<p><strong>Aim.</strong> The study is aimed at presenting the protocol of intraoperative organ protection, analyzing its effectiveness during aortic arch surgery and evaluating the rate of postoperative complications in this group of patients. <br /><strong>Methods.</strong> The study included 141 patients. In the first group (n=70) patients underwent aortic arch surgery with hypothermic circulatory arrest (target core temperature 26 °C) and antegrade cerebral perfusion. Patients of the second group (n=71) underwent ascending aortic replacement using cardiopulmonary bypass with moderate hypothermia (target core temperature 32 °C). Cerebral and tissue oxygenation monitoring was performed in all the cases. In the first group transcranial Doppler monitoring was also performed. 33 patients in the first group and 34 patients in the second group underwent testing before and after surgery in order to evaluate cognitive function. Patients’ condition was evaluated during the in-hospital period that was about 15.97±20.54 days. <br /><strong>Results.</strong> In-hospital mortality rate was 4,2 % in the first group and 0% in the second one (p=0.12). Stroke was observed in 1.4 and 0 % of cases respectively. The rate of encephalopathy (as the leading symptom) was 7.1 and 5.6 % in 1st and 2nd groups respectively. Multimodal monitoring enabled to dynamically adjust the flow rate of antegrade cerebral perfusion. As a result, cerebral SctO2 and linear velocity were maintained within the acceptable range.<br /><strong>Conclusion.</strong> The presented protocol proved to be effective, it allows to perform aortic arch surgery with the same postoperative neurological complications’ rate as after ascending aortic replacement. We recommend performing reconstructive aortic arch surgery by using moderate hypothermic circulatory arrest (26-28 °С) and selective antegrade cerebral perfusion. In this modality, it is important to perform the distal anastomosis quickly and start patient’s rewarming (this will significantly shorten the duration of cardiopulmonary bypass and, as a result, decrease the rate of postoperative complications) and to carry out both precise intraoperative monitoring of the brain condition (by using cerebral oxymetry and transcranial Doppler) and central core temperature.</p><p>Received 21 June 2016. Accepted 21 October 2016.</p><p><strong>Funding:</strong> The study had no sponsorship.<br /><strong>Conflict of interest:</strong> The authors declare no conflict of interest.<br /><strong>Author contributions</strong><br />Conceptualization and study design: Belov Yu.V., Charchyan E.R., Akselrod B.A.<br />Material acquisition and analysis: Khachatryan Z.R., Oystrakh A.S., Medvedeva L.A., Guskov D.A., Fedulova S.V.<br />Statistical data processing: Khachatryan Z.R., Guskov D.A., Skvortsov A.A.<br />Article writing: Akselrod B.A., Khachatryan Z.R., Skvortsov A.A. <br />Review & editing: Charchyan E.R., Akselrod B.A., Eremenko A.A., Belov Yu.V.</p>
В настоящее время данных о применении отечественного рекомбинантного активированного фактора VII (Коагил-VII) в терапии коагулопатических кровотечений в кардиохиругии недостаточно� Цель: оценить эффективность и безопасность отечественного рекомбинантного активированного фактора VII (Коагил-VII) для лечения рефрактерных кровотечений при операциях на грудном отделе аорты� Методы. В исследование включено 82 взрослых пациента с аневризмами и расслоениями аорты, которым выполнены реконструктивные вмешательства на восходящей и дуге аорты в условиях искусственного кровообращения (ИК) и циркуляторного ареста� Все больные разделены на 3 группы: 1-я группа (контрольная)-27 больных с неосложненным течением операции и кровопотерей менее 1 000 мл и стандартным протоколом восстановления гемостаза после ИК; 2-я группа-26 человек с повышенной кровоточивостью, которым для нормализации гемостаза дополнительно применяли тромбоконцентрат; 3-я группа (основная)-29 больных, у которых для лечения сохраняющейся повышенной кровоточивости использован Коагил-VII� Результаты. После введения Коагила-VII в дозе 37-100 мкг/кг наблюдались уменьшение кровоточивости раны, снижение количества перелитой эритроцитарной массы и свежезамороженной плазмы, а также уменьшение послеоперационной кровопотери в сравнении с группой больных с применением тромбоконцентрата и контрольной группой� Побочных реакций на введение гемостатика не отмечено� Анализ лабораторных показателей гемостаза свидетельствовал о том, что под действием Коагила-VII имела место нормализация показателей коагуляции: активированное частичное тромбопластиновое время снизилось на 13%, протромбиновое время-на 17%, а международное нормализованное отношение-на 36%� Заключение. Отечественный рекомбинантный активированный VII фактор коагуляции (Коагил-VII) в дозе 66,0 ± 19,5 мгк/кг является эффективным и безопасным средством в лечении коррекции нарушений гемостаза при операциях на грудном отделе аорты� Ключевые слова: рекомбинантный активированный фактор VII, Коагил-VII, операции на восходящей и дуге аорты, гемостаз Для цитирования: Трекова Н� А�, Гуськов Д� А�, Гончарова А� В�, Аксельрод Б� А� Эффективность отечественного рекомбинантного активированного фактора VII для лечения кровотечений и нормализации гемостаза при операциях на грудном отделе аорты // Вестник анестезиологии и реаниматологии�-2019�-Т� 16, № 3�-С� 25-31�
Introduction. Assessment of the state of the hemostasis system in cardioanesthesiology is carried out both clinically and using standard laboratory tests — thromboelastography (TEG), rotational thromboelastometry (ROTEM), or a combination of both. Both TEG and ROTEM are designed to detect disorders in the hemostasis system in real time. Aim – to evaluate the informativeness of ROTEM performed at the stage of cardiopulmonary bypass (CPB) before neutralization of heparin with protamine and to study the prognostic value of this study in assessing the risk of postoperative bleeding during cardiac surgery with a high risk of bleeding. Materials and methods. The assessment of the diagnostic significance of ROTEM studies at the CPB stage is based on the observation of 31 patients operated on from July to October 2018. The median age of these patients was 55 years (31–72 years). The criteria for inclusion of patients in the study were the performance of planned cardiac surgery with a high risk of bleeding: operations on the aorta, combined operations (coronary bypass surgery and/or surgery on the valve(s), multivalve correction), including repeated. Methods of descriptive statistics, correlation and comparative analyses, and ROC-analysis were used to assess the diagnostic and prognostic capabilities of ROTEM research during CPB against the back=-ground of high doses of heparin. Results. A statistically significant linear correlation was noted between A5 and MCF indicators in EXTEM, FIBTEM and PLTEM tests performed both during and after CPB. The results obtained indicate that determining the cause of bleeding and deciding on the choice of therapy is possible significantly earlier than the MCF indicator is determined, namely 5 minutes after the start of blood clotting in the ROTEM study. The informative value of ROTEM studies performed during CPB is shown, however, when interpreting the results, it is necessary to focus not only on the reference intervals, but also on the obtained cut-off levels for ROTEM parameters during CPB for early detection of hypofibrinogenemia or thrombocytopenia after CPB. Conclusion. ROTEM performed with the use of high doses of heparin during CPB is informative for the choice of pathogenetically justified therapy for possible bleeding.
Aim. This study aims to assess the association between levels of biomarkers and postoperative complications in patients after thoracic and thoracoabdominal aortic reconstruction.Material and methods. This study included 132 patients. The most of them underwent ascending aortic and aortic arch reconstruction (65 and 57, respectively).The concentrations of proadrenomedullin, presepsin, procalcitonin, troponin I and N-terminal brain natriuretic peptide were measured before induction anesthesia, at the end of the surgical operation and in 6 hours after surgery.Results. 69 patients had postoperative complications. Among them, inflammatory (27,3%) and cardiovascular complications (12,1%) prevailed. At the end of the surgical operation, the levels of the biomarkers in patients without postoperative complications and with postoperative complications were for presepsin 326 [206; 451] и 620 [332; 829] p<0,00001, tropononin I 0,77 [0,46; 1,39] and 1,49 [0,59; 3,39], p=0,01, proadrenomedullin 0,894 [0,683; 1,221] and 1,201 [0,944; 1,762], p=0,0002, procalcitonin 0,206 [0,147; 0,452] and 0,563 [0,307; 2,107], p=0,0002, respectively. According to log-linear regression model, the level of prepepsin at the end of the surgical operation >459,5 (odds ratio (OR) 6,84, 95% confidence interval (CI): 3,14-14,87) or proadrenomedullin >0,788 (OR 5,47, 95% CI: 1,52-19,68) are associated with the increased risk of postoperative complications. The level of presepsin >519,5 pg/ml at the end of the surgical operation (OR 4,55, 95% CI: 1,97-10,47) is associated with the increased risk of inflammatory complications. Regarding the prognosis of the risk of prolonged cardiotonic drug infusions, threshold values for troponin were >1,04 at the end of the surgical operation (sensitivity 75%, specificity 71,3%, AUC 0,785), >1,57 in 6 hours after surgery (sensitivity 81,3%, specificity 71,6%, AUC 0,794).Conclusion. High levels of presepsin at the end of the surgical operation may be useful to predict the postoperative complications in patients who underwent the aortic surgery however, the low levels of presepsin do not exclude the development of postoperative complications. The increased level of troponin I at the end of the surgical operation and in 6 hours after surgery can be a predictor of the need for cardiotonic support in the postoperative period.
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