TRANSVERSUS ABDOMINIS PLANE BLOCK OR QUADRATUS LUMBORUM BLOCK FOR POSTOPERATIVE ANALGESIA AFTER TOTAL ABDOMINAL HYSTERECTOMIES: THE RETROSPECTIVE STUDY

Background. Techniques of myofascial blockades are widely used after gynecological surgeries. The aim of study was to compare TAP block and QL block for postoperative analgesia of total abdominal hysterectomies. Materials and methods. We provided the retrospective single-center cohort study and included 51 patients 40-65 years old with complicated symptomatic uterus fibroids, who need total abdominal hysterectomy. Both groups underwent general anesthesia. In addition, in I group it was performed TAP block bilaterally via lateral access; in II group – QL block bilaterally via anterior (transmuscular) access. After surgery both groups` patients received multimodal analgesia with dexketoprofen, paracetamol, nefopam; in case of severe pain - nalbuphine. The stages of the study were 6 hours (h6), 12 hours (h12), 24 hours (h24), 48 hours (h48), 72 hours (h72) after surgery. We made the analysis pain level (with visual analogue scale - VAS), heart rate, mean arterial pressure, daily requirement of nalbuphine, duration of hospitalization. Results and discussion. It was found that the level of pain according to VAS in I group reached its maximum values on the stages h6 and h12 and was 4.8 [3,3; 5.8] points and 5.0 [3.9; 6.4] points, while in II group - 2.5 [2,3; 3.5] points and 2.1 [1.6; 4.1] points, respectively (p <0.05). We found significant differences in heart rate between groups on h12 stage when it was 86 [82; 90] beats / min in I group, and 72 [63; 79] beats / min in II group (p = 0.05). The daily requirement of nalbuphine on h12 stage had the tendency (p = 0.07) to be lower in II group (20.9 ± 1.1 mg / day), compared with the I group I (31.4 ± 2.9 mg / day). The need for nalbuphine use on h24 stage was significantly lower (p <0.05) in II group (5.8 ± 0.8 mg / day), compared with I group (22.5 ± 4.1 mg / day). The duration of hospitalization in I group was 7.8 ± 0.5 days, in II group - 6.2 ± 0.5 days (p>0,05). Conclusion. The use of QL block, compared with TAP block, showed a pain severity decreasing in 2 times (p <0.05), a tendency to reduce the need for nalbuphine use in 2.5 times (p> 0.05), and a tendency to reduce the duration of hospitalization by 1.6 days (p> 0.05).

SEVERE COVID-19 IN PATIENT AT EARLY POSTOPERATIVE PERIOD AFTER WHIPPLE’S OPERATION WITH MARGINAL PORTAL VEIN RESECTION

Introduction. Pancreatoduodenectomy (PDR or Whipple’s operation) remains the only effective radical method of surgery for tumors of the pancreatic head, distal common bile duct and Vater’s papilla. The most frequent complications of the early postoperative period are: gastrostasis, pancreatic fistula, postoperative bleeding and pulmonary complications. According to World Health Organization (WHO) and reviews, severe COVID-19 usually occurs in older age patients, and in patients with oncological diseases. Case description. Patient V., 64 years old, due to a tumor of the head of the pancreas with invasion of the distal common bile duct and the development of obstructive jaundice, underwent PDR. Histopathologically, ductal adenocarcinoma of the pancreatic head, G-2, was confirmed. The PDR operation was performed within healthy tissues, which was confirmed by histopathology. On the second day after surgery, patient was admitted to ICU because of respiratory failure, the SARS-CoV-2 antigen test was positive, we suggest that the patient was in the latent period of COVID-19 disease during the surgery. Patient received hormone therapy, anticoagulants in therapeutic doses, O2-therapy. On the 5th day, because of severe ARDS, the patient was intubated, on the 7th day - convalescent plasma transfused (1 dose). On the 9th day, a tracheostomy was applied for airways care and early activation. Respiratory support was provided twelve days. Patient received early activation, exercises, as well as early enteral nutrition. After ICU discharge, patient’s condition was complicated by the gastro-intestinal bleeding, blood transfusion and embolization of the dorsal pancreatic artery were performed. On the day 66th after surgery patient was discharged home in satisfactory condition. Conclusion. General care and early activation of the patient within early tracheostomy, convalescent plasma usage and the well-coordinated work of the surgical and anesthesiological teams allows timely identification and elimination of early postoperative complications after Whipple’s operation with marginal resection of the portal vein.

INFLUENCE OF IRRATIONAL PRESCRIPTION OF ANTIBACTERIAL THERAPY ON THE PROGNOSIS OF TREATMENT AND SURVIVAL IN PATIENTS WITH COVID-19

IIntroduction. The COVID-19 pandemic became a major challenge for healthcare systems around the world. The development and improvement of basic treatments for coronavirus patients is important to improve public health and improve quality of life after recovery. The aim of the study: to determine the frequency and structure of prescribing antibacterial drugs in the prehospital and hospital stages, used in patients with COVID-19. Assess the relationship between irrational use of antibacterial drugs with the length of hospital stay of patients with coronavirus disease, the risk of transfer to the intensive care unit (ICU) and mortality. Materials and methods: Statistical, retrospective analysis of 400 case histories of patients with COVID-19 who were treated at the Municipal Non-Profit Enterprise «Kyiv City Clinical Hospital №17» (KNP «KMKL#17») for the period from September 2020 to November 2021 with severe coronavirus disease. Results: 400 medical charts were selected for the study, which were divided into two groups according to the purpose of antibacterial therapy. Of the group of patients who received pre-hospital antibacterial therapy (200 people), indications for its appointment had only 7 % of patients. Among the group receiving antibacterial drugs there is a prolongation of the length of stay in the hospital, the risk of transfer to ICU increases. There is also higher risk of mortality in patients of group 1 (14,5 %), compared with group 2 (8 %), whose antibacterial drugs were not prescribed at the prehospital stage. Conclusion: as a result of the study it was found that patients who were unreasonably prescribed antibacterial therapy prolongs the period of general hospitalization by 2.3 ± 0.8 days, increasing the need for transfer of patients due to deterioration to ICU by an average of 13 %, increase in the incidence of antibiotic-associated diarrhea by 7-8 %, and there is a tendency to increase mortality from COVID-19. Antibacterial drugs should be used only on the basis of indications in the case of proven bacterial co-infection (superinfection) or reasonable suspicion of it in patients with respiratory disease caused by SARS-CoV-2 and in no case should be prophylactic.

POLY-COMPONENT FAT EMULSIONS IN THE PARENTAL NUTRITION OF PATIENTS IN THE INTENSIVE CARE UNIT

One of the main problems in the departments of anesthesiology and intensive care is the lack of energy in patients. In order to solve it, parenteral nutrition, which contains fat emulsions is prescribed for critical patients. It is known that fat emulsions consist of essential fatty acids which can have both pro-inflammatory (linoleic acid) and anti-inflammatory (linolenic acid) effects. In order to reduce the impact on the immune system, the use of alternative fat emulsions is recommended, as this may provide better clinical results. The first generation of fat emulsions consisted of soybean oil, but it was proven that this oil can increase the risk of purulentseptic complications. Second-generation fat emulsions contain medium-chain triglycerides, the metabolism of which can lead to acidosis, so their use is limited, especially in patients with diabetes. Third-generation fat emulsions contain olive oil, which reduces the risk of thrombosis, is considered immunoneutral and less sensitive to lipid peroxidation. Fourth-generation fat emulsions contain fish oil, which has anti-inflammatory properties and can reduce the duration of patients staying in critical condition. The most promising is the usage of balanced fats, among which there is a 20% SMOFlipid available in Ukraine. For patients who require parenteral nutrition, fat emulsions are an integral part of it, and for critically ill patients fat emulsions containing fish oil are recommended. However, it is recommended to assess baseline triglycerides prior to administration. Thus, lipids provide the delivery of fatty acids that affect important body processes, including metabolism, immune response, blood clotting. Alternative fat emulsions can be a better source of energy, also showing antioxidant effects and less suppression of immune system.

FEATURES OF CARDIOPULMONARY RESUSCITATION IN PATIENTS WITH MORBID OBESITY

Resume. Resuscitation of the obese patient presents a challenge for even the most skilled physician. Changes in anatomy, metabolic, cardiopulmonary reserve, ventilation, circulation, and pharmacokinetics require special consideration. This article focuses on critical components in the resuscitation of the obese patient, namely circulatory resuscitation, defibrillation, approach to the obese airway and mechanical ventilation, pharmacotherapy of cardiovascular drugs. Materials and methods: Electronic databases of Scopus and PubMed were searched using keyword searches Conclusions. Obesity causes important anatomical and physiological changes that affect resuscitation measures. Healthcare professionals should take into account the specifics of cardiopulmonary resuscitation in patients with morbid obesity to increase the effectiveness of resuscitation in this group of patients

BLOOD CORTISOL CONCENTRATION, HEMODYNAMICS AND METABOLISM OF PATIENTS WITH SECONDARY HYPERPARATHYROIDISM, POSSIBILITIES OF PERIOPERATIVE CORRECTION

A clinical case of severe bleeding from the wells of extracted teeth in a 9-year-old girl with Glanzman’s thrombasthenia is reported. Literature data on diagnosis and management of such patients are given. The authors emphasize that in the treatment of such patients sometimes it is necessary to make extraordinary decisions that can save the patient’s life. In this case, a direct blood transfusion was performed.

TO CHARACTERISTICS OF THE ETIOLOGICAL STRUCTURE AND ANTIBIOTIC SENSITIVITY PATHOGENSOF INFECTIOUS RESPIRATORY ORGANS IN NEWBORN AFTER ARTIFICIAL PULMONARY VENTILATION

Objective. The study of the etiological structure, properties of pathogens of the Vinnytsia National Medical University named after E. Pirogova, respiratory process in newborns who have underwent artificial mechanical lung ventilation (MLV) and their resistance to antibacterial agents is especially relevant in modern conditions, expands the search for new approaches to pathogens, improves treatment and reduces mortality from this pathology. The purpose of the study - to determine the etiological structure, sensitivity to antibiotics of the leading pathogens of the infectious process of the respiratory system in newborns who were on mechanical ventilation. Materials and methods. In total, the species composition of the leading microorganisms that colonized the airways of 180 newborns treated in the Neonatal Intensive Care Unit (VAITN) of Vinnytsia Regional Children’s Clinical Hospital (VRCCH) was studied in 2020. A total of 285 isolates of microorganisms were isolated. 62 patients who underwent mechanical ventilation were involved in a prospective microbiological study, 86 clinical strains of microorganisms were isolated. The susceptibility of microorganisms to 30 antibacterial agents was determined according to the generally accepted method (order of the Ministry of Health of Ukraine №167; recommendations). Research results. The etiological significance of opportunistic pathogens (Enterobacter cloacae - 29%, Staphylococcus aureus - 24.4%, Pseudomonas aeruginosa - 18.6%, Candida albicans) was proved in patients who were on mechanical ventilation in VAITN VRCCH in 2020 for pneumonia. Clinical strains of S. aureus are sensitive to vancomycin, oxacillin and clindamycin. Conclusions. Pathogens of the respiratory process in newborns who have been on mechanical ventilation, are resistant to a number of antibiotic drugs (cefepime, gentamicin amikacin, piperacillin).

РЕТРОСПЕКТИВНЫЙ АНАЛИЗ ПРИЧИН ЛЕТАЛЬНОСТИ У БОЛЬНЫХ С ТЯЖЕЛЫМ ТЕЧЕНИЕМ COVID-19

In Ukraine, more than 3.5 million cases of COVID-19 have been registered during the pandemic, and the death toll is almost 90,000. Ukraine is a leader in Europe in the growth of new cases of COVID-19 and mortality from this disease. The search for effective treatment regimens and new approaches to the management of patients with coronavirus disease in order to reduce the severity of coronavirus disease, reduce mortality, the number of complications and improve the rehabilitation period is very important nowadays. The aim of the work. To determine the main causes of mortality in patients with severe COVID-19 by analyzing the frequency and structure of complications in deceased patients. Materials and methods. The study conducted a retrospective analysis of 122 medical charts of deceased patients with COVID-19 who were hospitalized in a communal non-profit enterprise “Kyiv city clinical hospital №17” for the period from September 2020 to November 2021. Results and discussion. The overall mortality among patients with COVID-19 was 9.3%, in the intensive care unit (ICU) – 48.4%. The most common causes of death in patients with COVID-19 were: respiratory failure (RF) – 100% of cases, pulmonary embolism (PE) and acute heart failure (AHF) - about 60%. The average length of stay of patients in inpatient treatment was 11.67 ± 8.05 days, and in the intensive care unit – 7.94 ± 6.24 days. The mean age of patients hospitalized in the ICU was 63.5 ± 12.9 years and the mean age of patients who died was 71.2 ± 10.29 years. Prognostically significant criteria for lethal consequences were the presence of comorbidity: cardiovascular diseases- 92.3%, endocrine system diseases – 28.4%, nervous system diseases – 23.07%, kidney diseases – 9.6%, cancer – 9,6%, autoimmune conditions – 7.69%, varicose veins – 5.7%, respiratory system diseases – 5.7%. In patients with fatal outcome lymphopenia (84.6%) was observed in patients on admission to the ICU. Vasopressor and inotropic support was performed in 50 % of patients with COVID-19. In 25 % of those who died during long-term treatment and long-term respiratory support, there was the development of multiple organ failure, which in most cases was the point of no return. Conclusions. The most common causes of death were: respiratory failure, thrombosis, acute cardiovascular failure, sepsis and multiple organ failure. The main nature of the complications is common, but the cohort may be affected by different factors and the percentage of complications may differ in other hospitals.

PRIMARY HYPERPARATHYROIDISM: OPTIMIZATION OF ANAESTHESIA

Background and Aims. The majority of cases of primary hyperparathyreosis (PHPT) due to solitary adenoma and require the target surgery. Research of new anesthesia/analgesia methods, which afford to have an opioid-sparing effect, is going. Methods. 127 patients with PHPT were divided into 3 groups: the group STI-BCSPB (n=26) was used combined general anesthesia (GA) with sevoflurane (SEV), the tracheal intubation (TI) with the myorelaxant introduction and bilateral cervical superficial plexus blockade (BCSPB); the group STI (n=82) was used SEV anaesthesia with IT and no BCSPB; the group PLM-BCSPB (n=19) was provided propofol (P) GA with protection air-ways by laryngeal mask (LM) and BCSPB. In both groups (STI-BCSPB and PLM-BCSPB) were used co-analgesics, such as dexamethasone (DXM) 8 mg IV, 2% lidocaine (L) 1,0-1,5 mg/kg IV, metamizole (M) or paracetamol (P) 1 g IV, dexketoprofen (DKTP) 50 mg IV as pre-emptive analgesia 30 min before surgery. Ketamine 25 mg IV was used for induction anaesthesia in these groups. In STI group only opioid with P were used for induction of GA. Duration of surgery (DoS), anaesthesia (DoA), opioid consumption, time from the operation ending until the eyes opening (EyOp), desaturation was measured. All data M±m Results. DoS for STI-BCSPB, STI and PLM-BCSPB was respectively 38.7±2.7, 37.8±1.3 and 35.6±1.7 min (NS), DoA was respectively 63.8±3.1, 59.4±1.4 m and 53,8±2.7 min (p= 0.028 STI vs PLM-BCSPB, p= 0.024 STI-BCSPB vs PLM-BCSPB, the difference is significant (DS). EyOp was 15.4±1.1, 15.6±1.2 and 11.6±0.9 min respectively for STI-BCSPB, STI and PLM-BCSPB (p=0.022 STI vs PLM-BCSPB (DS) and p=0.025 STI-BCSPB vs PLM-BCSPB (DS). Desaturation (SpO2 below 92%) due to residual sedation and the effect of muscles relaxants was observed in 39 (47.6%) and 11 (42,3%) patients in STI and STI-BCSPB during the first 30 min postop compared to 2 cases (10.5%) in PLM-BCSPB (both STI groups were DS vs PLM-BCSPB, chi-square test). The dose of intra-op fentanyl was 334.3±17.1, 256.5±16.9 197.3±15.3 mcg in STI, STI-BCSPB and PLM-BCSPB respectively, (DS for PLM-BCSPB vs other groups, DS between STI groups). Conclusions. Combine methods GA with BCSPB have some benefits over mono GA. Co-analgesics afford to achieve an opioidsparing effect. Under ectomy of single parathyroid adenoma, the use of propofol and BSCPB with the laryngeal mask without muscles relaxants seems more preferable compared to sevoflurane anesthesia with BBSCP and tracheal intubation due to the shorter anesthesia duration, time to eye-opening after surgery, lower desaturation frequency.

PATIENT-CENTERED ANALGESIA OF THE ANTERIOR ABDOMINAL WALL IN CHILDREN OF DIFFERENT AGES: OWN EXPERIENCE

Introduction. Regional anesthesia in pediatric practice is one of the most valuable and safest tools for perioperative pain management. The advantages of regional anesthesia are early recovery of children, reducing opioid consumption, postoperative pain, respiratory complications, nausea, vomiting, as well as health care costs. The aim of the study was to analyze the data on the effect of the quadratus lumborum block and the transversalis fascia block on the duration and effectiveness of postoperative analgesia and propose a model of combining two blocks with a single injection. Materials and methods. Today there is growing interest in the use of new methods of regional anesthesia, especially the anterior and posterior torso blocks. The quadratus lumborum block and the transversalis fascia block are aimed at providing analgesia over the T7-L1 dermatomes, namely the ilio-inguinal and iliac nerves, which extend from the lateral portion of the psoas major, the lower edge of the 12th rib; however, there is evidence of cranial spread to the T4 – T5 dermatomes, and caudal spread to the L2 – L3 dermatomes. Currently, there are enough publications concerning the quadratus lumborum block and the transversalis fascia block. Results. For adequate perioperative multimodal anesthesia, the authors proposed a combination of the transversalis fascia block and the quadratus lumborum block with a single injection and ultrasound guidance. Conclusions. The advantages of the proposed method include simplicity, less invasiveness, adequate analgesia during surgery, as well as during the postoperative period (exclusion of somatic and visceral components), as evidenced by the assessment on a visual analogue scale (no more than two points). In addition, it significantly reduces the perioperative opioid use.