotic drugs and is often accompanied by severe complications, often leading to death. One of such complications is Takotsubo syndrome – an acute condition characterized, as a rule, by reversible dysfunction of the left ventricular myocardium. In the development of serious complications, standard therapeutic approaches to those patients are often insufficiently effective, which necessitates the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This method serves not only to support vital functions, but also to correct metabolic disorders, creating optimal conditions for the recovery of the body. The aim of this work was to demonstrate clinical experience of using veno-arterial extracorporeal membrane oxygenation in severe methadone poisoning complicated by the development of Takotsubo syndrome. Results Patient S., 21 years old, was found at home in a state of depressed consciousness and respiration. At the time of examination by the ambulance team: level of consciousness and response to stimuli were reduced (GCS 5), bradypnea, bradycardia, severe arterial hypotension, signs of aspiration of gastric contents. The time spent in a comatose state was unknown. The patient was provided with first aid, including tracheal intubation, mechanical ventilation, and vasopressor support with norepinephrine. After that, the patient was urgently hospitalized in the intensive care unit of a city clinical hospital. Despite the intensive care, progression of signs of cardiac and respiratory failure was noted. On the 4th day, the patient was transferred to the intensive care unit of the regional vascular center (ICU RVC) of the N.V. Sklifosovsky Research Institute for Emergency Medicine. Based on the results of instrumental and laboratory tests, the following diagnosis was established: “Methadone poisoning. Toxic cardiomyopathy. Unspecified Takotsubo syndrome. Acquired long QT syndrome. Cardiac arrest with successful restoration of cardiac activity. Hospital-acquired bilateral polysegmental pneumonia. Purulent tracheobronchitis. Toxic encephalopathy”. Due to the development of refractory cardiogenic shock, the use of VA ECMO was initiated. On the 11th day, against the background of persistent stabilization of cardiorespiratory function, the patient was successfully weaned from the VA ECMO system. On the 12th day from the moment of hospitalization, the patient was transferred to the specialized toxicology intensive care unit to continue complex therapy. On the 31st day, the patient was discharged from the N.V. Sklifosovsky Research Institute for Emergency Medicine in a stable somatic condition. Conclusion The presented observation demonstrates the high efficiency and feasibility of using VA ECMO in refractory cardiogenic shock caused by severe methadone poisoning with the development of Takotsubo syndrome.
A Rare Congenital Heart Defect in a Child: a Clinical Case
Congenital heart defects remain one of the most common developmental anomalies. Modern medicine has made significant progress in the diagnosis and treatment of these diseases; but malformations are still a serious problem for pediatric cardiology. A single ventricle of the heart is one of the rare and unique congenital defects. The natural progression of the disease is unfavorable: about two-thirds of the patients die in the first year of life due to severe pulmonary hypertension; increasing heart failure; severe hypoxemia and arrhythmias. This article presents a clinical case of a patient with prenatally diagnosed concomitant heart disease in the form of a functionally single left ventricle with tricuspid valve atresia; right ventricular hypoplasia (with the formation of a ‘graduate’); without pulmonary artery stenosis; the presence of atrial and interventricular septal defects. In order to stabilize the condition of the newborn after the first month of life; a surgical intervention was performed in the form of narrowing of the pulmonary artery trunk. At the age of 6 months; a surgical intervention was performed to form a bidirectional cavopulmonary anastomosis. The average life expectancy of this category of patients in the natural course of the defect is no more than 5-6 years; and in the first year more than 75% of the patients die from the progression of heart failure and hypoxia; and only about 20% live up to 25 years. These defects are especially difficult for cardiac surgery; since their radical correction is anatomically impossible. In this regard; a step-by-step surgical treatment is performed - hemodynamic correction. Surgical formation of a bidirectional cavopulmonary anastomosis becomes a ‘lifeline’ for patients with the single left ventricle. It should be noted that at present this surgical intervention is carried out at the earliest possible age; since chronic arterial hypoxemia causes irreversible changes in all organs and systems.
Pancreaticoduodenal Resection in the Long-Term Period After Beger Procedure
Background We present a case report of chronic pancreatitis complicated by compression of the common bile duct, and segmental portal hypertension. Chronic pseudotumorous cephalic pancreatitis, postnecrotic cysts of this localization, persistent abdominal pain, biliary hypertension are the indications for surgical intervention. Two versions are discussed in the literature: 1 — organ-preserving operation with duodenum protection and natural bile flow preservation, and 2 — pancreaticoduodenal resection with biliodigestive drainage. Each method has advantages and disadvantages. The progression of chronic pancreatitis, duodenal dystrophy, and mechanical jaundice in the long-term period after the Beger procedure are indications for proximal pancreatic resection. The aim was to present a case report of staged surgical treatment of cephalic chronic pancreatitis with biliary hypertension and pain syndrome. Material and methods A 34-year-old male who abused alcohol, underwent the Beger procedure for post-necrotic cyst of the pancreatic head and biliary hypertension because of ineffective conservative treatment. The biliary drainage was removed 1,5 months later. In 3 days, acute pain appeared in the right hypochondrium. Biliary hypertension was diagnosed and treated with transpapillary stenting of the choledochus. Follow-up examination was scheduled in 3 months, but the patient did not come. The male presented to our Clinic 8 years later with choledocholithiasis, jaundice, and duodenal passage disorder. Duodenal dystrophy was diagnosed, and pancreaticoduodenal resection was performed. Results The Beger procedure and choledochus stenting ensured a satisfactory health level for several years. The patient did not follow a diet and systematically included alcohol in the menu. He didn’t show up for the checkup. Pancreatoduodenal resection effectively solved the problems that appeared.