Year of manufacture: 2006

Genre: Anesthesiology

Format: DjVu

Quality: Scanned pages

Description: The book “Etudes of Critical Medicine” presents materials on the main problems of the ISS: organization of the service, current trends in the sections of the ISS, monitoring problems, multiple organ failure, cardiopulmonary resuscitation and post-resuscitation care of patients. The role of the immunoreactive system in organizing the vital activity of the body in health and illness and its disorganizing role in critical conditions are emphasized.
The book “Etudes of Critical Medicine” analyzes modern information from the literature and the experience of the Department of Anesthesiology and Reanimatology with a postgraduate education course at Petrozavodsk State University. The material is presented and illustrated in a non-standard style, justified by the author’s desire to provide the reader not only with medical information on the issues discussed, but also to expand his humanitarian horizons.
For anesthesiologists, intensivists (resuscitators), emergency physicians, senior medical students, as well as clinicians whose practice often involves patients in critical condition.

Chapter 1. Structure and functions of the ISS
What is a critical condition: terminological aspect
Functional states of the body
Structure of critical care medicine
Principles of division of specialties
Multidisciplinary or specialization ISS?
Anesthesiologist-resuscitator or anesthesiologist and resuscitator?
Creation of recovery rooms in the operating unit
Rationalism in service organization
Specific features of critical care medicine
Extreme situation
Presence of multiple organ dysfunction
The need for monitoring and technicality
Lack of psychological contact
Invasiveness of research and treatment methods
Interdisciplinarity of pathology
Specifics of ethical and legal standards
Chapter 2. Current trends in the ISS: 1 - anesthesiology and other sections of the ISS
ANESTHESIOLOGY
Profiling of anesthesiologists
Regional anesthesia as a component of anesthesia care
“Proactive” analgesia and “memory of pain”
Maintaining consciousness under anesthesia
Depth of anesthesia
Explicit and implicit memory
Reasons for too superficial anesthesia
Consequences of maintaining consciousness during superficial anesthesia
Diagnostics and monitoring
Is this pathology common?
What to do?
"Therapeutic" anesthesia
Preoperative grading of the severity of the condition and assessment of anesthetic risk
Preliminary assessment of anesthetic risk
INTENSIVE CARE (RESENSIMATOLOGY)
Growth and profiling of intensive care beds
Cost-effectiveness analysis
SOIT - intensive care unit syndrome
Risk factors for ICU syndrome
Early signs of SOIT
Prevention and therapy of SOIT
Optimal level of sedation
EMERGENCY MEDICINE
System of paramedics and specialized teams
Hospital emergency departments
Improving patient transportation
Urgent telephone consultations
DISASTER MEDICINE
Classification and structure
Principles of medical care
Planned training of personnel and facilities
“Global Perestroikas” and the ISS
Chapter 3. Current trends in the ISS: 2 - medicine without blood, without pain, without misconceptions
MEDICINE WITHOUT DONOR BLOOD
Reduction of allotransfusions
Fundamental disadvantages of allohemotransfusions
Manifestation of immune incompatibility
Acute transfusion-induced lung injury (ATLI)
Clinical physiology of acute blood loss
Compensatory reactions of the body: autocompensation
Principles of intensive care for blood loss
Algorithm for monitoring and intensive care
Saving the patient's blood: principles and methods
Preoperative period
Operating period
Postoperative period
MEDICINE WITHOUT PAIN
Pain and pain syndromes
John D. Bonica and the rise of pain science
And interpleural analgesia
Anatomical and physiological prerequisites
Mechanism of interpleural analgesia
Method of performing the blockade
Drugs for interpleural analgesia
Clinical practice
Contraindications
Complications
MEDICINE WITHOUT MISCONCEPTIONS
Principles and methods of evidence-based medicine in the ISS
Archie Cochrane and Evidence-Based Medicine
Principles of randomization
Performance assessment
HRQOL - health-related quality of life
Stages of implementation of evidence-based medicine
I - compiling DM reviews
II - access to reviews via the Internet
III - evaluation of reviews and decision making
Specificity of EBM in critical care medicine
Objective difficulties on the way to implementing evidence-based medicine
Dangers of forced introduction of EBM
Chapter 4. Clinical physiology - applied section of the ISS
What is physiological analysis
Physiology as a branch of fundamental sciences
The difference between clinical physiology and normal and pathological
Clinical physiology is the main basis of the ISS
Practical complexes of the ISS
MCS specialist as a clinical physiologist Autoregulation of functions and paths of development of medicine
Instructions or clinical and physiological analysis?
Organization of clinical physiology services in hospitals
Chapter 5. Critical condition monitoring
Terminological aspect
The role of monitoring in the ISS
Monitoring principles
Degree of difficulty
Goals and objects of monitoring
Monitoring the patient's functions
Control of therapeutic actions
Environmental control
Monitoring technology
Invasive and non-invasive methods
Accuracy and speed of assessment
Comprehensiveness of the assessment
Controlled parameters
Circulation
Breath
Blood system
Liver and kidneys
Metabolism
Central nervous system
Muscular system
Sophisticated Monitoring
Diagnosis of pulmonary embolism
Depth and quality of anesthesia
Transition from mechanical ventilation to spontaneous ventilation
Monitoring the severity of the condition
Ethical and legal aspects of monitoring

Monitoring Standards
Chapter 6. Objectification of the severity of the patient’s condition
Goals and methods
TISS system
APACHE system
Other systems
Chapter 7. Immunological aspects of the ISS: 1 - IRS is responsible for everything
Immune reactivity is the very first property of life
Main functional systems of the body
Immunoreactive system in phylogenesis
Problems of immunity
The Life and Death of Paul Langerhans
Pradoxes of infection at the junction of the 2nd and 3rd millennia
Causes of infectious paradoxes
Intensive care units are the main source of nosocomial infection
Vascular catheter infections
Antibiotic resistance
Dysbacteriosis
Invasive mycoses
The luminaries are not against infection, but for IRS
ARRS - general reactive inflammation syndrome
Critical illness as disimmunity syndromes
The Life and Death of Roger Bone
The problem of apoptosis and autocorrection of IRS
Apoptosis - programmed cell death
Chapter 8. Immunological aspects of the ISS: 2 - sepsis, septic and anaphylactic shocks
SEPSIS AND SEPTIC SHOCK
Terminology and classification
Diagnostics
Patho- and thanatogenesis
Hemodynamic damage
Respiratory impairment
Other PON components
Intensive care of septic shock
Ideological preamble
Hemodynamic correction
Breathing correction
Correction of coagulopathy
Impact on IRS functions
Correction of the digestive tract
Correction of other components of MODS
Elimination of the source of infection
ANAPHYLACTIC SHOCK: CLINICAL PHYSIOLOGY AND INTENSIVE CARE
Historical milestones in the study of anaphylaxis
Anaphylaxis
Classification of hyperimmune reactions
Patho- and thanatogenesis
Classic anaphylactic shock
Anaphylactoid shock
Anaphylactogens
Diagnostics
Morphological signs of anaphylactic shock
Anaphylactic shock during anesthesia
Intensive care and prevention
Ideological preamble
Blockade of mastocytes and basophils
Blockade of mediators and receptors
Correction of syndromes
Prevention
IRS AND ISS: FUTUROLOGICAL ASPECT
Why was the role of IRS in physiology and pathology appreciated so late?
And PC in critical conditions
Visible prospects and rules of conduct today
Chapter 9 Multiple organ dysfunction (MOD) and failure (MOF): 1 - etiology and pathogenesis
History and terminology of the problem
The emergence of the concept of PON
Multiple organ dysfunction (MOD) as an object of the ISS
Body signaling systems and multiple organ failure
Theories of control of a multicellular organism

Etiology of multiple organ failure
Iatrogenesis in modern medicine
Patho- and thanatogenesis
Endothelial physiology and mediator mechanism of MODS
Endothelial functions
Nitric oxide (N0) and blood flow
Distal, paracrine and autocrine effects
Cytokines and eicosanoids
Microcirculatory and reperfusion mechanisms
Hypovolemic vicious circle
Reperfusion paradoxes
The digestive tract is the engine of PON and the infectious mechanism
Selective gut decontamination (SDC)
Abdominal compression syndrome
Autoimmune damage and the double hit phenomenon
Iatrogenic double whammy
Clinic: parallelism or sequence of syndromes?
Summary of patho- and thanatogenesis
Chapter 10. Multiple organ dysfunction (MOD) and failure (MOF): 2 - strategy and tactics
Principles of patient management: strategy
Objectification of damage to functions and severity of condition
Assessing the severity of the condition
It is necessary to prevent PON at the AML stage
Steps of action
Antimediator effect
Normalization of energy production
Detoxification
Syndrome therapy
Reducing the invasiveness of actions
Methods of patient management: tactics
Outcomes and quality of life of patients
Chapter 11. Specialized CPR complex: 1 - artificial blood flow and ventilation
Historical aspects of CPR
Ancient methods
Biophysics of artificial blood flow: heart or chest pump?
Indirect methods of artificial blood flow
Compression of the chest simultaneously with artificial inspiration
Vest CPR
Inserted abdominal compression (IAC)
Active compression-decompression (ACD)
DTP with inspiratory resistance
Cough autoresuscitation
CPR in the prone position (compressing the chest from the back)
Direct methods of artificial blood flow
Open (direct) cardiac massage
Assisted circulation
Non-invasive ventilation methods
"Key of Life"
Face mask with valve
Conditionally invasive methods of ventilation
Ducts with artificial dead space
Single and double lumen air duct obturators
Laryngeal mask airway
Invasive methods of ventilation
Tracheal intubation
Coniotomy
Hand-held respirators
Automatic respirators
Translaryngeal jet ventilation
Chapter 12. Specialized CPR complex: 2 - auxiliary methods, tactics, prognosis
Drug therapy
The optimal route of drug administration
Adrenaline or vasopressin?
Lidocaine or amiodarone?
Should I use sodium bicarbonate?
Should calcium supplements be administered?
Place of atropine in CPR
Electrical defibrillation of the heart
The main rule: EMF must be early
Procedure
Monitoring and prognostic criteria
CPR monitoring
Predicting the outcome
Preventing Brain Damage
Mechanisms of brain damage
Preventive and therapeutic measures
Post-resuscitation illness
Errors, dangers and complications
Classification of CPR complications
Complications of the CPR procedure
CPR tactics: clinical, ethical and legal aspects
To start or not to start CPR?
Stopping CPR
Chapter 13. Cognition of the terminal state (PTS phenomenon)
History of the problem
Manifestations of the PTS phenomenon
Physiological mechanisms of the phenomenon
Theory of phase states of the brain
Drug intoxication
Analyzers in terminal state
Parapsychological mechanisms
What distinguishes humans from animals?
The future of CPR
ISS in the healthcare system (instead of the Conclusion)
Contents and summary in English
Literature

Place of work: Academic degree: Academic title: Alma mater: Awards and prizes:

Anatoly Petrovich Zilber(born in 1931) - organizer of the first intensive respiratory therapy department in Russia (1989), then a respiratory center (2001). Author of the concept of critical care medicine (MCM) (1989). Doctor of Medical Sciences (1969), professor (1973), academician of the Russian Medical-Technical Academy (1997) and the Academy of Security, Defense and Law Enforcement of the Russian Federation (2007).

Honorary and full member of the Board of the Federation of Anesthesiologists and Reanimatologists of the Russian Federation, Honored Scientist of the Russian Federation, Honorary Worker of Higher Professional Education of the Russian Federation, People's Doctor of the Republic of Karelia, Knight of the Orders of Friendship and Honor.

Biography

Bibliography

Author of more than 400 published works, including 34 monographs. Being one of the founders of domestic anesthesiology and resuscitation, A.P. Zilber pays great attention to the study of the respiratory system, and his first monograph “Operating position and anesthesia” has the subtitle “Postural reactions of blood circulation and breathing in anesthesiology.” The subject of his research is the reaction of the respiratory system in any critical condition. For A.P. Zilber, the respiratory system is not only a structure that provides the entire body with the necessary amount of oxygen and relieves it of excess carbon dioxide. This is the most important life support system of the body, protecting it from “external and internal enemies”, creating the conditions necessary for the normal functioning of other vital organs. It is difficult to say what is more surprising in his works - the non-standard approach to the problems being studied or the unexpectedness of the findings and identified patterns. A clear proof of this is the professor’s main works on this topic: “Regional functions of the lungs. Clinical physiology of uneven ventilation and blood flow”, “Respiratory therapy in everyday practice”, “Respiratory failure” and, finally, “Respiratory medicine”(!). The main feature of these (and other) books by A.P. Zilber, which makes them books “for all times,” is their clinical and physiological focus and validity. This is probably why none of the fundamental provisions derived by A.P. Zilber from his research was refuted or, at least, reasonably rejected. Zilber A.P. Blood loss and blood transfusion. Principles and methods of bloodless surgery. - Petrozavodsk: Petrozavodsk State University Publishing House, 1999. - 114 p. - 5000 copies. - ISBN 5-8021-0057-5.

Zilber A.P. Clinical physiology in anesthesiology and resuscitation. - 1984. - 486 p.

Zilber A.P. Sketches of critical medicine. - 2006.

Zilber A.P.. - Ministry of Health of the Russian Federation, 2001.

Zilber A.P. Treatise on euthanasia. - Petrozavodsk: Peter. State University, 1998. - 464 p.

Zilber A.P. Ethics and law in critical care medicine. - Petrozavodsk: Petrozavodsk University Publishing House, 1998. - 560 p.

Famous sayings

if the doctor is familiar with modern ideas about the clinical physiology of blood, blood loss and blood transfusion, he will find alternative methods suitable for a particular patient and will do without donor blood transfusion

Jehovah's Witnesses proved useful to medicine […] They... forced doctors to reconsider the effectiveness of blood transfusions, prompted the search for alternative methods, and, finally, increased attention to the rights of patients. Thus, paraphrasing Voltaire, who ... wrote - “If God did not exist, he would have to be invented,” I would say - “If Jehovah’s Witnesses did not exist, they would have to be invented,” so that we would quickly get a correct idea of ​​the acute blood loss and the role of blood transfusion

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Excerpt characterizing Zilber, Anatoly Petrovich

- Well, what, my Cossack? (Marya Dmitrievna called Natasha a Cossack) - she said, caressing Natasha with her hand, who approached her hand without fear and cheerfully. - I know that the potion is a girl, but I love her.
She took out pear-shaped yakhon earrings from her huge reticule and, giving them to a beaming and blushing Natasha, immediately turned away from her and turned to Pierre.
- Eh, eh! kind! “Come here,” she said in a feignedly quiet and thin voice. - Come on, my dear...
And she menacingly rolled up her sleeves even higher.
Pierre approached, naively looking at her through his glasses.
- Come, come, my dear! I was the only one who told your father the truth when he had a chance, but God commands it to you.
She paused. Everyone was silent, waiting for what would happen, and feeling that there was only a preface.
- Good, nothing to say! good boy!... The father is lying on his bed, and he is amusing himself, putting the policeman on a bear. It's a shame, father, it's a shame! It would be better to go to war.
She turned away and offered her hand to the count, who could hardly restrain himself from laughing.
- Well, come to the table, I have tea, is it time? - said Marya Dmitrievna.
The count walked ahead with Marya Dmitrievna; then the countess, who was led by a hussar colonel, the right person with whom Nikolai was supposed to catch up with the regiment. Anna Mikhailovna - with Shinshin. Berg shook hands with Vera. A smiling Julie Karagina went with Nikolai to the table. Behind them came other couples, stretching across the entire hall, and behind them, one by one, were children, tutors and governesses. The waiters began to stir, the chairs rattled, music began to play in the choir, and the guests took their seats. The sounds of the count's home music were replaced by the sounds of knives and forks, the chatter of guests, and the quiet steps of waiters.
At one end of the table the Countess sat at the head. On the right is Marya Dmitrievna, on the left is Anna Mikhailovna and other guests. At the other end sat the count, on the left the hussar colonel, on the right Shinshin and other male guests. On one side of the long table are older young people: Vera next to Berg, Pierre next to Boris; on the other hand - children, tutors and governesses. From behind the crystal, bottles and vases of fruit, the Count looked at his wife and her tall cap with blue ribbons and diligently poured wine for his neighbors, not forgetting himself. The countess also, from behind the pineapples, not forgetting her duties as a housewife, cast significant glances at her husband, whose bald head and face, it seemed to her, were more sharply different from his gray hair in their redness. There was a steady babble on the ladies' end; in the men's room, voices were heard louder and louder, especially the hussar colonel, who ate and drank so much, blushing more and more, that the count was already setting him up as an example to the other guests. Berg, with a gentle smile, spoke to Vera that love is not an earthly, but a heavenly feeling. Boris named his new friend Pierre the guests at the table and exchanged glances with Natasha, who was sitting opposite him. Pierre spoke little, looked at new faces and ate a lot. Starting from two soups, from which he chose a la tortue, [turtle,] and kulebyaki and to hazel grouse, he did not miss a single dish and not a single wine, which the butler mysteriously stuck out in a bottle wrapped in a napkin from behind his neighbor’s shoulder, saying or “drey Madeira", or "Hungarian", or "Rhine wine". He placed the first of the four crystal glasses with the count's monogram that stood in front of each device, and drank with pleasure, looking at the guests with an increasingly pleasant expression. Natasha, sitting opposite him, looked at Boris the way thirteen-year-old girls look at a boy with whom they had just kissed for the first time and with whom they are in love. This same look of hers sometimes turned to Pierre, and under the gaze of this funny, lively girl he wanted to laugh himself, not knowing why.
Nikolai sat far from Sonya, next to Julie Karagina, and again with the same involuntary smile he spoke to her. Sonya smiled grandly, but apparently was tormented by jealousy: she turned pale, then blushed and listened with all her might to what Nikolai and Julie were saying to each other. The governess looked around restlessly, as if preparing to fight back if anyone decided to offend the children. The German tutor tried to memorize all kinds of dishes, desserts and wines in order to describe everything in detail in a letter to his family in Germany, and was very offended by the fact that the butler, with a bottle wrapped in a napkin, carried him around. The German frowned, tried to show that he did not want to receive this wine, but was offended because no one wanted to understand that he needed the wine not to quench his thirst, not out of greed, but out of conscientious curiosity.

At the male end of the table the conversation became more and more animated. The colonel said that the manifesto declaring war had already been published in St. Petersburg and that the copy that he himself had seen had now been delivered by courier to the commander-in-chief.
- And why is it difficult for us to fight Bonaparte? - said Shinshin. – II a deja rabattu le caquet a l "Autriche. Je crins, que cette fois ce ne soit notre tour. [He has already knocked down the arrogance of Austria. I am afraid that our turn would not come now.]
The colonel was a stocky, tall and sanguine German, obviously a servant and a patriot. He was offended by Shinshin's words.
“And then, we are a good sovereign,” he said, pronouncing e instead of e and ъ instead of ь. “Then that the emperor knows this. He said in his manifesto that he can look indifferently at the dangers threatening Russia, and that the safety of the empire, its dignity and the sanctity of its alliances,” he said, for some reason especially emphasizing the word “unions”, as if this was the whole essence of the matter.
And with his characteristic infallible, official memory, he repeated the opening words of the manifesto... “and the desire, the sole and indispensable goal of the sovereign: to establish peace in Europe on solid foundations - they decided to send part of the army abroad and make new efforts to achieve this intention “.
“That’s why, we are a good sovereign,” he concluded, edifyingly drinking a glass of wine and looking back at the count for encouragement.
– Connaissez vous le proverbe: [You know the proverb:] “Erema, Erema, you should sit at home, sharpen your spindles,” said Shinshin, wincing and smiling. – Cela nous convient a merveille. [This comes in handy for us.] Why Suvorov - they chopped him up, a plate couture, [on his head,] and where are our Suvorovs now? Je vous demande un peu, [I ask you,] - he said, constantly jumping from Russian to French.

Anatoly Petrovich was born in Zaporozhye, received his secondary education in Tashkent. Being a graduate of the Lenin Medical Institute in 1954, he glorified him with his numerous merits. Among other things, A.P. Zilber becomes an academician of the Russian Medical-Technical Academy, as well as the Academy of Security, Defense and Law Enforcement of the Russian Federation.

Achievements

In 1989, Anatoly Petrovich Zilber organized the only intensive respiratory therapy department of its kind, which in 2001 grew into a respiratory center. In 1989, he was the author of an interpretation of critical care medicine. In 1969 he became a doctor of medical sciences, and later, in 1973, a professor.

Zilber and the respiratory system

The respiratory system was the most interesting path for this scientist; his first serious work was devoted to it. The doctor described in detail the directly proportional dependence of the reaction of breathing and the respiratory tract on their relatively critical state, noting all kinds of changes, both positive and negative dynamics.

In 1959, he created one of the first departments of ITAR, at the same time he took the well-deserved position of chief anesthesiologist, first in the USSR, and then in the Russian Federation. In addition, Anatoly Petrovich independently organized a course in general anesthesiology and resuscitation, heading the department of Petrozavodsk State University, where he first proposed a fundamentally new training model, which he himself developed.

Scientific works of A. P. Zilber

From the pen of Anatoly Petrovich came such scientific works as:

• “The Concept of Critical Care Medicine (ISS 1989)”,
• "Operative position and anesthesia"
• “Respiratory therapy in everyday practice”, etc.

One of the most important qualities of Anatoly Petrovich’s works is their direct originality, originality, non-standardity - this list can be continued indefinitely! Zilber went down in history as a talented physician-scientist who saved many lives, literally pulling them out of the clutches of death by a straw.

I created this project to tell you in simple language about anesthesia and anesthesia. If you received an answer to your question and the site was useful to you, I will be glad to receive support; it will help further develop the project and compensate for the costs of its maintenance.

A.P. Zilber

CLINICAL

PHYSIOLOGY

in anesthesiology

and resuscitation

Moscow “Medicine” 1984

UDC 617-089.5+616-036.882/-092

ZILBER A. P. Clinical physiology in anesthesiology and resuscitation. - M.: Medicine. 1984, 380 pp., ill.
A.P. Zilber - prof., head. course of anesthesiology and resuscitation at Petrozavodsk University.

The book is a fundamental guide to clinical physiology as applied to the needs of anesthesiology and resuscitation. It outlines the clinical physiology of critical illness syndromes, regardless of the nosological form of the diseases in which these syndromes developed, as well as the physiological effects of intensive care. The possibility of using clinical and physiological analysis in special areas of medicine - obstetrics, pediatrics, cardiology, nephrology, neurosurgery, traumatology, etc. is considered.
The manual is intended for anesthesiologists and resuscitators.
The book contains 56 figures, 15 tables.
Reviewer: E. A. DAMIR - Prof., Head, Department of Anesthesiology and Reanimatology of the Central Order of Lenin Institute for Advanced Training of Physicians.

4113000000-118 039(01)-84

Publishing house "Medicine" Moscow 1984

Clinical physiology of critical conditions is a relatively new branch of medicine. The principle of presentation of materials that the reader will encounter in this manual seems most suitable for considering clinical and physiological problems. We have systematized in three parts of the book the physiology of the main syndromes, methods of intensive care and the principles of private physiological analysis. This plan for constructing the manual is due not only to the impossibility of giving a systematic presentation of the physiology of each body system, as we tried to do in “Clinical Physiology for the Anesthesiologist” (M., 1977) and the length of the book, but also to the principle substantiated in the introduction to the manual.

Expressing our attitude to this or that clinical and physiological problem, we, for fundamental reasons, sought to give the book the character of a conversation with the reader. We believe that the style of reasoning stimulates the reader’s activity in perceiving the material, his agreement and disagreement with the author’s position and, therefore, forces him to think about the problem, rather than thoughtlessly trust someone’s authority. In such a little-studied field of knowledge as the clinical physiology of critical conditions, the active, interested and, perhaps, even creative position of the reader seems to us the most promising in resolving difficult and far from unambiguously interpreted clinical and physiological problems of anesthesiology and resuscitation. We strived to ensure that the drawings not only illustrated the text, but also aroused the reader’s desire to think.

It would seem that the very name of the manual determines the main contingent of its readers - anesthesiologists and resuscitators. However, anesthesiologists and resuscitators almost always work on foreign territory, both literally and figuratively: (with a surgeon in the operating room, with an obstetrician in the delivery room, with a cardiologist, neurologist, pediatrician in intensive care wards). But if we manage a patient together in different specialties, schools, traditions, then we should develop a unified clinical and physiological platform of action.

INTRODUCTION

In the life activity of the human body and its interaction with the external environment, three states can be distinguished: health, illness and terminal or critical condition.

If some external or internal factor has affected the body, but compensatory mechanisms have maintained the constancy of the internal environment (homeostasis), then this state can be designated as health.

Subsequently, post-aggressive reactions leading the body to a terminal state proceed according to the following scheme. Primary aggression causes a local specific reaction characteristic of each of the numerous factors of aggression: inflammation in response to infection, hemostasis in response to vascular damage, edema or necrosis in response to a burn, inhibition of nerve cells under the influence of an anesthetic, etc.

Depending on the degree of aggression, various functional systems of the body are included in the general post-aggressive reaction, ensuring the mobilization of its protective forces. This phase of the general post-aggressive reaction is the same for various factors of aggression and begins with stimulation of the hypothalamic-pituitary, and through it the sympathetic-adrenal systems. Increased ventilation, blood circulation, increased liver and kidney function are observed, immune reactions are stimulated, redox processes in tissues change to increase energy production. All this leads to increased catabolism of carbohydrates and fats, consumption of enzymatic factors, displacement of electrolytes and fluids in the cellular, extracellular and intravascular spaces, hyperthermia, etc. This condition can be designated as a disease (Fig. 1).

If this phase (the so-called catabolic) of the general post-aggressive reaction is harmonious and adequate, the disease does not become critical and does not require the intervention of resuscitators. Despite the similarity of the physiological mechanisms of the general post-aggressive reaction to various factors of aggression, as long as the autoregulation of functions is preserved, specific phenomena prevail in the clinical picture of the disease. The most radical therapy of this period is etiological. Naturally, the patient is treated by a surgeon, a cardiologist, a neuropathologist - a specialist who “belongs” to this disease in terms of its etiology and pathogenesis.

But too much or prolonged aggression, imperfect reactivity of the body, accompanying pathology of any functional systems make the general post-aggressive reaction inharmonious and inadequate. If any function is exhausted, the others are inevitably disrupted and the general post-aggressive reaction turns from protective to killing the organism: pathogenesis becomes thanatogenesis. Now, previously beneficial hyperventilation leads to respiratory alkalosis and a decrease in cerebral blood flow; centralization of hemodynamics disrupts the rheological properties of the blood and reduces its volume. The hemostatic reaction turns into diffuse intravascular coagulation with dangerous thrombus formation or uncontrollable bleeding. Immune and inflammatory reactions not only block the microbe, but cause anaphylactic shock or bronchiolospasm and pneumonitis. Now not only reserves of energy substances are burned, but also structural proteins, lipoproteins and polysaccharides, reducing the functionality of organs. Decompensation of the acid-base and electrolyte state occurs, and therefore enzymatic systems and information transfer are inactivated. This is a terminal (critical) condition.

Rice. 1. Three states of vital functions: health (1), illness (2), critical (terminal) condition (3), in which only a lifebuoy with the inscription “ITAR” gives the patient the opportunity “not to drown.”
We depicted these interdependent and mutually reinforcing disorders of the vital functions of the body in the form of intertwining vicious circles, among which three main ones can be distinguished (Fig. 2).

The first circle is a violation of the regulation of vital functions, when not only central regulatory mechanisms (nervous and hormonal) are damaged, but also tissue ones (kinin systems, the action of biologically active substances such as histamine, serotonin, prostaglandins, cAMP systems that regulate blood supply and metabolism of organs, permeability membranes, etc.). Syndromes that are mandatory for a terminal state of any etiology develop: impaired rheological properties of blood, hypovolemia, coagulopathy, metabolic damage (the second vicious circle). The third circle is organ disorders: acute functional failure of the adrenal glands, lungs, brain, liver, kidneys, gastrointestinal tract, blood circulation.

Each of these disorders can be expressed to varying degrees, but if a specific pathology has reached the level of a critical condition, elements of all of these disorders always exist, so any critical condition should be considered as multiorgan failure.

Unfortunately, today there is no universal objective criterion that allows us to distinguish between illness and critical condition, and this is hardly possible. At the same time, there are attempts to quantify the severity of a critical condition, such as the Treatment Action Scale (TISS),

^ Rice. 2. Damage to vital functions in critical condition.

Regardless of the specifics of the primary lesion, any pathology that has reached the stage of a terminal (critical) condition is characterized by a violation of all types of regulation, numerous syndromes and organ disorders: damage to the lungs (1), heart (2), liver (3), brain (4) , kidneys (5), digestive tract (6). BAS - biologically active substances (serotonin, histamine, angiotensin, etc.).
proposed in 1974 by D. J. Cullen et al. In accordance with this scale, the various syndromes observed in the patient and the therapeutic actions necessary for him are expressed in points. The sum of points characterizes the severity of the patient’s condition, which is necessary not only for assessing immediate tactics, but also for subsequent analysis. However, after 3 years, D. J. Cullen (1977) considered it necessary to evaluate not only syndromes and therapeutic effects, but also a third important component - functional tests characterizing the respiratory, circulatory, blood systems and various metabolic indicators.

According to the TISS scale, patients with a score of 5 points are under observation, i.e., they are not a contingent of intensive care units. At 11 points, careful monitoring of vital functions is required, at 23, therapeutic actions that can be carried out by a nurse are added to it. With 43 points, highly specialized medical actions are required aimed at correcting vital functions, because the patient is in a terminal (critical) condition.

For 20 years, the Karelian Autonomous Soviet Socialist Republic has been using a five-point risk scale for a patient who requires intensive care, anesthesia and resuscitation (ITAR). This scale takes into account the patient’s condition, the underlying and concomitant pathology, the nature of the upcoming intervention (including surgery), the skills and capabilities of the team that will work with the patient. The risk assessment is written on a working punch card, which records the procedures performed and the various vital signs.

Currently, our department is testing a new risk objectification scale, which details the functional state of seven systems (respiration, circulatory, blood, liver, kidney, central nervous system, digestive) and individual metabolic indicators that are difficult to attribute to one system. The total assessment of the patient's functional state in points, taking into account the remaining gradations of risk according to the old scale, allows us to objectively judge the state of the severity of the patients and the risk awaiting them. It is intended to: 1) rationalize the work of staff in ITAR departments by dividing the services required by patients into the four complexes discussed below; 2) predicting complications for their timely prevention; 3) retrospective analysis of the effectiveness of ITAR for various pathologies, different teams, etc. It should be noted that quantitative assessment of the severity of the patient’s condition and risk facilitates the processing of materials using a computer, including monitoring of functions (see Chapter 18).

At this stage of pathology, the specificity of the primary factor of aggression (trauma, infection, hypoxia, damage to any organ) does not matter for the management of the patient and the outcome of the disease. From the moment when autoregulation of functions disappears and an inadequate inharmonious post-aggressive reaction begins to kill the body, a methodologically uniform artificial replacement of the vital functions of the body is required. This should be undertaken by an anesthesiologist, resuscitator or doctor of any specialty who is faced with a critical condition. If all medicine is about managing the functions of the body during illness in general, then resuscitation manages them in critical conditions. The task is to introduce the general post-aggressive reaction into such a framework that the specific therapy corresponding to the original factor of aggression again becomes the main one. The anesthesiologist or resuscitator must return the patient to his “legitimate” specialist for further treatment and rehabilitation.

We believe that the work of an anesthesiologist and resuscitator consists of four complexes. Complex I is the main and most labor-intensive. This is intensive therapy, i.e. artificial replacement of vital body functions or control of them. Complex II, which may precede or complete the first, is intensive observation and care, when monitoring of vital functions is required if the nature of the pathology is such that their management may be required, i.e. intensive therapy. Complex III - resuscitation, which can be defined as intensive therapy in case of circulatory and respiratory arrest. IV complex - anesthesiological benefits - is essentially the use of complexes I and II in connection with surgical intervention. In anesthesiology, pain relief is only a small component of complex I (intensive care), and the anesthesiologist must work so that the patient does not require complex III. Thus, complex IV (anesthetic care) is only intensive observation and intensive therapy (complexes I and II) of a patient undergoing surgery.

An anesthesiologist or resuscitator should not act according to inspiration or intuition, although without these elements no creativity is conceivable. The most informative basis for the creative work of a specialist in the treatment of critical illnesses is clinical physiology.

Before substantiating this main thesis, let us define the essence of clinical physiology.

Physiology is the science of body functions. Perhaps this is the only definition related to physiology that does not cause controversy. Regarding the division of physiology into sections and the definition of the boundaries of these sections, opinions differ. There are general and specific physiology, normal and pathological, clinical, experimental, comparative, age-related, sports, underwater, aviation, etc.

The so-called normal and pathological physiology is the most important part of the theoretical disciplines that shape the modern doctor. With their help, he learns the general patterns of vital activity of a healthy and sick organism, and through these traditional, most important sections of biological science, the medical student begins to study the clinic.

What is clinical physiology?

We consider clinical physiology as a branch of applied medicine, through which physiological methods of research and treatment are applied directly at the patient’s bedside; we consider it the most important section of modern clinical practice, which only begins and ends with functional research, but necessarily includes physiological therapy that restores autoregulation of body functions. With this perception of the role of clinical physiology in medicine, its specific tasks can be formulated as follows (Fig. 3).

1. Determination of the functional capacity of various systems of the human body with precise localization of the functional defect and its quantitative assessment.

2. Identification of the main physiological mechanism of pathology, taking into account all the systems involved, as well as the ways and degree of compensation in a particular patient with all the diversity of his individual characteristics and concomitant diseases.

3. Recommendation of measures of physiological therapy, i.e. methods in which impaired functions will be corrected or artificially replaced, so as not to deplete already damaged mechanisms, but to manage them until natural autoregulation is restored.

4. Functional control of the effectiveness of therapy.

The question may arise: isn’t restoring the body’s natural autoregulation the ultimate goal of any branch of clinical medicine? Of course, the ultimate goals of clinical medicine and clinical physiology are the same, but the ways in which they can achieve them are different, and in some cases even opposite.

^ Rice. 3. Objectives of clinical physiology.

These interrelated tasks (stages) of clinical and physiological analysis could also be designated as follows: what is it (I), why is it (II), what to do (III) and what will happen (IV).

Clinical medicine uses any means of etiological, pathogenetic and symptomatic therapy to achieve the ultimate goal - recovery. She can equally address her efforts to different systems and organs according to the principle of urgent instructions “to everyone, everyone, everyone,” and the disappearance of symptoms of the disease and restoration of ability to work is the main criterion of its success.

Clinical physiology uses etiological factors and symptomatic treatment only to the extent that they help determine the main physiological mechanism of the pathology and the therapeutic effect on this precisely localized mechanism. Clinical physiology is that transitional stage in medicine, which provides the doctor with the opportunity for physiological analysis in everyday clinical practice today.

Many people believe that physiological analysis in the clinic should be called clinical pathophysiology rather than physiology. This opinion is quite logical, but we still use the term “clinical physiology” and not “pathophysiology” for two reasons. Firstly, modern clinical practice has three complexes: prevention, treatment and rehabilitation. In the first of them, the main pathological process does not yet exist, but in the latter it no longer exists. Thus, pathophysiology should be called physiological analysis that relates to only one of the three main components of clinical practice. Secondly, traditionally, pathophysiology has been used to mean the study of experimental animal models. Although the definition of “clinical” emphasizes the application of physiological analysis to a sick person, we still prefer the term “clinical physiology”, without at the same time considering the term “clinical pathophysiology” to be completely unacceptable.

Thus, we conditionally distinguish three related areas of physiology and medicine, which do not have clear boundaries, and sometimes, on the contrary, are intricately intertwined: 1) theoretical (normal and pathological) physiology models - one of the foundations for obtaining medical knowledge and the education of a doctor; 2) clinical practice, which has many foundations, including theoretical physiology; 3) clinical physiology - the application of the principles and methods of physiological analysis directly to the patient.

Let's return to the thesis: “Clinical physiology is the main basis of anesthesiology and resuscitation.”

We proceed from the principle that anesthesia during surgery, cardiogenic shock, toxic coma, amniotic embolism, etc. are critical conditions that should be dealt with by a specialist in the treatment of critical conditions, who, unfortunately, does not yet have a name adequate to its purpose .

There is no clear and generally accepted name for the specialty, which in the future will inevitably be fragmented, but there is a single principle that is preserved wherever an anesthesiologist or resuscitator works: management, artificial replacement and restoration of vital functions in conditions of aggression to a degree that exceeds the capabilities of autoregulation of body functions .

The main principle of the resuscitator's efforts is intensive therapy, i.e. temporary replacement of an acutely lost vital function of the body. For successful work, you need to know the refined physiological mechanism of damage; in order to localize and specify intensive care measures, targeted shooting is required, not a massive blow (Fig. 4). The resuscitator has no other options and no time reserves.

Everyday clinical and physiological analysis, which in conditions of a critical condition is performed by a doctor, no matter what his name is and no matter what position of the staff he occupies, should consist of four stages: determining the mechanism and degree of damage to the function, predicting the pathology development paths, choosing means of replacing the function or managing it and immediately monitoring its effectiveness. In other words, physiological analysis should help resolve the following questions: what is it, why is it, what to do and what will happen.

^ Rice. 4. Difference between the clinical and physiological approach (right) and routine clinical practice (left).
Summarizing the introductory discussions, we would like to dwell on the principle of construction of this manual. In 1977, the publishing house “Medicine” published the book “Clinical Physiology for an Anesthesiologist”, in which clinical and physiological materials were presented in accordance with the functional systems of the body, i.e. its structure was fundamentally different from the structure of this manual. The desire to include as much new material as possible on the clinical physiology of critical conditions forced us to abandon such consideration of a number of important problems set out in the previous book and which have not undergone significant changes over the past years.

What is the leadership structure? There is no need to look for two extremes in this book: theoretical physiology, which describes the patterns of functioning of the body without connection with the healing process, or a clear schedule of all therapeutic actions. The three parts of the book can be briefly designated as follows: physiology of syndromes (I), physiology of methods (II) and physiological correction in various sections of healthcare (III). All three parts fall within the scope of the anesthesiologist and resuscitator, who, wherever they work, use three main complexes - intensive care, anesthesia and resuscitation (ITAR).

Without pretending to introduce new mandatory names or organizational forms, we only want to emphasize the fundamental commonality of the conditions of anesthesia, intensive care and resuscitation - the need to manage the vital functions of the body in a critical condition of the patient, which makes ITAR applied (clinical) physiology.

The author sees the main goal of this book as showing the complexity of the physiological processes in which the anesthesiologist and resuscitator constantly intervene, to justify therapeutic actions that allow the body to restore autoregulation of functions impaired by a critical condition. In other words, in this book, an interested specialist should look for a physiological basis for the fact that necessary what to do for a patient in critical condition and what to do it is forbidden.

Part I

^ CLINICAL PHYSIOLOGY OF THE MAIN SYNDROMES OF CRITICAL ILLNESS

The materials in this part should help answer the first two questions of clinical and physiological analysis: what is it and why is it. The answer to the question of what to do in the materials of this part is given only schematically, since Part II of the book is devoted to it.

Anatoly Petrovich Zilber- graduate of the First Leningrad Medical Institute in 1954. The first official anesthesiologist of the Republican Hospital of Karelia (1957). In 1959 he created one of the first ITAR branches in the country. From this year until 2009 - chief anesthesiologist of the Ministry of Health of the KASSR. In 1966, he organized the first independent course in anesthesiology and resuscitation in the USSR (since 1989 - department) at Petrozavodsk State University, and became its head. The course worked according to the original program developed by A.P. Zilber.

Organizer of the first intensive respiratory therapy department in Russia (1989), then a respiratory center (2001). Author of the concept of critical care medicine (MCM) (1989). Currently, Anatoly Petrovich is the head of the Department of Critical and Respiratory Medicine, Doctor of Medical Sciences (1971), Professor (1973), Honored Scientist of the Russian Federation (1989), Academician of the Russian Academy of Medical and Technical Sciences (1997) and the Academy of Security, Defense and Law and Order of the Russian Federation (2007), Honorary Worker of Higher Professional Education of the Russian Federation (2000), Honored Doctor of the Russian Federation, People's Doctor of the Republic of Karelia (2001), Visiting Professor at Harvard and Southern California Universities (USA), Honorary Professor at Khorezm University (Uzbekistan, 2004), Honorary and full member of the Board of the Federation of Anesthesiologists and Reanimatologists of the Russian Federation (2000), Honorary Citizen of Petrozavodsk (2003), Chairman of the Ethics Committee under the Ministry of Health and Social Development of the Republic of Kazakhstan and Petrozavodsk State University.

Author of more than 450 published works, incl. 42 monographs, editor of translations of four manuals on the specialty: J. Duke “Secrets of Anesthesia.” M.: Medpress-inform, 2005. 552 pp.; "Guide to Clinical Anesthesiology", ed. B.J. Pollard. M.: Medpress-inform, 2006. 912 pp.; J.P. Rafmell, D.M. Neal, Cr.M. Viscomi "Regional anesthesia." M.: Medpress-inform, 2007. 272 ​​pp.; P. Marino “Intensive care”. M.: GEOTAR-media, 2010. 900 p. Co-author of the first textbook for medical universities on resuscitation, “Resuscitation and Intensive Care.” M.: Publishing center "Academy", 2007. 400 p. Co-author (with V.I. Bragina) of the monograph “Humanitarian Culture of Medical Education” - the first book on this most important topic of modern education.

Organizer of Petrozavodsk annual educational and methodological seminars of critical care medicine (since 1964). Currently these are international seminars “Silber School. Open Forum”, held under the auspices of the Committee on European Education in Anesthesiology (CEEA) of the European Association of Anesthesiologists (ESA). A total of 50 (!) seminars were held on current issues in critical care medicine. Physicians who have participated in six SEEA seminars are entitled to take the European Diploma in Anesthesiology exam.

A.P. Zilber has repeatedly given lectures in different cities of Russia, as well as in Austria, Sweden, Finland, Israel, Hungary, the USA, Canada and other countries near and far abroad. Currently, using the capabilities of telecommunications, Anatoly Petrovich gives lectures for doctors not only in Russia, but also in other CIS cities. In 2013 alone, the professor gave more than 30 video lectures. A record was given to giving a lecture on problems of medical ethics and law in critical care medicine to 8 different audiences at once - from Moscow to Yerevan and Krasnoyarsk.

Area of ​​scientific interests

• Clinical Physiology and Critical Care Intensive Care;
• clinical physiology of breathing;
• promotion of the humanitarian foundations of training and practice of doctors;
• study of the activities of doctors who became famous outside of medicine (so-called medical truthism).

No one in Russia, and perhaps in the world, knows as much about the non-medical activities of doctors as Anatoly Petrovich Zilber knows. He talks about them with pleasure and writes books called "Truent Doctors."

Awards

For his contribution to the development of medical science and practice in Russia, increasing the authority of Russian medicine in the world, A.P. Zilber was awarded the Order of Friendship (1998), Honor (2006), the Order of Hippocrates, medals “For outstanding achievements in resuscitation” (2004), “For strengthening the authority of Russian science" (2007), "A.L. Chizhevsky Gold Medal for professionalism and business reputation" (2008), Lomonosov Medal (2012), gold badge "Ibi Victoria ubi Concordia" ("Where there is agreement, there is victory") (2012), Memorial Medal named after Academician of the Russian Academy of Medical Sciences V.A. Negovsky - “For significant contribution to the development of anesthesiology and resuscitation, aimed at preserving and strengthening human health, and training highly qualified scientific personnel” (2013).

• Order "Sampo" (2019)
• Certificate of Honor from PetrSU (2016)
• Certificate of honor from Petrozavodsk (2015)
• Order of Honor (2006)
• Honorary title Honorary Citizen of Petrozavodsk (2003)
• Honorary title Laureate of the Republic (2001)
• Honorary title People's Doctor of the Republic of Kazakhstan (2001)
• Honorary title "Honorary Worker of Higher Professional Education of the Russian Federation" (2000)
• Honorary title of 100 laureates of the year in Petrozavodsk (1999)
• Order of Friendship (1998)
• Honorary title Honored Scientist of the Russian Federation (1989)
• Honorary title Honored Doctor of the Republic of Kazakhstan (1968)

Publications

Articles (16)

• Zilber, A.P. Medical education: creativity or standard? (Etymological excursion [Text] / A.P. Zilber // History of the Medical Institute of PetrSU 2015-2019. - Petrozavodsk, 2019. - P.115-122.
• Zilber, A.P. COMMENTARY ON THE ARTICLE by K.A. TOKMAKOVA ET AL. "ENGLISH FOR ANESTHESIOLOGIST AND RESUSCITATOLOGIST: A TRIBUTE TO FASHION OR NECESSITY?" [Text] / A.P. Zilber // Bulletin of Intensive Therapy named after. A.I. Saltanova. - Moscow, 2018. - No. 4. - P.88. (RSCI)
• Zilber, A.P. Critical and respiratory medicine needs a humanitarian culture. [Text] / A.P. Zilber // Bulletin of intensive care. - Moscow, 2017. - No. 2. - P.8-11. - ISSN 1726-9806. (RSCI)
• Zilber, A.P. How to develop the Federation of Anesthesiologists and Resuscitators of Russia? [Text] / A.P. Zilber // Bulletin of intensive care. - Moscow, 2016. - No. 1. - P.61-67. (RSCI)
• Zilber A.P. History of the critical care medicine service (MCS) in Karelia. [Text] / A.P. Zilber, A.P. Spasova, V.V. Maltsev // Current problems of anesthesiology and resuscitation: collection of articles and abstracts. - Svetlogorsk, 2016. - P. 17 - 24. (RSCI)
• Zilber, A.P. Iridium from the Greek “Iris” – rainbow [Text] / A.P. Zilber // History of the Medical Institute of PetrSU. - Petrozavodsk, 2015. - P.162-170.
• Zilber, A.P. Rationalism in the management of patients with respiratory failure [Text] / A.P. Zilber // Ukrainian Pulmonological Journal. - Kyiv, 2013. - No. 2 (80). - P.20–25. - ISSN 2306-4927. (VAK)
• Zilber, A.P. Do we need to find new anesthesia techniques? [Text] / A.P. Zilber // Bulletin of anesthesiology and resuscitation. - 2013. - No. 1. - P.70-71. (VAK, RSCI)
• Zilber, A.P. Critical medicine as a modern but unnatural section of healthcare [Text] / A.P. Zilber // Bulletin of intensive care. - Moscow, 2012. - No. 1. - P.4-7.
• Zilber, A.P. Correction of metabolism - p. 54-58, Artificial ventilation - p. 58-62, Shock lung syndrome - p. 266-269, Aspiration syndrome - p. 268-269, Hyperthermia and hyperthermic syndromes - p. 302-304, Amniotic embolism - p. 308-310. [Text] / A.P. Zilber // Handbook of anesthesiology and resuscitation. - Moscow: Medicine, 1982.