Anti-shock Therapy Research Articles

Extracorporeal membrane oxygenation combined with hemoperfusion to assist in the rescue of aconitine poisoning: A case report.

Extracorporeal membrane oxygenation (ECMO) has been widely used as a clinical bridge for cardiopulmonary failure. We recently used combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and haemoperfusion to successfully treat a patient with acute aconitine poisoning. The patient was admitted to the Emergency Intensive Care Unit (EICU) in a state of coma and shock. Her received comprehensive treatment, including haemoperfusion and anti-shock therapy. 40 minutes after admission, the patient experienced sudden respiratory and cardiac arrest. After conventional defibrillation and cardiopulmonary resuscitation proved ineffective, veno-arterial ECMO was immediately initiated. One hour after initiation of VA-ECMO, the patient's heart rhythm stabilised to sinus rhythm. After 33 h of supportive care, the patient was awake, haemodynamically stable and the VA-ECMO was successfully removed. The patient made full recovery 7days after admission.

Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report.

Uterine inversion is a rare medical condition that is categorized as puerperal and nonpuerperal. Repositioning of uterine involution can be done manually or surgically, the latter of which involves abdominal manipulation and disruption of the integrity of the uterine wall, which can lead to complications for the patient in subsequent pregnancies, such as uterine rupture. We report a case of acute puerperal uterine inversion that was manually repositioned transvaginally. An ultrasonogram and reset schematic were also presented. A 23-year-old woman (gravida 1 para 0) was admitted to the hospital with a full-term pregnancy. In the postpartum period, we found placental adhesions and uterine inversion into the uterine cavity, which was confirmed by bedside ultrasound. We administered analgesic, relieving uterine spasms, and antishock therapy along with manual stripping of the placenta and ultrasound-guided uterine repositioning. After successful repositioning the patient vaginal bleeding decreased rapidly and she was discharged 3 days after delivery. Early recognition, antishock therapy and prompt repositioning are key in the management of puerperal uterine inversion. We hope that this case will enable clinicians to better visualize the ultrasound imaging of uterine inversion and the process of manual repositioning.

Клинический случай оказания экстренной медицинской помощи пациенту с сочетанной травмой после дорожно-транспортного происшествия

Abstract. This research demonstrates a clinical observation of emergency medical care to a patient with associated trauma after a road traffic accident with the diagnosis: “Closed-skull brain injury. Brain concussion. Closed blunt chest trauma. Fracture of the IV–VII ribs on the right and left. Bruise of the right and left lungs. Closed comminuted fracture of the left femur in the middle third with displacement. Paresis of the left oculomotor nerve. Traumatic shock of the III degree”. The description of this case report allows to analyze the clinical and instrumental examination of the victim, tactics of intensive therapy and surgical treatment, clearly demonstrating that the primary task in the management of a victim with severe polytrauma after an accident is diagnosis, anti-shock therapy, pain relief, recovery of impaired vital functions of the body, stabilization of the patient’s condition and surgical treatment of damages and fractures. The research provides a demonstration of successful surgical treatment of a complex closed comminuted diaphyseal fracture of the left femur. A multidisciplinary approach to the treatment of a victim in a road traffic accident with combined trauma is an integrated approach that includes the coordinated action of specialists in various fields, aimed at maximizing the improvement of the victim’s condition. Correctly chosen tactics of diagnostic and treatment measures play a key role in ensuring a positive result and recovery of the victim. Thanks to the coordination of the actions of doctors of various specializations, the victim receives the necessary assistance at each stage of treatment, which contributes to rapid recovery and return to normal life.

PROTECTED BETA-LACTAM PRESCRIPTION FOR PATIENTS WITH SEPTIC SHOCK

The purpose of this retrospective study is to evaluate the clinical efficacy of two protected drugs, imipenem/cilastine/relebactam and piperacillin/tazobactam, in the treatment of septic shock. The material of the study and observation included 17 patients with septic shock, 9 of them (Group 1) were treated with imipenem/cilastin/Relebactam, 8 of them (Group 2) were treated with piperacillin/tazobactam. All patients received adequate anti-shock therapy, invasive or non-invasive ventilation, and renal replacement therapy. Bacteriological examination showed the presence of four gram-negative pathogens in the biological material of patients. A multidrug-resistant strain of Acinetobacter baumanii with high resistance to both the studied antibiotics and Pseudomonas aeruginosae. Further phenotyping and genotyping confirmed the production of metallo-β-lactamases in both cases and class D carbapenem hydrolyzing oxacillinase in Acinetobacter bau- manii. Treatment of patients with septic shock caused by these strains was equally ineffective with both IMI/REL and PTZ and resulted in death. The results obtained can be used in the meta-analysis and planning of further clinical trials of inhibitor-protected beta-lactams.

TREATMENT OF COMBAT SURGICAL TRAUMA OF THE LIMBS IN THE CONDITIONS OF MODERN WAR

Among the total number of wounded who entered the Military Medical Clinical Center of the Western Region from February to September 2022, combat injury to the limbs was in 63.3%. Bullet wounds caused combat injury to the limbs in 10.4%, shrapnel and mine-explosive – in 68.1%, explosive injury – in 21.5%. At the second role of medical care, emergency surgical interventions were performed on the wounded, immobilization of bone fractures with an external fixation and anti-shock therapy. At the third and fourth roles – the treatment of the wounded consisted in the use of a multidisciplinary approach with the involvement of doctors of various specialties, first of all, general surgeons, traumatologists, vascular, plastic surgeons and anesthesiologists. The most frequent surgical intervention was repeatened and secondary debridment of gunshot wounds, which was required by 93% of the wounded. The main pathogens that vegetated in wounds were Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter aerogenes, Proteus vulgaris, Enterococcus faecalis with high levels of microbial contamination – 104-108/g in tissues., Various types of plastics were used to close soft tissue defects, according to the rule of the reconstruction ladder. After healing a soft tissue wound to determine the timing of replacing the method of fixing fractures with internal osteosynthesis, were analyzed clinical and laboratory parameters and assessed the risks of complications. The main causes of amputations of the limbs were common defects in soft tissue and bones, which were not subject to reconstruction with no prognosis for bone fusion and progression of the infectious-necrotic process.

Experience of the trauma operative treatment of the lower extremities main vessels in the work injuries

Objective. The structure of combined osseous–vascular work injury of the lower extremities was studied, and the results of its operative treatment analyzed retrospectively.
 Materials and methods. The data concerning 147 patients with combined osseous–vascular work trauma of the lower extremities were analyzed. All the patients managed were from 19 to 48 yrs old, and their average age constituted 30.2 yrs old. The mine trauma with injuries of femoral and/or the shin bones and a. poplitea prevailed – in 129 (87.8%) and 116 (78.9%) observations, accordingly. There were performed 92 two–staged interventions in a common operative team with traumatologists.
 Results. Positive result of operative treatment was noted in 73 (79.3%) patients. The time span between the trauma moment and the operation beginning in this group of the patients have constituted from 2 to 5 h, while the degree of an acute arterial ischemia in accordance to V. S. Savelyev (1973) were signed as IIa–IIb. The operation duration have constituted from 3 to 4 h. All the patients have had a combined shock Degree II. The preoperative blood loss volume has been ranged from 1 to 2.5 l. The a. poplitea injury have had prevailed and occurred in 43 (58.9%) patients. In 6 (6.5%) patients after reconstructive intervention the extremity amputation was performed.
 Conclusion. Mostly favorable result was obtained in the injured persons, who were delivered early (upto 2 h) to specialized stationaries with conduction of preoperative antishock therapy.

An alveolate kidney

Rationale: Emphysematous pyelonephritis is a life-threatening infectious disease that requires early diagnosis and treatment. The disease is often misdiagnosed due to its diversity of clinical manifestations. Patient's concern: A 62-year-old woman was admitted to the emergency department following a 12-hour history of abdominal pain and dyspnea. Physical examination showed percussion pain on the right costovertebral angle. Besides, she had a history of diabetes mellitus and urinary calculus. Diagnosis: Emphysematous pyelonephritis. Intervention: The patient accepted antishock therapy, tight glucose control, and broad-spectrum anti-infective therapy. After stabilization of the general condition, an ultrasound-guided percutaneous nephrostomy was performed. Outcome: Her conditions became stable over the following days. She presented a favorable clinical course, with normalization of renal function and positive improvements in imaging findings in a month. Lessons: Early diagnosis and rapid medical management are the keys to successful treatment. CT is an important method for the diagnosis of emphysematous pyelonephritis. For patients with severe lesions, percutaneous renal drainage combined with active anti-infection should be given in time.

Політравма та поєднана травма: що спільного і які відмінності?

Актуальність. Пацієнти з політравмою є найтяжчою категорією травмованих, потребують невідкладної протишокової терапії, багатьох хірургічних втручань, інтенсивної терапії у відділеннях реанімації, комплексного відновного лікування та значних фінансових витрат. Для виокремлення пацієнтів із політравмою з масиву постраждалих із поєднаними і множинними травматичними ушкодженнями проведено порівняльний аналіз об’єктивних показників гомеостазу, які характеризують синдром взаємного обтяження. Матеріали та методи. Для оцінки розладів функцій забезпечення життя організму і об’єктивного обґрунтування розвитку синдрому взаємного обтяження у постраждалих із закритою поєднаною травмою (ЗПТ) проведено аналіз гомеостазу за 50 показниками клінічно-лабораторних обстежень і інтегральної реографії тіла у 27 постраждалих із закритою ізольованою травмою — Abbreviated Injury Scale (AIS) ≥ 3, у 90 постраждалих із ЗПТ, в яких поєднувалось тяжке пошкодження (AIS ≥ 3) і нетяжке пошкодження (AIS ≤ 2), і у 96 постраждалих із закритою тяжкою поєднаною травмою (ЗТПТ), в яких поєднувались два тяжких пошкодження (AIS ≥ 3 кожного): при госпіталізації, через 6, 24 і 48 годин після надходження. Результати. За результатами проведеного порівняльного клінічно-статистичного аналізу встановлено, що у постраждалих із ЗТПТ, в яких поєднувались два тяжких пошкодження (AIS ≥ 3 кожне), розвинулися виражені специфічні розлади гомеостазу у відповідь на механічну травму, що знайшло відтворення у синдромі взаємного обтяження при госпіталізації постраждалих. Цих пацієнтів трактували як пацієнтів із політравмою. У постраждалих із ЗПТ, в яких поєднувалось тяжке пошкодження (AIS ≥ 3) і нетяжке пошкодження (AIS ≤ 2), синдром взаємного обтяження розвинувся тільки на третю добу після госпіталізації, потім його прояви поступово зникали, тому їх зараховували до пацієнтів із поєднаною травмою. Вірогідно встановити числове значення за шкалою ISS для поєднаної травми і політравми не вдалось, оскільки і в одній і в другій групі були пацієнти з тяжкістю пошкоджень за шкалою ISS понад 18 балів, проте у більшості пацієнтів із політравмою це число було вищим, ніж у пацієнтів із поєднаною травмою. Висновки. Сумарна анатомічна й анатомо-функціональна оцінка тяжкості пацієнтів із поєднаною травмою з урахуванням особливостей впливу синдрому взаємного обтяження дозволяє провести індивідуальну оцінку їх тяжкості та виокремити пацієнтів із політравмою, в яких анатомічна тяжкість не менше двох пошкоджень становить за шкалою AIS ≥ 3 балів, і вже при надходженні у травмованих виявляється синдром взаємного обтяження.

Effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage.

In recent years, it has been reported that the anti-shock effect of plasma substitutes in adult patients with major burn in shock stage is not good. However, due to the shortage of clinical frozen plasma supply, it is impossible to guarantee that frozen plasma is used as colloidal solution for anti-shock treatment. The purpose of this study is to explore the effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage. This study enrolled 586 adult patients with major burn by selecting the hospitalization burn patients, who had been hospitalized at the Jiangxi province burn center from September 2014 to April 2019. The patients with the infusion ratio of frozen plasma to plasma substitutes ≥2꞉1 at 48 hours after admission were included in the experimental group, otherwise they were included in the control group. The basic clinical data and clinical prognosis indicator in the 2 groups were compared. Logistic univariate regression analysis was used to screen the influential factors of 30-day mortality in adult patients with major burn, and logistic multivariate regression analysis was used to obtain independent risk and protective factors; Kaplan-Meier method was used to draw the survival curve of the 2 groups, and log-rank test was used to compare the 30-day survival rate of the 2 groups. There were significant differences in the infusion volume of frozen plasma and plasma substitutes between the 2 groups at 48 hours after admission (both P<0.05). The duration of mechanical ventilation in the experimental group was shorter than that in the control group, the percentage of continuous renal replacement therapy (CRRT) in the experimental group was lower than that in the control group, and the in-hospital mortality and 30-day mortality in the experimental group were lower than those in the control group, the differences were statistically significant (all P<0.05). The percentage of burn area and total body surface area (TBSA) was an independent risk factor for 30-day mortality of adult patients with major burn (OR=1.228, 95% CI 1.010 to 1.439, P=0.039), while the infusion ration between of frozen plasma and plasma substitutes 48 hours after admission was an independent protective factor (OR=0.016, 95% CI 0.001 to 0.960, P=0.023). The 30-day survival rate of the experimental group was significantly higher than that in the control group (P<0.001). Infusion ration between frozen plasma to plasma substitutes at 48 hours after admission is an independent protective factor for 30-day mortality of adult patients with major burn. In the early stage of adult patients with major burn, frozen plasma should be used as the anti-shock therapy as far as possible (frozen plasma꞉plasma substitute ≥2꞉1) to improve the prognosis and reduce the of 30-day mortality.

Impact of infusion therapy programs on homeostasis indicators in patients suffering from shockogenic trauma from the point of view of statistical reliability

From the point of view of statistical reliability, the influence of various infusion therapy programs on homeostasis indicators of patients suffering from shockogenic trauma is considered. It has been revealed that when entering the intensive care and intensive care department in patients suffering from severe traumatic shock, against the background of algorithms of anti-shock measures at the pre-emergency and hospital stages there are significant individual intervals of examined homeostasis parameters, which indicates expressed personalized disorders of indicators of reflecting function of organs and systems of patients. The variation in the canonical space of the investigated parameters in patients increased after 12 hours, after admission to the intensive care and resuscitation department. Anti-shock therapy contributed to the fact that the distribution of patients of all three groups in the canonical space after the first 24 hours was dynamically compacted, indicating a decrease in differences between patients of each group during the treatment process. Cluster analysis and multi-dimensional scaling revealed the multilateral dynamics of the relationship between independent variables in various infusion therapy programmes. When patients were admitted to the intensive care and intensive care unit, almost the same orientation of the features of connections between independent variables was noted, however, their polarity was recorded during the treatment process. This shows that the infusion therapy program in patients suffering from severe traumatic shock should be carried out taking into account the dynamics of individual disorders of the investigated homeostasis parameters. It has been statistically proven that different infusion therapy programs have very different effects on homeostasis rates. The use of sterofundin isotonic and 4% modified gelatin in this category of patients has been proven to be the most effective and safe volemic recovery scheme.

Retrospective cohort study on the correlation between high value of lactic acid and risk of death in 127 patients with extensive burn during shock stage

Objective: To analyze the relationship between serum lactic acid value and risk of death in patients with extensive burn during shock stage and the related influencing factors. Methods: Clinical data of 127 patients (111 males and 16 females) with extensive burn admitted to Institute of Burn Research of the First Affiliated Hospital of Army Medical University from January 2009 to December 2013 and Department of Plastic Surgery and Burns of the Affiliated Hospital of Southwest Medical University from January 2016 to December 2018, who met the admission criteria, were retrospectively analyzed. The patients aged 21 to 62 years, with total burn area more than 50% total body surface area. All patients were treated with antishock therapy after admission. (1) According to the treatment outcome, the patients were divided into survival group (n=98) and death group (n=29). The gender, age, total burn area, partial-thickness burn area, full-thickness burn area, abbreviated burn severity index (ABSI), admission time after injury, number of patients with inhalation injury, number of patients with acute renal failure, and serum lactic acid values on admission and at post admission hour (PAH) 12, 24, 36, and 48 were recorded. (2) According to the optimal positive cut-off value of serum lactic acid 48 hours after admission, the patients were divided into high lactic acid group and normal lactic acid group. Age, gender, total burn area, indexes at PAH 48 including urea nitrogen, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total serum bilirubin, alkaline phosphatase (ALP), albumin, white blood cell count, platelet count, lymphocyte count, prothrombin time (PT), hematocrit value, oxygenation index, respiratory index (RI), the alveolar-arterial oxygen partial pressure difference, mean arterial pressure (MAP) at PAH 48, the average urine volume within 48 hours after admission, the total volume of intravenous fluid infusion within 48 hours after admission, the volume of fluid infusion per kilogram of body mass within the first 24 hours after admission, the volume of fluid infusion per one percent of body surface area per kilogram of body mass within the first 24 hours after admission, the volume of urine per kilogram of body mass per hour within the first 24 hours after admission, and the percentage of hospital death were recorded. Data were processed with t test, chi-square test, and Fisher's exact probability test. Cox regression analysis was used to screen independent risk factors affecting the prognosis of patients. Receiver operating characteristic curve (ROC) of serum lactic acid value at PAH 48 of 127 patients was drawn to predict patients' death and determine the optimal positive cut-off value. Multivariate logistic regression analysis was used to screen independent risk factors causing increase of serum lactic acid. Results: (1) There were significantly statistical differences in total burn area, full-thickness burn area, and ABSI of patients between survival group and death group (t=6.257, 4.476, 5.727, P<0.01), while other indexes between the two groups were close. (2) The serum values of lactic acid of patients in death group on admission and at PAH 12, 24, 36, and 48 were (4.00±0.28), (4.50±0.26), (4.02±0.31), (3.48±0.22), (3.40±0.19) mmol/L, respectively, which were significantly higher than those in survival group [(3.30±0.21), (3.20±0.19), (2.33±0.17), (1.85±0.18), (1.50±0.09) mmol/L, t=14.552, 29.603, 38.133, 40.648, 74.973, P<0.05 or P<0.01]. (3) Cox regression analysis showed that the serum value of lactic acid at PAH 48 was the independent risk factor affecting the prognosis of patients, with risk ratio of 1.853 and 95% confidence interval of 1.342-2.559, P<0.01. (4) The total area under ROC of serum value of lactic acid at PAH 48 to predict death of 127 patients was 0.811, with 95% confidence interval of 0.699-0.924, P<0.01. The optimal positive cut-off value of serum value of lactic acid was 1.75 mmol/L, with sensitivity of 75.0% and specificity of 79.5% for predicting death. (5) There were significantly statistical differences in total burn area, ALT, AST, ALP, PT, total serum bilirubin, total volume of intravenous fluid infusion within 48 hours after admission, volume of fluid infusion per kilogram of body mass within the first 24 hours after admission, and percentage of hospital deaths of patients between high lactic acid group (n=34) and normal lactic acid group (n=93), t=3.592, 6.797, 10.367, 2.089, 2.880, 4.517, 2.984, 4.044, χ(2)=58.498, P<0.05 or P<0.01, while other indexes were close between the two groups. (6) Multivariate logistic regression analysis showed that AST and total serum bilirubin were independent risk factors for increase of serum lactic acid, with odds ratios of 1.021 and 1.064 and 95% confidence intervals of 1.001-1.040 and 1.001-1.132, P<0.05. Conclusions: Serum value of lactic acid at PAH 48 can independently predict the death of patients with extensive burns. Liver injury is an important risk factor causing hyperlacticemia during burn shock stage. Widespread increase of vascular permeability and large amount of fluid resuscitation are the core factors leading to aggravation of abdominal organ injury.

The first domestic devices for intraosseous infusion - is the great advance of military medicine in pre-hospital stage enhancement

Traumatic shock is considered to be the most common clinical form of a severe patient’s condition (63%). Timely and adequate blood volume resuscitation is one of the most important procedures in providing medical care to critically injured casualties and patients at the forward medical evacuation stage. The key to this problem, especially when the infusion therapy is needed at the pre-hospital stage, is the development of alternative (extravascular) techniques of plasma volume expander administration. The article presents the results of testing of the first domestic medical devices for intraosseous infusion in critically injured casualties and patients. At present, on commission of the Russian Ministry of Defense and with the scientific support of Kirov Military Medical Academy, domestic enterprises developed test samples of medical devices to provide intraosseous infusions: a «Disposable device for intraosseous infusion of solutions if there is no intravenous access, which was designed on the basis of a spring drive» - the index «VKI-P», developed by limited liability company «Novoplast-М» and a set for intraosseous infusion using an electric drive - the index « VKI-E», developed by limited liability company «Research engineering company «Spetsproekt». Assessment of performance of test samples of the medical devices for intraosseous infusions «VKI-P» and «VKI-E» was carried out using pathophysiologic model of traumatic shock in 14 experimental animals (pigs) by creating artificial blood loss of medium severity, 25% of circulating blood volume (in average 440 ml), followed by its resuscitation with intraosseous infusion of 0,9% solution of NaCl. As a result of the performed tests it was found that the device «VKI-P» and the set «VKI-E» provide for NaCl infusion in major vessels (with an intraosseous infusion), 750 ml of volume during 45-50 min, and can be used as an alternative access to provide infusion as a part of anti-shock therapy, which solves the problem of volume resuscitation when giving care to severely injured casualties and patients at the forward medical evacuation stages. These samples may be recommended for inclusion into the medical service list of complete supplies and the Medical Corps supply support, the Armed Forces of the Russian Federation.

Fournier gangrene – ward experience

Introduction. Fournier’s gangrene is a necrotising soft-tissue infection characterized by insidious and rapid onset. It belongs to the group of necrotising soft-tissue infections. The disease is more common in patients with systemic predispositions such as diabetes mellitus, obesity, hepatic cirrhosis, cancer, etc. Aim. The results of medical treatment thirtieths patients (man from 34 to 84 years old, middle age 67 years old) and co-morbidity with Fournier’s gangrene was presented. Material and methods. The co-morbidity was discussed and analized. The patients were treated by antishock therapy, proper antibiotic therapy was applied. The complications were presented during treatment, procedures with wounds, debridement and wounds treatment and final treatment skin deficiency. All patients had covered skin deficiency by mesh grafts, they were discharged from hospital with healed wounds or almost healed. Treatment from medical literature dealing with treatment and experience of Urological Wards was also presented (Fournier’s gangrene is a part of this disease). Results. Mortality was not observed in this group of patients. Conclusions. Fournier’s gangrene is a rapid-onset, life-threatening, acute urological disease requiring immediate diagnosis, as well as anti-shock and antibacterial therapy combined with intensive surgical debridement followed by the management of skin and soft tissue defects.

Retrospective analysis of 18 cases of anaphylactic shock induced by bupleurum injection

Objective To investigate the clinic features and regularity of anaphylactic shock induced by bupleurum injection, and to provide reference in clinic for rational use of bupleurum injection. Methods Checked out the case reports of anaphylactic shock induced by bupleurum injection in the data-bases in China from 1996 to 2015 for statistics and analysis. Results 18 cases of anaphylactic shock were reported and sexual equality, and all were injected intramuscularly; 13 cases(72.2%) occurred within 5min and cardiovascular system and central nervous system as the main clinical manifestations.By the active anti-shock therapy, 17 cases recovered and 1 case died. Conclusion Allergic shock induced by bupleurum injection happens now and then in clinics, so clinical drug using should pay attention to the history of allergies and medication adverse reactions in the process of observation, in order to reduce drug safety hazards. Key words: Anaphylaxis; Shock; Bupleurum Injection; Retrospective Studies

Anesthetic management of patients with active infective endocarditis undergoing cardiac valve surgery under cardiopulmonary bypass

Objective To summarize experience and characteristics of the perioperative anesthetic management of patients with active infective endocarditis(AIE)undergoing cardiac valve surgery under cardiopulmonary bypass (CPB). Methods A total of 117 patients of both sexes, aged 18-70 yr, of American Society of Anesthesiologists physical status Ⅱ-Ⅳ, undergoing cardiac valve surgery under CPB from January 2014 to June 2015 in Peking Union Medical College Hospital, were enrolled in the study and divided into AIE group (n=57) and non-AIE group (n=60). Anesthesia was induced by IV injection of midazolam 1-2 mg, etomidate 0.15-0.30 mg/kg, sufentanil 0.3-0.5 μg/kg and rocuronium 0.6-1.0 mg/kg.After orotracheal intubation, the patients underwent high-frequency volume-controlled ventilation with low tidal volume, and positive end-expiratory pressure was increased appropriately.Esophageal echocardiography was used for evaluation.Anesthesia was maintained by inhalation of 1.0%-1.5% sevoflurane, intermittent IV boluses of sufentanil 0.2-0.3 μg/kg and IV infusion of piperium bromide 2 mg/h, and the bispectral index value was maintained between 40-60 during surgery.Sensitive antibiotics were given during surgery according to the results of preoperative blood culture in AIE group.The following data were collected: baseline patient characteristics, preoperative blood routine, erythrocyte sedimentation rate, concentrations of hypersensitive c-reactive protein and amino-terminal pro-brain natriuretic peptide, operation time, CPB time, intraoperative consumption of vasoactive drugs, fluid intake and output, use of antibiotics, length of postoperative intensive care unit stay, extubation time, new invasive operation (intra-aortic balloon counterpulsation was performed), time for use of vasoactive drugs, postoperative 24 h drainage, length of hosptial stay, serious complications (postoperative bleeding, pericardial tamponade, severe arrhythmia, heart failure, acute lung injury, renal failure and other organ function failure, etc.) and development of death. Results Compared with non-AIE group, age, body mass index and preoperative Hb, Hct, systolic blood pressure and diastolic blood pressure were significantly decreased, the rate of preoperative hypertension, neutrophil count, erythrocyte sedimentation rate, concentrations of hypersensitive c-reactive protein and amino-terminal pro-brain natriuretic peptide, body temperature and heart rate were increased, the intraoperative volume of allogeneic blood transfused and consumption of norepinephrine, phenylephrine and ephedrine after CPB were increased, the time for postoperative use of vasoactive drugs, extubation time and length of postoperative intensive care unit stay were shortened, and the length of hospital stay was prolonged in AIE group (P<0.05). Conclusion For the patients with AIE undergoing cardiac valve surgery under CPB, comprehensive evaluation should be performed and heart failure be corrected actively before surgery; esophageal echocardiography should be used for evaluation, the application of vasoactive drugs could be increased appropriately and anesthetists should pay attention to respiratory management during surgery; cardiotonic and anti-shock therapy should be maintained, arrhythmia prevented and anti-infective therapy strengthened after surgery. Key words: Endocarditis; Cardiac surgical procedures; Cardiopulmonary bypass; Anesthesia

Death from poisoning of snake venom, as a result of a viper’s bite

Aspect of poisoning after a black adder’s bite can be very various (from the absence of clinical picture of poisoning to the mortal case) and unforeseeable in its progress. Poison of black adder is more toxic in comparison with Orsini’s viper, the death after a black adder’s bite comes approximately in 1% cases. Unpredictability of consequences of such bite depends on such objective factors as: weight of the injured person’s body (the reaction is more severe for children); state of health (presence of co¬existing diseases); places of bite (the most dangerous bites are considered in head or neck and discovering of poison in cutaneous vein); size of snake (the larger snake has more poison); amount of the entered poison (a viper produces a poison gradually, and if a poison is used by it recently, a bite can be absolutely safe «dry bite». In the spring time the viper’s venom is more toxic than in the summer time. Composition of the viper’s venom contains the enzyme components, winch form a clinical aspect of poisoning substantially by these poisons, The proteases of vipers’ poison cause the local damage of tissues, zonal hemorrhoidal edema, myonecrosis, as well as have fibrogenic, fibrinolytic, coagulating and bradykinin liberatoral actions. The proteolytic enzymes of poisons can be divided into two groups: serine proteases and metalloproteases.&#x0D; Serine proteases are thermolabile endopeptidases, having a kind of action similar to thrombin enzymes of takininogenases. The second group of proteases of the snake venom contains thermolabile proteins, which hydrolyze protein substrates (casein, haemoglobin, insulin etc.). Activity of these metal!oproteases appears in the presence of bivalent metals.&#x0D; In this case a citizen A., born in 1938, asked for medical assistance to the district hospital on May 3, 2016 at 15.20 with complaints of pain in the left lower limb in the place of a bite, a pain at the back of a breastbone, general weakness, dizziness, nausea, common cold. She considers itself as diseased woman during about two hours, when she was bitten by the unknown animal (snake) during work on a vegetable garden. She felt a sharp pain in the left foot. She was examined by a doctor: on the dorsum of the left foot there is the «place of a bite» with a diameter of 0,2 cm. A foot was swollen, hyperaemic, and hot. The size of hypodermic haematoma is 7x5 cm. The patient has unstable hemodynamics, permanent nausea. Antitoxic therapy, antishock therapy, hormonal preparations, preparations against vomit were assigned for the patient. Biological death of the patient came at 4 hours. It is necessary to note, that in her lifetime the patient had an ischemic heart trouble, hypertensive illness. At carrying out of medical and legal expertise of dead body, at external investigation it was discovered: hypodermic hemorrhage of violet color, oval form, with the size of 17x11 cm on the dorsum of the left foot, on a background the edema of soft tissues, from fingers to the limit of bottom third of the left shin. On a background the above mentioned hypodermic hemorrhage in the projection of instep bone of the first finger of the left foot on a back-internal surface it is discovered a two wounds of the rounded form with even edges, having a diameter of 0,2 cm, spread to wound canals. A liquid flows from the clearance of wounds of dark-red blood . At dissection of soft tissues, muscles were saturated with a blood, divided into layers. It is discovered a liquid blood in layers.&#x0D; At internal research there were signs of rapid death coming (head cerebral and lungs edema, hyperemia of the inward parts of the body, dark-red blood in the cavities of heart and large vessels, hemorrhages of dark-red colour under the pleura of lungs and epicardium of heart).&#x0D; Results of histological research: imposition of blood on an epidermis, hemorrhagein all layers of derma and to the hypodermic-fatty cellulose in soft tissues in the area of a bite, consisting of partly laky red corpuscles. Leukostasis in vein, dissection and homogenization of vascular walls, edema and homogenization of tissue. In kidneys on a background of anaemia of cork substance it is discovered the centre of venous plethora of tissue, erythrocytic sludged blood in venules, albuminous degeneration of the twisted channels. It is discovered the irregular blood filling of tissues. Taking into account macro- and microscopic picture of changes in organs and tissues, circumstances of the case it may be concluded that the victim’s death occurred from the action of the snake’s venom.

Fournier’s gangrene

The review highlights the issues of etiology, pathogenesis, clinical and laboratory picture, radiodiagnosis, treatment and prognosis of fulminant perineum gangrene, or Fournier’s gangrene. According to modern concepts, Fournier’s gangrene is one of the rare forms of necrotizing fasciitis of polymicrobial etiology with a primary lesion of the skin, subcutaneous tissue and superficial fascia of the scrotum, penis, and perineum. Fournier’s gangrene refers to acute surgical diseases of pyonecrotic nature and is characterized by rapid septic course, high mortality, reaching 80%, in spite of the modern antibiotic therapy advances. Over the last decade the Fournier’s gangrene incidence increased in 2.2-6.4 times, due to the increasing number of immunocompromised patients in the population. The disease most often occurs in older men with diabetes, alcoholism and obesity. The Fournier’s gangrene occurrence is preceded by different inflammatory diseases of the colon, urinary organs, scrotum and perineum skin. The disease diagnosis in full-scale stage usually is not difficult. In rare cases, namely in the disease early stages, various radiological methods of investigation, laboratory tests and exploratory surgery with affected soft tissues express biopsy are used with differential diagnosis purposes. The cornerstone in the Fournier’s gangrene treatment is an emergency surgical intervention in combination with a powerful anti-bacterial and anti-shock therapy. To improve the wound healing course and reduce the septic complications risk, new methods of adjuvant treatments such as hyperbaric oxygen therapy and vacuum therapy are used. Hospitalization duration in Fournier’s gangrene is usually lengthy, due to the need to use repeated sanitation necrectomy and reconstructive plastic surgery and are associated with considerable economic costs for treatment. The Fournier’s gangrene prognosis depends on the timing of specialized medical care provision and, above all, on the time interval between the disease onset and surgery performing.

Rescue and Nursing of Acute Severe Viral Myocarditis in Children

&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To explore clinical rescue and nursing measures for children with acute severe viral myocarditis. &lt;strong&gt;Method: &lt;/strong&gt;Patients in the hospital were immediately given positive anti-heart failure, anti-shock therapy and correct treatment of arrhythmia. Large doses of gamma globulin, adrenal cortical hormone, pulse therapy, direct current cardioversion, vitamin C, oxygen inhalation, ECG and other treatments were given. &lt;strong&gt;Results&lt;/strong&gt;&lt;strong&gt;: &lt;/strong&gt;58 cases were rescued successfully and the prognosis was good. However, there were 3 cases of patients with severe myocardial damage, ECG, ventricular fibrillation, and 1 invalid death. &lt;strong&gt;Conclusion: &lt;/strong&gt;In the treatment of acute severe viral myocarditis of children, timely, accurate and safe implementation of various rescue measures is the key to improving the success rate.&lt;/p&gt;

Efficacy of Various Arrangements of Pelvic External Rod Fixators in Polytraumatized Patients at Resuscitation Step

Application of external fixators (EF) in pelvic fractures is one of the important components of antishock therapy in patients with polytrauma. However various fixation techniques possess certain advantages and disadvantages. Comparative analysis of 4 most commonly used variants of pelvic EF mounting, i.e. classic - via upper flaring portion of the ilium, supra-acetabular, orthogonal - combination of screws passes through the wings and supra-acetabular region, and subcristal, that were applied in 32, 48, 13 and 3 patients, was performed. Results of the analysis showed that supra-acetabular pelvic fixation technique a preferable one due to its high efficacy and lower rate of complications as compared to other external fixation methods.

Efficacy of Various Arrangements of Pelvic External Rod Fixators in Polytraumatized Patients at Resuscitation Step

Application of external fixators (EF) in pelvic fractures is one of the important components of antishock therapy in patients with polytrauma. However various fixation techniques possess certain advantages and disadvantages. Comparative analysis of 4 most commonly used variants of pelvic EF mounting, i.e. classic - via upper flaring portion of the ilium, supra-acetabular, orthogonal - combination of screws passes through the wings and supra-acetabular region, and subcristal, that were applied in 32, 48, 13 and 3 patients, was performed. Results of the analysis showed that supra-acetabular pelvic fixation technique a preferable one due to its high efficacy and lower rate of complications as compared to other external fixation methods.