The aim of the study was to estimate the significance of delayed percutaneous coronary interventions (PCIs) in the treatment of ST-segment elevation myocardial infarction (STEMI), to weigh the initial mortality risk (MR) while determining the indications for their use and the time window for the use of mechanical reperfusion in late hospital admission. Total 2226 patients admitted to the Institute with STEMI for the period 2008–2017 were studied. Emergency coronary angiography was performed in 945 admitted patients in the initial 12 hours and in 834 patients after 12–72 hours of STEMI onset; PCI was performed in 784 and 619 patients, respectively. In all patients, MR was scored by TIMI; angiographic success was assessed as TIMI 3 coronary flow and compared to ECG signs of reperfusion. The baseline MR score averaged 5 or 12.5%, being corresponded to score 4.2 or 8% in patients with PCI performed in the initial 12 hours, score 5 or 12.5% in those with PCI performed after 12–72 hours, and score 6 or 16% in patients without PCI; or with respect to the patient age, MR scored 3.7 or 7%, 6 or 16%, and 7.5 or 25%, for those under the age of 65 years, those from 65–75 years, and those over 75 years old, respectively. Mortality in patients with an early and delayed PCI was 5.2% and 4.2%, respectively, and 15.6% in patients without PCI; after patient distribution by age under 65, 65–75, and over 75 years old, the respective mortality rates were 3.8%, 4.9%, and 10.8% after an early PCI; 2.6%, 5.8%, and 8.2% after a delayed PCI; and 8.4%, 19.4%, and 28% among those without PCI. For 10 years, the number of primary PCIs had increased from 39% to 78%. The ratio of early to delayed PCI made 56% to 44%. Of 195 deaths (67 patients with PCI and 128 without PCI), 90% of patients had a three-vessel disease; 83% of patients had the MI area over 30%; and the cause of death in 84% was pulmonary edema. The presented data suggest a high practical significance of delayed PCI in patients with initially high MR, its most weighty components being the age over 75 years and severe manifestations of acute heart failure (AHF). Unlike early PCIs, the delayed PCIs are used less frequently, the initial MR is not taken into account, and they are abstained from in respect to people over 75 years of age. The reduction in mortality, proportional to the baseline MR, suggests their correlation to PCI results and the feasibility of PCI use without age restrictions. The use of primary PCIs in late hospital admissions, by analogy with early ones or selectively in high MR, will help to optimize the treatment tactics and minimize mortality.

Atrial fibrillation and chronic renal failure are common diseases in the population with similar risk factors. Both conditions are independent risk
factors for the development of thromboembolic complications. There is compelling evidence to support the benefits of anticoagulant therapy for atrial fibrillation in the general population, but in patients with advanced chronic renal failure, the use of anticoagulants may be limited. A number of studies have shown conflicting results, and this topic is of interest for further discussion and a comprehensive analysis of the existing data.

This article describes clinical cases of patients with ischemic heart disease complicated by severe chronic heart failure during basic therapy with the inclusion of Mildronate. The results of the treatment prove the effectiveness of the use of this drug, in the form of an increase in exercise tolerance, regression of CHF phenomena, and improvement in the quality of life of patients with a burdened cardiovascular history.

Chronic kidney disease (CKD) is the most common manifestation of target organ damage in chronic heart failure (CHF). The aim of the study was to determine the risk factors associated with the course of CKD in patients with CHF infected with the human immunodeficiency virus (HIV). According to the results obtained, the prevalence of CKD among HIV-infected patients with CHF is 58.82%, which is 4 times more common than in patients with HIV infection without CHF. The dependence of glomerular filtration rate (GFR) on three main factors that reflect damage to the heart muscle – blood plasma NT-proBNP concentration, left ventricular ejection fraction (LVEF%) and left ventricular myocardial mass index (LVMI) was proved, which together, being included in the regression model, determine 42.2% of the variance of GFR values and are decisive in the development of CKD in patients with CHF on the background of HIV infection. The concentration of NT-proBNP in the blood plasma of patients with CHF equal to or greater than 683.65 pg/ml can be considered as a diagnostic criterion for the development of CKD in HIV-infected people with a sensitivity of the method of 75.0% and a specificity of 75.4%, respectively. In addition, risk factors for the development of CKD in patients with CHF and HIV infection are smoking, alcohol and drug use, a history of chronic and acute forms of coronary artery disease, atrial fibrillation, ventricular arrhythmias, diabetes mellitus, chronic viral hepatitis C, anemia and thrombocytopenia. Patients with CHF and CKD have a more rigid arterial wall – there is a significant excess of the stiffness indices of the aorta and peripheral arteries. Long-term use of antiplatelet agents, NRTIs, NNRTIs, and protease PIs may aggravate the course of CHF in HIV-infected people with CKD manifestations.

Infusion therapy is an important component of many diseases treatment – and one of the main methods of intensive care for intensive care patients. Active infusion therapy using different infusion media, large volumes and high rates of intravenous fluid is especially relevant in critical patients, the most severe of which remains patients with septic shock. For more than two centuries of clinical use, infusion therapy has gone through a long evolutionary path and has become more effective and safer. However, like any drug, infusion therapy (in general and specific infusion media) has a number of side effects, especially when used excessively. Therefore, in recent years, the use of infusion therapy is considered as the appointment of any drug, taking into account indications, contraindications, methods of administration, dosing, duration, deescalation. This made it possible to identify the main stages of infusion therapy of critical conditions and shock: intensive infusion therapy (rapid administration of a large fluid volume), optimization of infusion therapy (reduction of the rate and volume of infusion), stabilization of the patient and minimization of infusion, de-resuscitation – removal of excess fluid from the body. With the development of clinical pathophysiology, the basic concepts of maintaining fluid homeostasis of the body in normal and critical conditions were revised, and the negative effects of infusion therapy at all stages of its use were studied. Therefore, in the intensive care of shock, the main clinical questions are: when to start fluid therapy, when to stop active fluid therapy, when to start fluid removal from the body, and when to stop fluid de-resuscitation. Thus, in order to implement the principle of personalized treatment, it is important to determine not only the «tolerance» of infusion therapy, but also the «sensitivity» to the infusion of a particular patient – the ability to maintain hemodynamics without the risk of fluid overload. Evaluation of routine clinical, instrumental and laboratory indicators of the state of macro- and microcirculation does not provide an opportunity to accurately answer these questions. Modern sonographic methods for monitoring central and peripheral cardiohemodynamics, ‘venous excess’ using Doppler and extended focus echocardiography allow us to assess the ‘tolerance of infusion therapy’. The implementation of this new direction will increase the efficiency and safety of infusion therapy and improve the outcomes of the critically ill patients’ treatment.

Objective. To improve the results of treatment of comorbid patients with acute arterial ischemia by substantiating the optimal type of spinal anesthesia for surgical intervention on the affected limb.
Materials and methods. The study involved 70 patients who were treated in the Department of Vascular Surgery of Clinical Hospital of ‘Russian Railways-Medicine Co.’ in Barnaul. The patients were divided into two groups: group 1 – patients operated under conditions of bilateral (bilateral) spinal anesthesia, group 2 – patients operated under conditions of monolateral (unilateral) spinal anesthesia. All patients underwent an assessment of the level of spinal block on the Bromage scale, monitoring of central hemodynamics using a MARG-10–01 rheograph, postoperative assessment of myocardial ischemia on the ECG, acute kidney damage to control diuresis.
Results. In the 2nd group, there was a sufficient sensory and motor block to perform surgery. In the intraoperative period in the group of patients who underwent unilateral blockade, the mean arterial pressure decreased by 3 mm Hg. In this regard, there was no clinically significant increase in heart rate and a decrease in the stroke index and the index of total peripheral vascular resistance. In the 1st group, the decrease in mean arterial pressure reached 20% of the original, which led to an increase in heart rate by 12% and a decrease in stroke index by 11%.
Conclusions. During the perioperative period, the indicators of central hemodynamics in the group 2 were more stable compared to the group 1, they did not need the use of vasopressor drugs and crystalloids. And in the early postoperative period, patients who underwent unilateral anesthesia did not show signs of acute kidney injury. Monolateral spinal anesthesia, compared with conventional spinal anesthesia, provides more stable hemodynamics in elderly patients with acute arterial ischemia.

Introduction. Hormones are traditionally not recommended in the presence of bacterial infection, as such use may lead in septic complications. However, we have found that early use of low to medium methylprednisolone doses in a specific administration mode we have developed on the basis of scientific publications and our own data may stop ARDS progression in hospitalized patients with COVID-19 associated bacterial pneumonia without complicating the bacterial process. The article looks into effects of methylprednisolone used in ‘bolus followed by continuous infusion’ mode within the complex therapy of COVID-19 associated bacterial pneumonia patients.
Materials and methods. We analyzed 37 patients admitted to our hospital during the 2nd and 3rd waves of COVID-19 at later stages of the disease, complicated by bacterial pneumonia. Apart from receiving comprehensive detoxication, anti-inflammatory, antibacterial and symptomatic therapy all patients received methylprednisolone used in ‘bolus followed by continuous infusion’ mode. The data was collected at two points and statistically analyzed. 
Results. Positive changes in all parameters were statistically significant, and none of the patient’s developed superinfection. Total survival was 86.49%, and none of the deaths was associated with septic complications. 
Conclusions. Our clinical observations and statistical analysis of data suggest that the early use of methylprednisolone in the ‘bolus followed by continuous infusion mode’ was associated with discontinuation of ARDS progression and did not lead to bacterial superinfection. On the contrary, bacterial infection regress was confirmed by the laboratory findings and statistically significant. Further research is needed for a detailed study of the results we here describe.

Introduction. Pain in the intensive care unit is a common problem in patients with acute pancreatitis of various etiologies. Given the severity of the pain syndrome, as well as the low effectiveness of nonsteroidal anti-inflammatory drugs or antispasmodic therapy, it is often necessary to resort to the administration of opioid analgesics or epidural analgesia. Each of these pain management methods has certain disadvantages and contraindications, which makes it urgent to search for a safe and effective method of relieving pain in patients with pancreatitis or pancreonecrosis.
Goal. To determine the effectiveness blockade of the nerves of the fascial space of the muscles’ erector spine in acute pancreatitis. Clinical observation. Patient X., 58 years old, was arrived to the emergency department of the V.M. Buyanov State Clinical Hospital with severe pain in the epigastric region (10 points out of 10 on the visual-analog scale).
Conclusions. ESPB in a patient with acute biliary pancreatitis complicated by pancreonecrosis allowed to control pain syndrome quickly and safely. Further randomized clinical trials will allow to implement and optimize the technique, improving the clinical outcome.

Acute sialoadenitis (К11.2 МКБ 10) is one of the early post-operative complications. Swelling and infiltration of the salivary glands occur within a few minutes to 24 hours after surgery. This post-operative sialadenitis resolves spontaneously within 1–5 days, but rarely it can lead to serious complications. We present the clinical case of a 62-year-old female who underwent a spinal surgery in the prone position under general anesthesia. Three hours after the operation, we noted swelling of the neck, signs of acute respiratory failure, which required observation in intensive care unit and re-intubation of the trachea. Within 72 hours, swelling and infiltration of the salivary glands decreases. The patient was extubated and transferred to the neurosurgical department. Thus, acute post-operative sialoadenitis can cause the upper airway obstruction.

Acute gastrointestinal injury develops in more than half of all patients in the intensive care unit, regardless of the underlying pathology and it is one of the main reasons for the onset and progression of multiple organ failure and systemic inflammatory response syndrome. The severity of the acute gastrointestinal injury correlates with the risk of death. A deeper understanding of the pathogenetic mechanisms of dysfunction of the gastrointestinal tract in critically ill patients is necessary for the development and implementation of an intensive care regimen that allows to quickly restore the function of the gastrointestinal tract and break the vicious circle of pathophysiological changes, which will ultimately lead to improvement treatment outcomes for critically ill patients and reduced mortality.