The constant mutation of the virus and the complicated epidemiological situation in other countries keep the probability of a third wave of the pandemic in the Russian Federation fairly high. It is important to summarize the gained experience as fast as possible to use it appropriately once it is needed.The objective: to analyze the specific parameters of care for critically ill patients with the novel coronavirus infection in Pavlov Multidisciplinary Medical Center.Subjects and methods. This is a result-based report on the work performed by the Infection Center, which was deployed twice in Pavlov Multidisciplinary Medical Center (from 28.04.2020 to 03.08.2020 and from 01.11.2020 to 15.03.2021). Totally, 3,830 patients with SARS-CoV-2 were managed (1,680 patients during the first deployment and 2,150 patients during the second one). In the preparatory period, the operation of the emergency department based on the inpatient emergency medical department (EMD) had been simulated to clarify its staff structure and the procedure for admission, examination, and treatment of patients. Here we compare the organizational approaches during the first and second waves of the pandemic and present the characteristics of the demographic data of the treated patients, the incidence of certain complications, and outcomes.Results. The overall lethality in the Center made 6.2%. Despite the experience gained in the first wave, the results of treatment during the second wave (autumn-winter) did not improve (5.7% died in the first wave and 6.7% in the second one). Lethality in ICU and EMD was 40.0% and 49.6%, in ICU only – 38.5% and 46.9% respectively. A moderate lethality increase in ICU was due to the concentration of critically ill and most critically ill patients. There were 51.4% of patients with comorbidities and 53.5% were above 65 years of age. Refinement and differentiation of tasks performed by departments, simulation of the operation of the Center before opening made it possible to increase the throughput of the medical unit avoiding rush during admission and deterioration the quality of treatment.Conclusion. Certain aspects of the organization of medical care affect the performance of a multidisciplinary medical institution transformed into an infectious diseases hospital. The experience gained under such circumstances can be useful in other emergencies with a large number of victims and patients.

The use of high-adsorption membrane hemofiltration in COVID-19 positive patients to reduce the severity of a cytokine storm is clearly beneficial but at the same time, there are no certain procedures for its practical use.The objective: to study the change in the levels of IL-6 and IL-18 in response to prolonged (24-72 hours) high-adsorption membrane hemofiltration.Subjects and methods. We retrospectively analyzed the data on IL-6 and IL-18 levels and their changes in 69 patients who were COVID-19 positive and had different degrees of lung damage, they had received high-adsorption membrane hemofiltration during their stay at the intensive care unit. The extent of lung lesions was the following: 4 people had CT-2, 44 people had CT-3, and 21 patients had CT-4. 18 patients had an unfavorable outcome of the disease. High-adsorption membrane hemofiltration (Prismaflex) was used in the group of patients who had clinical signs of the rapid progression of the disease and also such laboratory findings as elevated values of C-reactive protein (above 100 mg/L), ferritin (more than 600 μg/L), and progression of lymphopenia. This intervention lasted for 24 hours at CT-2/3, and 48 hours at CT-4. The effluent dose was 30.0 ± 6.4 ml/kg/h. The levels of IL-6, IL-18, and procalcitonin were tested before and after the completion of the intervention, and the difference between their concentration before and after high-adsorption membrane hemofiltration was calculated. The potential association between received data (IL-6, IL-18, delta of IL-6, delta of IL-18) and degree of lung damage and outcomes was analyzed.Results. It was detected that the more the lungs were affected, the lower levels of IL-6 and IL-18 were and vice versa and this correlation was not associated with the use of tocilizumab (used in 44 people). The maximum decrease in the level of cytokines was observed in the group of patients with CT-2. There was a significant association between the delta of IL-6 (F = 6.69; p ≤ 0.05) and the outcome which was especially pronounced in people with a favorable outcome.Conclusion. As the inflammation progresses in the lungs, the levels of IL-6 and IL-18 decrease which may be a manifestation of the depletion of the cytokine storm. The use of prolonged high-adsorption membrane hemofiltration (24-48 h) allows reducing the level of cytokines. The delta value reflects a decrease in IL-6 concentration, it significantly correlates with the outcome which indicates the importance of using this method in a continuous mode.

Estimations of the frequency of acute kidney injury in SARS-CoV-2 (COVID-19) coronavirus disease are very diverse. The literature data is highly inconsistent and shows AKI ranging from 0.5 to 80%.The objective: to analyze the incidence of renal dysfunction in COVID-19 patients and assess the significance of systemic inflammation for its development.Subjects and methods: The analysis was performed basing on data of 3,806 patients with COVID-19 treated at the Pavlov State Medical University, 395 of them were admitted to the intensive care units (ICU). The criterion for establishing renal dysfunction (RD) is the increase in blood creatinine level above the upper limit of reference values (0.115 mmol/l). Patients with end-stage chronic kidney disease who needed to continue routine long-term dialysis were not included in the study. We analyzed the incidence of renal dysfunction, changes in blood levels of creatinine, urea, and electrolytes during 8 days. In addition, glomerular filtration rate, diuresis volume, levels of hematocrit, hemoglobin, LDH, CRP, ferritin, and procalcitonin were evaluated.Results. The frequency of RD among all patients was 19.0%, among patients in the ICU – 41.0%. In 79% and 81%, respectively, it was detected on the first day of hospitalization. The increase in the number of patients with RD and the aggravation of the existing dysfunction occurred after 6 days. At the initial stage of the disease, the manifestations of RD in most cases were not expressed even in those with an unfavorable course of the disease but the level of creatinine showed a weak but significant (p < 0.5) correlation with changes in CRP (r = 0.110), ferritin (r = 0.137), and procalcitonin (PCT, r = 0.418). The difference in the level of creatinine in patients with PСT level above and below 0.5 ng/ml was observed on the first day only; the value of this parameter returned to normal faster in the subgroup of patients whose procalcitonin level did not exceed 0.5 ng/ml.Conclusion. In case of the signs indicative of RD, it is advisable to distinguish between primary and secondary injury. In the first case, it is primarily due to systemic inflammation, in the second case it is caused by additional impact of other aggressive factors. This will make it possible to clarify the renal and non-renal indications for renal replacement therapy (RRT) in patients with COVID-19, and to evaluate the results adequately since the effectiveness of RRT at different stages of the disease cannot be the same.

Научно-клинический центр анестезиологии и реаниматологии ГБОУ ВПО «Первый Санкт-Петербургский государственный медицинский университет им. акад. И. П. Павлова», Санкт-Петербург В статье описан случай реперфузионного синдрома после кесарева сечения у родильницы с гигантским новообразованием печени, проявившийся развитием множественной органной дисфункции с нарушением гемодинамики, острым респираторным дистресс-синдромом, острым почечным повреждением. Представленное наблюдение подтверждает гипотезу о том, что реперфузионный синдром может осложнять течение беременности и послеродового периода, и показывает, что проблема интраабдоминальной гипертензии у беременных требует дальнейшего изучения.Ключевые слова: реперфузионный синдром, синдром полиорганной дисфункции, внутрибрюшная гипертензия, акушерство.The article describes the clinical case of reperfusional syndrome after caesarean section in the new mother with giant liver tumor which manifested through development of multi-organ dysfunction with hemodynamic disorders, acute respiratory distress syndrome, and acute liver lesion. This clinical case confirms the hypothesis that reperfusion syndrome can complicate the course of pregnancy and post-delivery period and shows that the issue of intra-abdominal hypertension in the pregnant requires further investigation.Key words: reperfusion syndrome, syndrome of multi-organ failure, intra-abdominal hypertension, obstetrics. Случаи из практики22. Zingarelli В., Scott G. S., Hake P. et al. Effects of ni-caraven on nitric oxide-related pathways and in shock and inflammation // Shock.

научно-клинический центр анестезиологии и реаниматологии Фгбоу во «пспбгму им. и. п. павлова» мз рФ, санкт-петербург, россия Сепсис по-прежнему остается глобальной медицинской проблемой, ассоциированной с высоким уровнем летальности� Это обусловливает сохраняющийся интерес к изучению его патогенеза и внедрению новых лечебных технологий� Современные рекомендации содержат четкие указания по интенсивной терапии, в том числе по проведению заместительной почечной терапии в случае ренальной дисфункции, однако использование других методов экстракорпоральной детоксикации, в том числе возможность применения селективной адсорбции эндотоксина, до сих пор остается предметом дискуссии� Цель: продемонстрировать возможности селективной лПС-адсорбции в комплексной терапии больных с септическим шоком на конкретном клиническом примере� результаты: у пациента с септическим шоком сразу после проведения селективной гемосорбции отмечена положительная динамика, проявившаяся в улучшении состояния, снижении температуры тела до субфебрильных значений, стабилизации показателей гемодинамики, снижении дозы норадреналина с 0,2 до 0,05 мкг/(кг • мин-1), уровня лактата с 2,3 до 1,7 ммоль/л и улучшении показателей респираторной функции� На фоне нормализации показателей гемодинамики улучшилась функция почек, что привело к снижению уровня сывороточного креатинина с 0,309 до 0,150 ммоль/л� На 9-е сут сеансы заместительной почечной терапии были вообще прекращены� Выраженность клинических проявлений множественной органной дисфункции, оцененных по шкале SOFA, снизилась с 10 до 4 баллов� Заключение. Клиническое наблюдение продемонстрировало позитивный опыт использования селективной лПС-адсорбции в комплексной терапии септического шока, вызванного грамотрицательной флорой� Применение экспресс-теста определения уровня активности эндотоксина у пациентов с септическим шоком повышает объективность выбора метода экстракорпоральной гемокоррекции�