54С.д. ШАпоВАЛ, и.Л. САВон, д.А. СмирноВА, м.м. СофиЛкАнЫч Характеристика микроциркУляции нижниХ конечностеЙ У пациентов с осложненнЫм синдромом диаБетическоЙ стопЫГу «запорожская медицинская академия последипломного образования», украина Цель. используя метод лазерной допплеровской флоуметрии исследовать кровоток нижних конечно-стей у пациентов с осложненным синдромом диабетической стопы (сдс) и выявить характерные наруше-ния микроциркуляции для каждой клинической формы.Материал и методы. обследовано 246 пациентов с осложненным сдс. возраст пациентов составил 59,4±3,3 года. мужчин было 155 (63%), женщин -91 (37%). у всех пациентов был сахарный диабет (сд) 2 типа, средняя длительность заболевания составила 12,3±1,5 лет. согласно классификации международной рабочей группы по проблемам диабетической стопы (нидерланды, 1991 г.), пациенты были распределе-ны по клиническим формам. изучение микроциркуляции проводилось методом лазерной допплеровской флоуметрии.Результаты. периферическая аутосимпатектомия, при нейропатической форме осложненного сдс, приводит к потере нейрогенного контроля. несмотря на увеличение объема притока артериальной крови, из-за отсутствия симпатической регуляции микроциркуляции, происходит ускоренный сброс крови через артериовенозные шунты. при ишемической форме показатели микроциркуляции свидетельствуют о застое крови в артериолах и венулярном звене повышение переменной составляющей микроциркуляции обу-словлено как более интенсивным функционированием механизмов активного контроля микроциркуляции, так и повышением сердечных и дыхательных ритмов. при смешанной форме выявлено более интенсивное функционирование механизмов активного контроля микроциркуляции. повышение амплитуды нейроген-ных колебаний приводит к усилению артериолярного тонуса и миогенных колебаний, что способствует снижению периферического сопротивления в капиллярной сети.Заключение. при нейропатической форме осложненного сдс потеря нейрогенного контроля приво-дит к прекапиллярной вазоконстрикции, увеличению внутрикапилярного давления и усилению кровотока через артериовенулярные шунты. при ишемической форме отмечено наличие нарушений связанных с уменьшением объема артериального притока и симпатической регуляцией. при смешанной форме реги-стрируются нарушения в системе регуляции за счет снижения эндотелиальной секреции, активации ней-рогенного и миогенного механизмов контроля. Ключевые слова: лазерная допплеровская флоуметрия, микроциркуляция, синдром диабетической стопыObjectives. Using laser Doppler flowmetry technique to study the blood flow in the lower extremities in patients with the complicated diabetic foot syndrome (DFS) and to reveal the specific microcirculatory disturbances for each clinical form.Methods. 246 patients with the complicated DFS were investigated. Patients' age was 59,4±3,3 years. There were 155 males (63%) and 91 females (37%). All the patients had diabetes mellitus (DM) of the 2nd type, the average duration of disease made up 12,3±1,5 years. In accordance with the classification of the International Working...

Cytokines are specific proteins that are produced by lymphocytes. Cytokine production and release occurs rapidly and is rigorously controlled. Their activity is characterized by ensuring the interaction between cells and systems, regulation of inflammatory reactions and responsible for the development of autoimmune processes. Patients with sepsis develop immunosuppression, when immune deficiency can progress to immunoparalysis. Cytokines cause effects similar to manifestations of acute and chronic infectious diseases having an ability to cause inflammation (pro-inflammatory) or inhibit the inflammatory process development (anti-inflammatory). The aim of the work is to find out the dynamics of changes in the most important cytokines in patients with sepsis caused by diabetic foot syndrome. Materials and methods. A total of 146 patients with sepsis who received treatment in the Zaporizhzhia Purulent-Septic Center with diabetic foot beds between 2006 and 2019 were examined and followed up. Patients were distributed according to the forms of the disease: group 1-104 (71.2 %) patients with sepsis, group 2-42 (28.8 %) patients with septic shock. The average age of the patients was 62.8 ± 3.4 years, and the duration of type 2 diabetes mellitus was 12.3 ± 3.4 years. The groups were representative in terms of sex, age and concomitant pathology. The studies were conducted in dynamics: upon admission, on the 7-8th and 12-16th days of the postoperative period. Results. The disease in sepsis patients was caused by wet gangrene of the lower extremities which occurred in 84.6 % of cases (88 patients). In 16 patients (15.4 %), the complications were caused by foot phlegmon and extended osteomyelitis. The cause of sepsis in patients with septic shock was wet gangrene of the extremities in 100 % of cases. Postoperative mortality in sepsis patients was 18.3%, and in patients with septic shock-70.8 %. The dynamics of changes in serum cytokines has been found to be indicative of these indicators imbalance which depends on the inflammatory process severity. The balance between cytokines is an important point in the regulation of inflammatory process onset and development. The course of the disease and its outcomes depend on this balance.

The use of regional anesthetic techniques in abdominal surgery is an essential component of the multimodal approach to perioperative analgesia, yet data on their use in obese patients remains limited. The aim of this study is to determine the effectiveness of the epidural analgesia (EA) and the transversus abdominis plane block (TAP-block) in laparoscopic obese patients, as well as to evaluate the possibility of using the rectus sheath block (RSB) as a "rescue" anesthetic technique after laparotomy in obese patients. Materials and methods. The data on the 102 obese patients operated on esophageal hiatal diaphramgmatic hernia, colon tumor, postoperative ventral hernia, morbid obesity and choledocholithiasis were analyzed. In laparoscopic surgery 20 patients received EA (EA group), 21 patients-TAP-block (TAP group), 21 patients-opioids and non-steroidal anti-inflammatory drugs (NSAIDs) without any regional anesthesia techniques (group TIVA 1). In laparotomic surgery 16 patients received RSB (RSB group) and 24 patients-only opioids and NSAIDs (TIVA 2 group). After the surgery the following was estimated: the time of extubation, the total dose of opioids, the level of pain according to the 10-point numeric range score (NRS), the incidence of dyspnea using the monitor Utas 300 (Ukraine), the incidence of postoperative nausea and vomiting (PONV), the time of active patient mobilization, and the level of satisfaction with analgetic regimen. For the RSB group, the complexity of the RSB and the mean time to achieve adequate analgesia (pain intensity ≤3 points per NRS) were determined additionally. The statistical analysis was performed using the Statistica for Windows version 6.0 software. Results. In the EA group, the intraoperative dose of fentanyl was twice lower, and patients were extubated two times faster than in the TAP, TIVA 1 , RSB, TIVA 2 groups (P < 0.05). At the same time, none of the patients in the EA group required the restoration of neuromuscular conduction with neostigmine (P < 0.05). After the surgery, the pain level was 2-3 times higher in the TIVA 1 , RSB, and TIVA 2 groups than in the EA and TAP groups (P < 0.05). "Rescue" analgesia in the RSB group was performed from the first attempt in all the patients in 5-10 minutes and provided an adequate effect in 3 (2-4) min. The complexity level of RSB was defined as "easy" in 12 (75 %) patients, as "average" in 4 (25 %) patients (P < 0.05). The incidence of dyspnea and opioid doses after surgery in the EA, TAP and RSB groups of patients were 2 times lower, and the incidence of PONV was 3 to 4 times lower than in the TIVA 1 and TIVA 2 patients' groups (P < 0.05). In the EA and TAP groups, patients became mobile after 8-13 hours after surgery, in the group TIVA 1-after 16-22 hours, in the group RSB-after 18-36 hours, in the group TIVA 2-after 48-96 hours (P < 0.05). 100 % of the respondents from the EA, TAP and RSB groups were satisfied with the analgesic regimen at the "excellent-good" level. In the TIVA 1 and TIVA 2 groups, 20-25 % of respondents identified...

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Objective. To estimate the analgetic efficacy and possibility of application of bilateral dual blockade of a rectal abdominal muscle vagina (RSB) as a «salvage» anesthesia after laparotomic operations in patients with obesity. Маterials and methods. In 16 patients with obesity the complexity of performance, аnalgetic efficacy and possibility of the RSB application as a «salvage» method of anesthesia after laparotomic operations were estimated. Results. There was established, that, using ultrasonographic support, it is simple to perform RSB in 75% patients, the procedure lasts 5 - 10 min, with general success rate of anesthesia - 94%, аdequate analgesia occurs in - (3 ± 1.5) min after a blockade conclusion. Postoperative application of RSB reduces the need in opioids in 2 times, and in 4 times - the іncidence of nausea and regurgitation (p < 0.05), promotes activation of patients already on the first day end (p < 0.05), guaranteeing analgetic comfort on level «excellent» or «good» in 100% of the patients (p < 0.05). Conclusion. RSB constitutes a purposeful component of multimodal analgesia after performance of median laparotomy in patients with obesity, which prevents excessive administration of opioids, reduces quantity of adverse events and enhances the anesthesia quality, which was assessed by 100% of the patients as «excellent» or «good».