BACKGROUND Acute proximal aortic dissection (Stanford type A) remains the most common fatal pathology of the thoracic aorta. Despite the improvement of surgical technologies, hospital mortality after emergency surgical interventions is 17–25%, in complicated cases it can reach 80–90%.

AIM OF STUDY Description of the perioperative treatment tactics adopted at the N.V. Sklifosovsky Research Institute for Emergency Medicine as well as the evolution of approaches that make it possible to obtain satisfactory hospital and long-term results in the treatment of aortic dissection.

MATERIAL AND METHODS the study included 278 patients operated on from 2015 to 2021 in the acute stage of aortic dissection (less than 48 hours from the moment of manifestation of the disease). The operated patients were divided into two groups, depending on the presence of complicated forms: group A, 102 patients with uncomplicated course of the disease; group B, 176 patients with complicated course of the disease. Additionally, patients were divided depending on the level of distal reconstruction performed: group I, 83 patients, surgery was limited to prosthetics of the ascending aorta, without removing the clamp; group II, 137 patients who underwent hemi-arch surgery; group III, 58 patients, with distal reconstruction involving the aortic arch.

RESULTS Total hospital mortality was 28.1%: 25.3% in group I, 29.1% in group II, 29.3% in group III. In the group of uncomplicated dissection, postoperative mortality was 18.6%, while in the group of complicated dissection it was 33.5%.

CONCLUSION An integrated multidisciplinary approach with the formation of an “aortic team”, an individual approach to surgery, depending on the anatomy of the dissection and the clinical status of the patient, will improve the results of the treatment of acute aortic dissection, as the most severe and multiple organ pathology of the aorta.

FINDING 1. Hospital mortality of complicated forms of dissection remains significantly higher — 33.5% versus 18.5% of uncomplicated course. 2. The most optimal method of distal reconstruction in patients with the peracute stage of dissection is an open anastomosis with the aorta using the “hemi-arch” technique. 3. If it is necessary to extend the surgical intervention on the aortic arch, a distal anastomosis in areas 0, 1, 2 with the possibility of a subsequent endovascular stage is the priority.

BACKGROUND Today, one of the urgent problems of emergency vascular surgery is the high mortality rate in acute ischemia of the lower extremities in elderly and senile patients.

AIM OF STUDY To evaluate the incidence of complications in elderly and senile patients with acute ischemia of the lower extremities of embologenic origin.

MATERIAL AND METHODS As an object of study, three groups of elderly and senile patients admitted with a clinical picture of acute ischemia of the lower extremities were studied. Group I — patients who underwent reconstructive interventions in the scope of the so-called proximal reconstruction; group II — patients who, for the purpose of complete revascularization, underwent extended reconstructive interventions using an additional surgical approach; group III — patients who underwent a “classic” embolectomy.

RESULTS Good results were statistically significantly more common in group II. Satisfactory and poor results were observed in group III. Amputations were statistically significantly more common in group III. In 69.6% of cases, the use of plasmapheresis and infusion therapy prevented the development of acute renal injury.

CONCLUSION Performing extended arterial reconstructions, including using an additional surgical approach, makes it possible to more fully restore the main blood flow in the ischemic limb and thereby completely restore the main blood flow in the ischemic limb and reduce the degree of ischemia, as well as reduce the severity of the manifestation and course of the post-ischemic syndrome.

The study was conducted in the Thoracoabdominal Department of the N.V. Sklifosovsky Research Institute for Emergency Medicine to explore the role of paravertebral block in the treatment of blunt chest trauma. The study included 715 patients with isolated chest trauma hospitalized between January 1, 2020 and August 2021. 55 patients received analgesic therapy in the form of paravertebral block. The comparison group included 660 patients who did not undergo paravertebral block, in their case pain relief was provided by systemic administration of analgesics. The compared groups did not differ significantly in sex and age composition. There were also no differences in the frequency of chronic diseases and interpleural complications. There were no significant complications during the block. The comparison revealed a significant decrease in the incidence of pleurisy and a shorter length of stay in hospital. Paravertebral block is an effective and safe method of pain management for patients with blunt chest trauma. The use of this technique reduces the incidence of post-traumatic pleurisy and duration of hospitalization.

AIM OF THE STUDY To study benzodiazepine poisoning in geriatric patients compared to patients of working age.

MATERIAL AND METHODS We examined 82 patients with benzodiazepine poisoning, hospitalized in the Department of Acute Poisoning and Somatopsychiatric Disorders of the N.V. Sklifosovsky Research Institute for Emergency Medicine in 2020–2021, which were divided into age categories: young (18–44 years old), middle (45–59 years old) and older (over 60 years old) age. The presence of benzodiazepines in urine was confirmed by immunochromatographic analysis and gas chromatography–mass spectrometry (GC-MS). The concentration of phenazepam in the blood and urine was determined in 45 patients by GC-MS. Statistical processing of the material was performed using the IBM program SPSS Statistics 27.0. The median (Me), 25th and 75th percentiles were determined. The comparison of quantitative data was performed using non-parametric criteria, the level of significance was taken as p<0.05.

RESULTS It was found that acute phenazepam poisoning prevailed in all age groups (90% of patients). Among young and middle-aged patients, moderate and deep stunning (GCS score 12–14) prevailed, and in older people moderate and severe poisoning prevailed (GCS score 3–12), with no statistically significant differences in blood concentrations of phenazepam between the groups. In patients of the older age group with benzodiazepine poisoning, compared to people of working age, the development of respiratory failure was statistically significantly more frequent — 13.8-fold, pneumonia — 12.6-fold, vein thrombosis of the lower extremities — 7.8-fold, trophic skin changes — 29-fold. The duration of treatment in older patients with benzodiazepine poisoning was 3.5-fold higher than in young and middle-aged patients, mortality in the older age group was 41%.

CONCLUSION The course of acute poisoning with benzodiazepines, including phenazepam, in the elderly and senile age differs in comparison with persons of working age with a high incidence of complications and adverse outcomes.

BACKGROUND One of the main pathogenetic aspects of the severe course of acute pancreatitis (AP) is endothelial dysfunction. Under normal physiological conditions, the endothelium has both anticoagulant and procoagulant properties. However, with the development of AP, endothelial dysfunction often begins as a diffuse activation of coagulation, which further potentiates the progression of the systemic inflammatory response syndrome (SIRS) and thereby complicates the course of AP.  

MATERIAL AND METHODS The present retrospective-prospective study included 78 patients; men — 52 (66.7%), women — 26 (33.3%) with severe AP. The mean age was 51.8±14.2 years. The patients were divided into two groups: the 1st group (n=39), based on a retrospective analysis of the data, included patients in whom the following hemostasis parameters were assessed: activated partial thromboplastin time, international normalized ratio, prothrombin. The second group (n=39) included patients in whom, in addition to the above, the following indicators were evaluated: fibrinogen, D-dimer, antithrombin III, protein C.  

CONCLUSION In the course of this study, it was found that routine methods for assessing the parameters of the hemostasis system, including the determination of only activated partial thromboplastin time, international normalized ratio, prothrombin, are uninformative and do not reflect the severity of the disease. A comprehensive comprehensive study of the coagulation system already in the early stages of the disease indicates an existing tendency to a severe course, which allows anticoagulant therapy to be immediately begun, thereby reducing the number of infectious complications, cases of multiple organ failure, and reducing mortality. 

RELEVANCE Treatment of patients with complicated abdominal infections (AI) is still a difficult task, as evidenced by high mortality rates.  

THE AIM OF THE STUDY is to analyze the results of microbiological investigations of patients with advanced diffuse peritonitis who were treated in the surgical department of the emergency hospital.  

MATERIAL AND METHODS In this study, the main pathogens of advanced peritonitis were identified in 69 patients (the average age of patients was 64±17 years). The cause of peritonitis in the absolute majority of cases (94%) was a perforation of the gastrointestinal tract. A study of various types of clinical material was carried out: blood — 143 samples, urine — 125 samples, bronchoalveolar lavage — 119 samples and 130 samples of wound discharge. 260 strains of microorganisms were isolated.  

RESULTS The predominance of the Enterobacteriacea species (K. pneumoniae and E. coli), non-fermenting bacteria (Acinetobacter spp.) as well as the increasing role of Enterococcus spp. and Staphylococcus spp. (S. aureus and CNS) were found. Multidrug-resistant strains dominated among the identified pathogens.  

CONCLUSION The obtained data on the structure of pathogens of complicated abdominal infection confirm global trends. In order to develop new treatment methods for complicated AI, one of the possible solutions may be the use of human microbial ecology approaches. 

RELEVANCE The problem of sudden cardiac arrest and sudden death among the students of educational institutions is highly relevant for the Russian Federation. In order to plan interventions aimed at improving effectiveness of management and reducing mortality from cardiac arrest in educational institutions, a clear understanding of level of readiness and motivation of teachers to provide help to a cardiac arrest victim is necessary.  

AIM OF STUDY To evaluate willingness of teachers of general education institutions to provide cardiopulmonary resuscitation (CPR) in cases of cardiac arrest, and to investigate factors and relationships that determine readiness of teachers to give help.  

MATERIAL AND METHODS In February–March 2021, an online questionnaire survey of teaching staff of general education institutions was conducted in the Republic of Crimea. As part of the survey, respondents were asked to evaluate their willingness to attempt CPR on a loved one, a stranger or a pupil on a five-point Likert scale, and to indicate potential barriers for performing CPR. The survey was voluntary and anonymous.  

RESULTS The questionnaire was completed by 5,921 teachers. Of all respondents, 9.2% were males, 31.6% — aged over 50 years, 32.3% — work in urban areas. The proportion of teachers who expressed absolute willingness to perform CPR on a loved one, a stranger or a pupil was 63.6% (n=3,766), 34.8% (2,058) and 41.0% (2,427), respectively. At the same time, 13.6% (804), 31.0% (1,836) and 30.6% (1,809), respectively, indicated that they would probably not or definitely not attempt CPR. A high readiness to perform resuscitation (4–5 points) was confirmed to be associated with previous CPR training (p<0.001) and with higher level of CPR knowledge (p≤0.006). The main barriers to providing resuscitation were “lack of CPR knowledge and skills” (indicated by 31.4–36.3% of the respondents depending on the type of presumed cardiac arrest victim) and “fear of causing harm to a victim” (49.2–51.4%).  

CONCLUSION Considerable portion of teachers of general education institutions demonstrate low level of readiness to provide life-saving help in case of cardiac arrest. Lack of CPR knowledge and skills constitute the main barrier to attempting resuscitation. In order to improve survival from cardiac arrest in educational institutions, comprehensive organisational interventions are required, which should primarily focus on ensuring full coverage of teachers with high-quality training and retraining in resuscitation. 

ABSTRACT Currently, the assessment of adrenal dysfunction in critically ill patients and ways to correct adrenal dysfunction with hormone replacement therapy are extremely difficult. The results of the Cochrane meta-analysis “Corticosteroids for treating sepsis” showed that survival was higher among patients with respiratory distress syndrome and septic shock who received glucocorticoids (mainly hydrocortisone) for a long course and at low doses. These results are in very good agreement with the concept of critical illness-related corticosteroid insufficiency (CIRCI) development in the subacute and chronic stages of a critical condition and the need to prescribe glucocorticoid replacement therapy in this situation. International guidelines for the treatment of sepsis and septic shock for 2016 suggest avoiding the use of hydrocortisone in patients who developed sepsis. Only the development of septic shock, and the persisting instability of hemodynamics against the background of achieving normovolemia and high doses of vasopressors, are the indication for the use of hydrocortisone 200 mg intravenously. In 2021, revised guidelines approved the administration of hydrocortisone to patients in septic shock without waiting for an adequate fluid loading to be achieved. In contrast to these recommendations, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, in their recommendations for 2017, suggest for adrenal dysfunction caused by a critical condition in patients with severe community-acquired pneumonia and circulatory arrest the use of hydrocortisone in the early stages, before the development of multiple organ failure. The existing guidelines do not consider the use of hydrocortisone in critical conditions during extracorporeal membrane oxygenation (ECMO). The timing of hydrocortisone administration to critically ill patients requiring ECMO, and the duration of this therapy are currently a topical issue for intensive care specialists. To ensure the completeness of the list of references for compiling a systematic review in the databases MEDLINE, PubMed, MeSH, eLibrary.EN a search was performed for matches, by keywords, and phrases, the roots of keywords, taking into account possible word forms, by the first two hundred relevant links, in case there were so many links. The exclusion criterion was “the use of synthetic glucocorticoids”.

This literature review analyzes Russian and foreign publications over the past five years on the three most discussed issues related to carotid artery surgery: 1.Which is more effective: eversion carotid endarterectomy or conventional carotid endarterectomy with patch closure? 2. Which is better: carotid endarterectomy (CEE) or carotid angioplasty and stenting (CAS)? 3. How soon after the development of ischemic stroke should cerebral revascularization be performed?  

The authors of the article came to the following conclusions: 1. According to the majority of large studies and meta-analyses, conventional CEE with patch closure is associated with a higher risk of internal carotid artery restenosis compared to eversion carotid endarterectomy. Single-center trials with small samples of patients do not find statistical differences between the outcomes of applying both surgical techniques. 2. Large multicenter randomized trials are required to address the effectiveness of CEA and CAS in symptomatic and asymptomatic patients. To date, there has been no consensus on this matter. 3. CEE and CAS can be equally effective and safe in the most acute and acute periods of ischemic stroke when performed in the presence of a mild neurological deficit and the ischemic brain lesion not exceeding 2.5 cm in diameter. Nevertheless, the choice of treatment strategy should be made strictly personalized by a multidisciplinary council based on the experience of the institution and current recommendations. 

Severe concomitant trauma has been a major demographic and medical problem for many years, being the cause of high mortality of the able-bodied population. The simultaneous formation of an array of destroyed tissues triggers a systemic inflammatory reaction, which, against the background of traumatic and hemorrhagic shock, leads to an imbalance in immune reactivity and predisposes to the development of septic complications. The review presents the basic concepts of post-traumatic reactions and violations of the balance of cellular and humoral immune mechanisms leading to the development of complications. 

BACKGROUND The question of the duration and volume of conservative measures in patients with acute adhesive intestinal obstruction (AAIO) remains the subject of numerous discussions. Aim of study To evaluate the efficacy and safety of various periods of conservative therapy in patients with AAIO using a systematic review.  

MATERIAL AND METHODS Criteria for inclusion in the systematic review were cohort studies investigating various regimens and duration of conservative therapy in adult patients with AAIO. The search for primary sources was carried out in the CENTRAL, PubMed and eLibrary databases. The assessment of the safety of various terms of AAIO was carried out by comparing the immediate results of treatment.  

RESULTS The review included 19 papers with a total of 2,570 observations. At the first stage, the effectiveness of various conservative therapy regimens was evaluated by calculating the risk ratio for the success of non-surgical treatment. Taking into account the significant statistical heterogeneity of the participants, the calculation of the final risk ratio was carried out using a random effects model. The hazard ratio for nonoperative success was 1.91 (95% CI 1.2–3.1) in favor of gastrografin and 3.71 (95% CI 1.3–10.6) in favor of preoperative intestinal intubation. Taking into account the multidirectional pathogenetic action of the studied methods of conservative therapy, the obtained results suggested that the probability of success of non-surgical treatment correlates to a greater extent with the total duration of the AAIO episode than with the duration of conservative therapy, which was indirectly confirmed by constructing scattering graphs with approximation lines and calculating the coefficients determination, which amounted to 0.69 and 0.77 for the subgroups of standard therapy and undiluted gastrografin, respectively. Subsequently, the impact of different duration of an episode of AAIO on the immediate outcomes was assessed: mortality, frequency of resection interventions, complications, and total bed-day. There were no statistically significant differences in favor of early interventions (up to 48 hours) for all compared parameters; an increase in the total duration of AAIO up to 89 hours was not associated with worse results.  

CONCLUSION The total duration of the episode of acute adhesive intestinal obstruction, including both the pre-hospital duration and the duration of non-surgical treatment is prognostically significant. In other words, when calculating the allowable duration of conservative measures, one should proceed from the total duration of intestinal passage disturbance, which should not exceed 89 hours. 

Closed chest injury occupies one of the leading places among all injuries. Rib fractures can lead to the formation of floating fragments of the chest wall, the “costal valve”. With multiple rib fractures, surgical methods of chest stabilization have been used since the beginning of the 20th century, which have become more popular in recent decades.  

Surgical treatment can significantly reduce pain, accelerate the recovery of respiratory function. In turn, a decrease in pain reduces the incidence of pneumonia, the need for mechanical ventilation and tracheostomy, and the period of hospitalization. There are four main surgical methods of treatment: 1) chest traction methods; 2) external fixation devices; 3) methods of permanent internal fixation; 4) plate osteosynthesis. We also separated the group of techniques performed via thoracoscopic access and the technique using biodegradable materials. Surgical options in the treatment of patients with multiple rib fractures have not been exhausted and are likely to improve with advances in technology. 

BACKGROUND This review is devoted to the analysis of the features of the immune response in COVID-19. The review indicates the clinical manifestations of COVID-19, modern data on the immunopathogenesis of the disease and its complications are considered.

Aim of STUDY To clarify some pathogenetic mechanisms of the immune response in COVID-19, which can help in creating an algorithm for examining patients for early prognosis and prevention of severe course and complications of the disease.

MATERIAL AND METHODS To achieve this goal, the results of domestic and foreign scientific studies on the pathogenesis, diagnosis and treatment of COVID-19 were analyzed. The literature search was carried out in electronic search engines Scopus and PubMed. For the analysis, scientific articles published in the period from 2019 to 2021 were selected; 88% of analyzed works are not older than 5 years.

CONCLUSION The late production of type I IFN, an increase in the level of pro-inflammatory monocytes, a decrease in the expression of HLA-DR on monocytes, violation of the presentation of the virus and the formation of specific lymphocytes, the death of T-lymphocytes and profound immunosuppression are of greatest importance for the development of a severe form of COVID-19.

The review is devoted to the role of psychological factors in the recovery of patients after spinal surgery (with spinal canal stenosis). The high epidemiological and economic significance of the back pain syndrome was noted. Research results of socio-demographic, clinical and psychological factors in assessing patient satisfaction with the result of the operation and quality of life after the surgery are given. The article presents studies of the effectiveness of psychological assistance methods in the preoperative period and their impact on recovery. The conclusion is made about a certain inconsistency of the existing data, the need for further research and the feasibility of psychological diagnosis before surgery to clarify the prognosis of recovery, identify targets for psychological assistance and conduct a course of psychological preparation to improve the results of surgical intervention.

AIM OF THE STUDY To compare the dynamics of thrombolytic therapy effectiveness in patients with stroke after the reorganization of medical care using JCI standards.

MATERIAL AND METHODS In 2022, a new system for routing patients with stroke at the level of the emergency department was introduced in the Emergency Care Hospital; and 976 patients with the diagnosis of brain infarction were treated. The analysis of the results was carried out by comparing the mortality rates from ischemic stroke, the number of thrombolytic therapies and procedures of mechanical methods of revascularization, as well as the indicators “Door-CT”, “DoorNeedle”, “Door-Opening” for 2021 and 10 months of 2022.

RESULTS After the introduction of the new routing system for patients with stroke at the emergency department level, there appeared the first positive results. Thus, the mortality rate from brain infarction in 10 months of 2022 decreased by 5.6% compared to 2021. The number of thrombolytic therapies performed increased by 5.2%, and mechanical revascularization procedures by 1.62% over the same period, while the “Door-CT” indicator decreased by 27 minutes, “DoorNeedle” by 22 minutes, “Door-Opening” by 31.6 minutes.

CONCLUSIONS The immediate results of the introduction of the new patient routing system at the level of the emergency department have proved successful, primarily due to the significant reduction in the mortality rate of patients with cerebral infarction by 5.6%. However, the process requires further investigation and has application points for further improvement.

The article highlights the key elements and results of the restructuring of emergency care for patients with acute myocardial infarction, the core of which is the teamwork of surgeons, anesthesiologist-intensivists and cardiologists of the department. The restructuring included a change in ideology, personnel changes, updating and expanding the range of equipment, development of inner protocols and their implementation. It took two years to transform the intensive care unit for patients with acute myocardial infarction into the cardiac intensive care unit, where patients with acute cardiac pathologies of various etiologies are treated and preoperative preparation and postoperative nursing are carried out.

ABSTRACT Today, the issue of the effectiveness of emergency specialized care for patients with acute aortic syndrome (AAS) is extremely relevant in Russian healthcare. Much attention is paid to logistics and management in the AAS. There is a tendency to increase the share of hybrid treatment of aortic pathology due to the rapid development of endovascular technologies in Russian healthcare institutions. This article presents the scheme of logistics at the prehospital stage, perioperative management and options for surgical treatment, including hybrid and endovascular options of AAS. Particular attention is paid to the resolution of the malperfusion syndrome. The main studies were carried out on the basis of SAHI RT Regional Center for Emergency Medical Care.

AIM OF STUDY Development of a logistics scheme and tactics for the treatment of patients with acute aortic pathology.

MATERIAL AND METHODS This article provides demographic data and incidence statistics. Not only the hospital stage of effective treatment is important, but logistics with routing and anesthesia management as well. Examples of the routing schemes used by us in practice for patients with AAS starting from 2017 are given. Variants of hybrid treatment and resolution of malperfusion syndrome in patients with AAS are shown on the example of clinical cases.

CONCLUSION The applied schemes for transporting patients with AAS allowed the optimal treatment strategy to be chosen, where time is of the essence. Proper perioperative management in patients with aortic pathology will allow deaths to be minimized and/or prevented. The options of performed surgical treatment showed a good result, a decrease in mortality. Penn classification, especially in a situation of high perioperative risk, made it possible to predict in-hospital mortality and outcomes of surgical treatment, and also helped choose an adequate treatment strategy

AIM Analysis of the outcomes of endovascular stent thrombectomy in patients with acute arterial thrombosis of the lower extremities on the background of COVID-19.

MATERIAL AND METHODS This retrospective study for the period from January 1, 2020 to March 1, 2022 included 34 patients with acute lower limb ischemia who were diagnosed with the novel coronavirus infection SARS-COV-2. Endovascular stent thrombectomy was performed according to the standard technique using a Destination 8F guiding sheath (Terumo), an Advantage 0.014`` guidewire (Terumo), and a Casper stent (Microvention, Terumo) as a stent retriever. In case of fragmentation of thrombotic masses in the guide sheath, manual aspiration of thrombi was performed using a standard 50,0 ml syringe. Self-expanding nitinol stents were implanted in 11 clinical cases.

RESULTS Intraoperative bleeding from the puncture site of the artery developed in 14.7% of cases, which required additional manipulation to achieve hemostasis. Every tenth (11.8%) patient developed myocardial infarction, in 2.9% of cases — ischemic stroke. In the hospital postoperative period during the first hours after surgery, 26.5% of patients developed rethrombosis which required re-intervention. In 8.8% of cases, retrombectomy was unsuccessful, and limb amputation was performed. A fatal outcome occurred in 67.6% of cases, which was due to an increase in multiple organ failure and the development of sepsis.

CONCLUSION Endovascular stent thrombectomy is characterized by a low risk of rethrombosis and amputation in the context of COVID-19.

Necrotizing forms of acute pancreatitis, as the most severe in terms of prognosis, occur in 25–30% of cases with a mortality rate of 27–32%, while in most cases these are adults of working age, which emphasizes the social significance of this problem. This article presents a rare observation of endoscopic intraluminal drainage of zones of pancreatogenic destruction in severe necrotizing pancreatitis. The multidisciplinary individual approach we have chosen makes it possible to treat this group of patients most effectively, which confirms the presented clinical observation.

RELEVANCE Pregnant uterus perforation during laparoscopy is a rare complication, accompanied by a higher risk of infection and miscarriage. Clinical management of pregnancy and its outcome have practical interest and need discussion.

AIM To provide a clinical case of pregnant uterus perforation during laparoscopy.

MATERIAL AND METHODS  Patient L., 34 years old, with a tumor of the right ovary and 21–22 weeks of pregnancy. Result The article describes a clinical case of independent childbirth on time after pregnant uterus perforation during laparoscopy with removing a significant volume of amniotic fluid in a 21–22 weeks pregnant woman.

CONCLUSION The prolongation of pregnancy and independent childbirth on time after uterus perforation with a gestation period of 21 or 22 weeks is possible in case of timely diagnosis of the complication, careful restoration of uterine integrity and rational management of the postoperative period.