«Anesteziologiya i Reanimatologiya
» №
4 2013
Abstracts of the articles
AN-1304-004
EFFECTS OF XENON ANESTHESIA ON CEREBRAL BLOOD FLOW IN NEUROSURGICAL PATIENTS
WITHOUT INTRACRANIAL HYPERTENSION
A.V. Rylova, A.Yu. Lubnin
FGBU Burdenko Neurosurgery Institute RAMS, Moscow, Russian Federation
Among anesthetic agents used in neurosurgery xenon appears to be the most advantageous. It preserves
arterial blood pressure, assures rapid recovery and neuroprotection. But the data is lacking on xenon effect
upon cerebral blood flow under anesthetic conditions. We measured flow velocity in middle cerebral artery in
neurosurgical patients without intracranial hypertension during closed circuit xenon anesthesia comparing
propofol and xenon effect in the same patients. In our study xenon didn’t seem to induce clinically relevant
changes in cerebral blood flow and preserved cerebral vascular reactivity thus proving its safety in patients
without intracranial hypertension.
Key words: xenon anesthesia, cerebral blood fl ow, cerebral blood fl ow velocity, cerebral autoregulation.
AN-1304-009
PREVENTION OF COGNITIVE DISORDERS IN POSTOPERATIVE PERIOD AFTER CAROTID
ENDARTERECTOMY
V.V. Shmelev, M.I. Neymark
Altay State Medical University, Barnaul
238 patients with atherosclerosis of carotid arteries after reconstructive operations under different types of
anesthesia were enrolled in the study. Neuropsychological survey with Montreal cognitive assessment scale,
frontal assessment battery and clock drawing test was performed in dynamics. Minimal cognitive dysfunction
was mentioned in patientswith symptomatic and asymptomatic stenosis after combined anesthesia with
regional anesthesia. Postoperative cognitive dysfunction was developed after sevoflurane and propofol
anesthesia in patients with asymptomatic stenosis. After inhalation anesthesia it was more severe.
Prevention of postoperative cognitive dysfunction with ceraxon was clinically effective. This therapy can
facilitate mental functions recovery and improve quality of life.
Key words: propofol, sevoflurane, combined anesthesia, regional anesthesia, carotid endarterectomy,
postoperative cognitive dysfunction, ceraxon.
AN-1304-014
MASS-SPECTROMETRIC CONTROL OF COMPOUND A DURING MINIMAL FLOW ANESTHESIA AND
ITS INFLUENCE ON LIVER AND KIDNEYS FUNCTIONS
I.I.Faizov1, A.I. Levshankov1, A.V. Shchegolev1, A.Yu.Elizarov2
1 Anesthesiology and Intensive care department of Kirov Military Medical Academy, Saint-Petersburg,
Russia,2 Ioffe Physical Technical Institute RAS, Saint-Petersburg, Russia.
The article contains results of mass-spectrometric control of sevoflurane and compound A concentrations
during inhalation anesthesia with minimal fl ow (. 0,5 l/min) and its influence on liver and kidney function. 40
patients (ASAI-II) were included in the study. Transsphenoidal pituitary adenomectomy was performed in all
cases. Patients didn’t have any signs of liver or kidneys disfunctions preoperatively. We used quadrupole
mass spectrometer "Prisma Plus» (Pfeiffer vacuum, Germany) to determine the real time concentration of
sevoflurane and compound A. Intensity of m/z = 131 peak sevoflurane and m/z = 128 peak compound A
were registered. Laboratory blood tests to assess liver and kidney fuction were carried out before
anesthesia, after anesthesia, and on the 1st day after anesthesia. They included: AST, ALT, total bilirubin,
total protein, urea, creatinine. Quantitative analysis of the compound A and blood test before and after
anesthesia showed only a tendency to increase biochemical markers levels within normal range, except
small, but significant, AST elevation and total protein reduction in postoperative period. We concluded that
maximal registered level of compound A (275 ppm/h) during minimal flow anesthesia didn’t associate with
significant liver and kidneysinjury in healthy patients.
Key words: anesthesia, sevofl urane, compound A, mass-spectrometry, minimal flow.
AN-1304-018
PATIENT POSITIONING ON THE OPERATING TABLE IN NEUROSURGERY: SITTING OR LYING
L.A. Israelyan, V.N. Shimanskiy, D.A. Otamanov, V.
К
. Poshataev, A.Yu. Lubnin
FGBU Burdenko Neurosurgery Institute RAMS, Moscow, Russian Federation
Efficacy and safety of microvascular decompression of trigeminal nerve depending on the position on the
operating table were assessed in 200 neurosurgical patients in retrospective observational study. It was
shown that effi cacy doesn’t depend on positioning. Lying position eliminates probability of such
complications as postural hypotension, hypotension during surgery, tension pneumocephalus and peripheral
nerves injury. Sitting position increases risk of air venous embolism by 25 times. Lying position increases risk
of postoperative nasal liquorrhea by 4 times, but eliminates risk of postoperative paresis of trigeminal nerve.
It is also decreases risk of corneal reflex reduction by 3 times, hyperpathia by 2 times and paresthesias by 5
times, but increases probability of postoperative hyperesthesia by 4 times. Microvascular decompression of
trigeminal nerve in lying position is safer than similar operation in sitting position.
Key words: posterior fossa surgery, sitting position, lying position, intraoperative complications.
AN-1304-026
MORPHOLOGICAL CHANGES IN THE LUMBAR DORSAL ROOT GANGLION OF THE DOMESTIC
PORCINE AFTER PULSED RADIOFREQUENCY
Mihails Arons1, Mara Pilmane 2, Edgars Vasilevskis1, Aleksey Shchegolev 3, Irina Evans1
1 Riga Stradins University Hospital, Pain Clinic, Riga, Latvia, 2 Riga Stradins University, Institute of Anatomy
and Anthropology, Riga, Latvia, 3 Kirov Military Medical Academy, Saint-Petersburg, Russia
Pulsed radiofrequency (PRF) is a percutaneous minimal invasive procedure that can be used when
conservative pain therapy methods have been ineffective. The effectiveness of PRF was demonstrated in
various good quality randomizedcontrol studies, but mechanisms of action are still unclear. The aim of our
study is to analyse the histological effects of PRF on the domestic porcine dorsal root ganglion (DRG), and
evaluate the expression of biomarkers in gangliocytes. 3 domestic porcines were investigated. Under
general anaesthesia and X-ray control, DRG PRF was performed. Four lumbar DRGs (L1, L2, L3, L4) were
randomly treated. The opposite side DRGs was used as control. One month after the procedure the animal
was euthanized. The lumbar region of the spine was placed in 10% formaldehyde for a month. After this
fixation DRG samples were prepared for slide analysis. They were embedded in paraffin in order to obtain
3.m thick sections, which were then cut by microtome and collected on slide glasses. Using standard
immunohistochemical 26 reactions, the materials were tinted to define biomarkers NF, GFAP, Hsp-70
expression and apoptosis by TUNEL kit. The number of cells with NF (26,0 ± 3,0 vs 16,1 ± 3,3; p<0,05),
GFAP (12,0 ± 1,3 vs 3,2 ± 0,9; p<0,05) and Hsp-70 (10,0 ± 1,6 vs 4,2 ± 1,0; p<0,05) expression, were larger
in the PRF side comparing with the control side. Additionally, glial cells in spinal ganglia of both sides
demonstrated immunoreactivity. The instances of apoptosis were not significantlydifferent, in statistical
terms, between the control and experimental sides (18,0 ± 4,0 vs 20,0 ± 4,0; p=0,35). PRF in spinal
gangliocytes of lumbar region increases neural tissue cytoskeleton factors like NF and GFAP suggesting
about active regeneration processes into the cells 1 month after the procedure. Spinal gangliocytes one
month after PRF treatment notably increases Hsp-70 expression suggesting about activation of cellular
activity and inhibitory role reducing of oxidative stress. Similar number of apoptotic cells in spinal ganglia of
lumbar region after PRF and control side suggests about inhibitory role of PRF on programmed cell death
and stimulation of cell survival.
Key words: pulsed radiofrequency, morphology, dorsal ganglion root, growth factors-apoptosis, stress
markers.
AN-1304-031
CEREBRAL AND EXTRACEREBRAL INSUFFICIENCY IN PATIENTS WITH POOR PROGNOSIS OF
SURGICAL TREATMENT OF HEMORRHAGIC STROKE.
L.P. Chepkiy, O.I. Kamenskaya, O.A. Tsimeyko, V.V. Moroz
Romodanov Neurosurgical Institute AMS of Ukraine, 04050, Kiev, Ukraine
Objective of the study was to investigate cerebral and extracerebral insufficiency in survived and died
patients after surgical treatment of hemorrhagic stroke for outcome prognosis and decision making on
postoperative intensive care. The study included 224 patients after transcranial surgery for hemorrhagic
stroke. 119 patients survived and 105 patients died. SOFA scale and SIRS criteria were used to assess
severity of the patients state. Hemorrhagic stroke before the operation was accompanied with cerebral
insufficiency (Glasgow Coma Scale . 9) in 19% of patients. Lungs and kidneys dysfunction (SOFA = 1-2)
were common. In the early postoperative period 54% of patients had cerebral insufficiency and 36% - organ
dysfunction. Acute cerebral insufficiency was closely associated with systemic infl ammatory response.
Severity of organs (heart, lungs, kidneys) failure and SIRS correlated with GCS score in early postoperative
period. There was close correlation between MODS and SIRS scores in survived patients and there wasn’t
such phenomenon in died patients. This indicates leading role of CNS in homeostasis regulation. SOFA
scale using for express diagnosis of perioperative complications is useful for providing adequate intensive
therapy.
Key words: hemorrhagic stroke, cerebral insufficiency, systemic inflammatory response syndrome, organ
failure, multiple organ failure.
AN-1304-037
PERFUSION-METABOLIC INTERACTION IN ACUTE CEREBRAL INSUFFICIENCY. ACIPS STUDY
PART I. CEREBRAL BLOOD FLOW EVALUATION.
V.S. Gromov, A.N. Ageev, A.M. Alasheev, A.A. Belkin, A.L. Levit
Ural State Medical Academy, Yekaterinburg, Russian Federation; Sverdlovsk regional clinical hospital №1,
Yekaterinburg, Russian Federation
Basic physiological position that metabolic requirements of brain determine perfusion characteristics of
cerebral blood flow underlies the definition of syndrome of acute cerebral insufficiency. So there is a
perfusion-metabolic interaction (PMI) in brain tissue at every moment. Based on this paradigm we should
synchronize measurement of these components in intensive care practice. The goal of ACIPS study (Acute
Cerebral Injury Protection System) is creating methodology of monitoring PMI and treatment algorithm based
on this monitoring. In this article we present data that volume cerebral blood flow can be assessed by
summing volume blood flows on brachiocephalic vessels measured with triplex ultrasound. Such results are
comparable with CT-perfusion results. Both methods can be used interchangeably if difference in -0,6 —
11.8 ml/kg/min isn’t clinical significant.
Key words: acute cerebral insuffi ciency, neuromonitoring, perfusion-metabolic conjugation, ultrasound,
cerebral blood flow.
AN-1304-042
DYNAMICS OF INTRACRANIAL PRESSURE IN PATIENTS WITH MASSIVE ISCHEMIC STROKE AFTER
DECOMPRESSIVE CRANIOTOMY
A.S. Nikitin3, S.A. Burov4, S.S. Petrikov 1,2, S.A. Asratyan3, K.M.Gorshkov3, V.V. Krylov1,2
1 Moscow State University of Medicine and Dentistry, Moscow, Russian Federation; 2 N.V. Sklifosovsky
Scientific Research Institute of Emergency Medicine, Moscow, Russian Federation; 3 Moscow city clinical
hospital №12,
Moscow, Russian Federation; 4 Central Clinical Military Hospital FSB RF, Moscow, Russian
Federation
The goal of the study was assessment of the value of ICP monitoring in patients with massive ischemic
stroke after decompressive craniotomy. 12 patients with massive ischemic stroke were performed ICP
monitoring after decompressive craniotomy. We identified 3 types of ICP dynamics: a) normal ICP, which no
need to treat; b) ICP elevation to 20 mm Hg and more in postoperative period, which can be treated by
nonsurgical therapy; c) refractory to therapy ICP elevation to 20 mm Hg and more with development of
intracranial hypertension. We consider that ICP monitoring in patients with massive ischemic stroke after
decompressive craniotomy can be useful for optimization of the therapy and correction of intracranial
hypertension.
Key words: massive ischemic stroke, intracranial pressure, ICP, decompressive craniotomy.
AN-1304-044
ICP PLATEAU WAVES IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY
A.V. Oshorov, I.A. Savin, A.S. Goryachev, K.A. Popugaev, A.A. Polupan, A.A. Sychev, A.G. Gavrilov, A.D.
Kravchuk, N.E. Zakharova, G.V. Danilov, A.A. Potapov
FGBU Burdenko Neurosurgery Institute RAMS, Moscow, Russian Federation
The goal of the study was to assess frequency of plato waves, their influence on outcomes and define
factors leading toplato waves. Ninety eight patients with severe traumatic brain injury (TBI) were included.
Blood pressure (BP), intracranial pressure (ICP), cerebral perfusion pressure (CPP) and pressure reactivity
index (Prx) were registered. Age was 34 ± 13.6. There were 73 male and 25 female. Glasgow Coma Scale
(GCS) was 6 ± 1.4. Plato waves developed in 24 patients (group 1), 74 patients (group 2) did not have plato
waves. Median of plato waves in the 1st group was 7 [3.5;7]. They developed on 3rd [2;4.5] day. Maximum
level of ICP during plato waves was 47.5 [40;53] mmHg, its duration was 8.5 [7;27] minutes. In the group 1
Prx was significantly lower during first day, than in the group 2. Duration of ICP monitoring was longer in the
group 1 due to presence of plato waves in these patients. CPP did not differ in groups, because CPP was
strictly controlled. Patients of the group 1 had preserved autoregulation and less severe trauma
(predominance of closed trauma and Marshall I, II type of brain damage). Plato waves did not predict bad
outcomes.
Key words: ICP monitoring; plato waves, traumatic brain injury.
AN-1304-050
CITICOLINE AS COMPONENT OF THE THERAPY OF POSTOPERATIVE DELIRIUM IN
NEUROSURGICAL PATIENTS.
K.A. Popugaev, I.A.Savin, E.Yu. Sokolova, A.V. Oshorov, B.A. Kadashev, P.L. Kalinin, M.A. Kutin
FGBU Burdenko Neurosurgery Institute RAMS, Moscow, Russian Federation
Delirium is a clinical sign of acute cerebral dysfunction. It is characterized by consciousness alterations with
attention impairment and mentally disorganization. Frequency of delirium is 40-80% in general intensive care
and more in patients in neurointensive care unit. We tried to assess citicoline (Ceraxon©, Nycomed) safety
and efficacy in treatment of postoperative delirium in patients with tumors of chiasm-sellar area of brain. 12
patients were included in citicoline group and 8 — in control group. In both group combined type of delirium
was common: 83,3% and 75%, accordingly. Citicoline didn’t influence on delirium duration. Median of
duration of mechanical ventilation was 1,5 and 6 days; mean and standard deviation were 10,5±15,4 and
17,5±27,9 days. Median of length of stay in ICU was 7 and 9,5 days; mean and standard deviation were
25,4±33,1 and 14,9±15,1 days. These results show that citicoline didn’t influence on duration of mechanical
ventilation and length of stay in ICU. Outcomes were similar in both groups, but frequency of full functional
state recovery in citicoline group was significantly higher: 5 (41,7%) to 2 (25%) in control group (p<0,05). We
consider that citicoline therapy is safe for patients with tumors of chiasm-sellar area and lead to increasing of
frequency of full functional state recovery.
Key words: delirium, tumors of chiasm-sellar area, complicated postoperative period, citicoline.
AN-1304-054
INFLUENCE OF CEREBRAL PERFUSION PRESSURE AND CARDIAC OUTPUT ON BRAIN
OXYGENATION AND METABOLISM
Yu. V. Titova, S.S. Petrikov, A.A. Solodov, V.V. Krylov
N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russian Federation
The article contains results of examination of correlation between systemic hemodynamic and brain
oxygenation and metabolism in patients with intracranial hemorrhage. Cardiac index (CI) and cerebral
perfusion pressure (CPP) levels were compared to brain oxygenation and metabolism in 8 patients with
intracranial hemorrhage (137 measurements). CI alterations didn’t influence on PbrO2, glucose level or
lactate/pyruvate ratio in the brain interstitial fluid in patientswith traumatic brain injury. CPP elevation led to
cerebral metabolism improvement. Optimal metabolic state was mentioned in CPP > 80 mm Hg. CPP
elevation led to PbrO2 increasing in patients with subarachnoid hemorrhage due to aneurism rupture. This
phenomenon can be explained by damage mechanisms of cerebral blood fl ow autoregulation. In these
cases CI elevation was accompanied by worsening of aerobic metabolism in theoretically intact regions and
improving it in injured brain regions.
Key words: cerebral blood flow autoregulation, cerebral perfusion pressure, cardiac output, brain
oxygenation, cerebral metabolism, traumatic brain injury, subarachnoid hemorrhage, lactate/pyruvate ratio.
AN-1304-059
PROGNOSTIC VALUE OF D-DIMER LEVEL IN NEUROSURGICAL PATIENTS BEFORE ELECTIVE
HOSPITALIZATION
D.A. Moshchev, A.Yu. Lubnin, A. V. Moshkin, N. N. Mochenova, S.V. Madorskiy, V. I. Luk’yanov
FGBU Burdenko Neurosurgery Institute RAMS, Moscow, Russian Federation
Deep vein thrombosis and pulmonary embolism in postoperative period are very dangerous complications
for patient with any surgical pathology. Frequency of deep vein thrombosis in neurosurgical patient can be
up to 25-30%. D-dimer level is considered as one of the most reliable indicator of thrombosis. We measured
D-dimer level before hospitalization for elective surgery in 4052 patients with different neurosurgical
pathology. It was found clear correlation with elevated D-dimer level and frequency of ultrasound signs of
thrombosis. In patients with simultaneous presence of elevated D-dimer level and external signs of varicose
veins diagnosis was confirmed by ultrasound in every cases. We consider that D-dimer can be reliable
screening method for assessment the risk of thrombosis in neurosurgical patients in preoperative period.
Key words: D-dimer, deep vein thrombosis, risk assessment, neurosurgery.
AN-1304-063
ENDOSCOPIC DIAGNOSIS, TREATMENT AND PREVENTION OF INTUBATION RELATED INJURIES
OF LARYNX AND TRACHEA IN NEUROSURGICAL PATIENTS
A.L. Gasanov, N.N. Levitskaya, T.P. Pinchuk, Sh.N. Danielyan, S.S. Petrikov, S.V. Efremenko
N. V. Sklifosovsky Research Institute of Emergency Medicine, Moscow, Russian Federation
The goal of the study was to assess of efficacy of endoscopic diagnosis, prevention and treatment of
intubation related larynx and tracheal injuries in patients with acute neurosurgical pathology and prolonged
mechanical ventilation. 199 patients with different neurosurgical pathology were enrolled in the study group.
Mean age was 50±14. Control group consisted of 399 patient. Mean age was 43±12. Clinical state of patient
from both group were similar. Endoscopic method in the study group included revision of airways via nasal
route with tracheostomy tube inserted. Larynx and tracheal injuries by endoscopy were identified in 42
patients (33,6%) in the study group and in 12 patients (7,6) in the control group. Such injuries weren’t
mentioned in 83 patients in study group and in 146 patients of the control group. Tracheal stenosis was
developed in the study group in 0,8% of patients, which is by 7,9 times lower than in the control group
(6,3%). We consider that this result was achieved due to our approach to treatment and prevention of
tracheal stenosis.
Key words: tracheal injuries, fi beroptic bronchoscopy, tracheal stenosis, laser photostimulation,
tracheoesophageal fistula.
AN-1304-066
NORMOBARIC HYPEROXIA INFLUENCE ON CEREBRAL OXYGENATION, METABOLISM AND
OXIDATIVE STRESS IN PATIENTS WITH NONTRAUMATIC SUBARACHNOID HEMORRHAGE DUE TO
CEREBRAL ANEURYSMS RUPTURE
A.A. Solodov, S.S. Petrikov, E.V. Klychnikova, E.V. Tazina, V.V. Krylov, M.A. Godkov, L.T. Khamidova N.V.
Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russian Federation
The development of cerebral vasospasm in subarachnoid hemorrhage (SAH) due to cerebral aneurysms
rupture results in cerebral circulation disturbances. Application of normobaric hyperoxia can be an effective
way for improving of oxygen delivery to injured brain tissues. The purpose of this study was to assess of
normobaric hyperoxia influence on intracranial pressure (ICP), cerebral oxygenation and metabolism,
oxidative stress and endogenous factors of vascular regulation in 11 critically ill patients with nontraumatic
SAH due to cerebral aneurysms rupture. Increase of FiO2 from 0.3 to 0.5 and 1.0 was accompanied with
brain oxygen tension (PbrO2) increase and cerebral extraction ratio for oxygen (O2ER) decrease.
Application of normobaric hyperoxia had no effect on ICP, cerebral perfusion pressure, arterial blood
pressure and cerebral metabolism. The results obtained from patients with nontraumatic SAH showed an
evident increase of oxidative stress which had a significant effect on vascular endothelial function, causing
an imbalance in theendogenous regulation of vascular tone. Application of normobaric hyperoxia was not
accompanied by an increase of free-radical processes in critically ill patients with nontraumatic SAH due to
cerebral aneurysms rupture.
Key words: subarachnoid hemorrhage; cerebral aneurysms rupture; cerebral vasospasm; normobaric
hyperoxia; cerebral oxygenation and metabolism; oxidative stress; nitric oxide.
AN-1304-071
CORONARY ARTERY STENTS AND NEUROSURGERY: CHOOSING THE LESSER OF TWO EVILS
A.V. Rylova, A.Yu. Lubnin
FGBU Burdenko Neurosurgery Institute RAMS, Moscow, Russian Federation
Patients with coronary artery stents are extremely dependent on antiplatelet therapy whose discontinuation
may lead tostent thrombosis with major cardiac adverse events. In neurosurgery chronic antiplatelet
medications uptake is supposedto be the major factor of postoperative intracranial hematoma associated
with poor outcome and high mortality. Thusplanning neurosurgical procedure in patients with coronary stents
needs a thorough evaluation of all risk factors ponder ing possible profit and danger. We discuss current
recommendations on perioperative management for high risk bleedingsurgery in high risk thrombosis
patients emphasizing the role of individual approach and multidisciplinary collaboration.
Key words: postoperative hematoma, neurosurgery; coronary artery stent, stent thrombosis, dual antiplatelet
therapy.
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