Zilber anesthesiology. Book: A

A.P. Zilber

CLINICAL

PHYSIOLOGY

in anesthesiology

and resuscitation

Moscow "Medicine" 1984

UDC 617-089.5+616-036.882/-092

A. P. ZILBER 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 in relation 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 have 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 resuscitation of the Central Order of Lenin Institute for the Improvement of Doctors.

4113000000-118 039(01)-84

Publishing house "Medicina" 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 guide seems to be the most appropriate for considering clinical and physiological problems. We have systematized in three parts of the book the physiology of the main syndromes, methods of intensive therapy and the principles of particular physiological analysis. Such a plan for building a guide 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 an Anesthesiologist (M., 1977) and the volume of the book, but also to the principle justified in the introduction to the guide.

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 activity of the reader in the perception of the material, his agreement and disagreement with the position of the author and, therefore, makes him think about the problem, and not thoughtlessly trust someone's authority. In such a little studied branch 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 tried to ensure that the drawings not only illustrate the text, but also arouse the reader's desire to reflect.

It would seem that the very name of the manual defines 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, neuropathologist, pediatrician in intensive care units). But if we manage the patient together with different specialties, schools, traditions, then we should develop a single clinical and physiological platform for action.

INTRODUCTION

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

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

In the future, 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 an infection, hemostasis in response to vessel damage, edema or necrosis in a burn, inhibition of nerve cells under the action 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 defenses. 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 work of the liver, kidneys are observed, immune reactions are stimulated, redox processes in tissues change in order to increase energy production. All this leads to increased catabolism of carbohydrates and fats, the consumption of enzymatic factors, the displacement of electrolytes and fluids in the cellular, extracellular and intravascular spaces, hyperthermia, etc. Such a 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 go into a critical state and does not require the intervention of resuscitators. Despite the similarity of the physiological mechanisms of the general post-aggressive reaction with 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 led by a surgeon, a cardiologist, a neuropathologist - a specialist who "belongs" this disease in terms of its etiology and pathogenesis.

But too much or prolonged aggression, imperfect reactivity of the organism, concomitant pathology of any functional systems make the general post-aggressive reaction inharmonious and inadequate. If any function is depleted, the rest are inevitably violated and the general post-aggressive reaction turns from protective into a killing organism: pathogenesis becomes thanatogenesis. Now, previously useful hyperventilation leads to respiratory alkalosis and a decrease in cerebral blood flow, the centralization of hemodynamics disrupts the rheological properties of blood and reduces its volume. The hemostatic reaction turns into disseminated intravascular coagulation with dangerous thrombus formation or uncontrolled bleeding. Immune and inflammatory reactions do not just block the microbe, but cause anaphylactic shock or bronchospasm and pneumonitis. Now not only reserves of energy substances are burned, but also structural proteins, lipoproteins and polysaccharides, reducing the functionality of organs. There comes a decompensation of the acid-base and electrolyte state, in connection with which enzymatic systems and information transfer are inactivated. This is the terminal (critical) state.

Rice. 1. Three states of vital functions: health (1), illness (2), critical (terminal) state (3), in which only a lifebuoy with the inscription "ITAR" gives the patient the opportunity to "not drown".
We have 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 the central regulatory mechanisms (nervous and hormonal) are damaged, but also tissue (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: violation of the rheological properties of blood, hypovolemia, coagulopathy, metabolic damage (the second vicious circle). The third circle - organ disorders: acute functional insufficiency 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 these disorders always exist, so any critical condition should be considered as a multiorgan failure.

Unfortunately, today there is no universal objective criterion that makes it possible to distinguish between a disease and a critical condition, and this is hardly possible. However, there are attempts to quantify the severity of a critical condition, such as the scale of therapeutic actions (TISS),

Regardless of the specifics of the primary lesion, any pathology that has reached the stage of a terminal (critical) state 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 momentary tactics, but also for subsequent analysis. However, after 3 years, D. J. Cullen (1977) considered it necessary to evaluate not only syndromes and therapeutic actions, but also the third important component - functional tests characterizing the respiratory, circulatory, blood systems and various metabolic parameters.

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

For 20 years, the Karelian ASSR has been using a five-point risk scale for a patient requiring 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 skill and capabilities of the team that will work with the patient. The risk assessment is applied to a working punch card, in which the procedures performed and indicators of various vital functions are recorded.

Currently, our department is testing a new risk objectification scale, which details the functional state of seven systems (respiration, blood circulation, blood, liver, kidneys, central nervous system, digestive system) 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 risk gradations according to the old scale, makes it possible to objectively judge the state of severity of patients and the risk that awaits them. It is designed to: 1) rationalize the work of the staff of ITAR departments by dividing the services required by patients into four complexes discussed below; 2) predicting complications for their timely prevention; 3) a retrospective analysis of the effectiveness of ITAR in various pathologies, different teams, etc. It should be noted that a quantitative assessment of the severity of the patient's condition and risk facilitates the processing of materials using a computer, including monitoring functions (see Chapter 18).

At this stage of the 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 the autoregulation of functions disappears and an inadequate inharmonious post-aggressive reaction begins to kill the organism, a methodologically uniform artificial replacement of the vital functions of the organism 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 the management of body functions during illness in general, then resuscitation manages them in critical conditions. The task is to bring 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. I complex - the main and most time-consuming. This is intensive therapy, i.e. artificial substitution of the vital functions of the body or their management. Complex II, which may precede or complete the first one, is intensive observation and care, when monitoring of vital functions is required, if the nature of the pathology is such that they may need to be managed, i.e., intensive care. Complex III - resuscitation, which can be defined as intensive therapy in case of circulatory and respiratory arrest. Complex IV - an anesthetic benefit - is, in fact, the use of complex I and II in connection with surgical intervention. In anesthesia management, pain relief is only a small component of complex I (intensive care), and the anesthesiologist must work so that the patient does not need complex III. Thus, the IV complex (anesthesiological benefit) is only intensive observation and intensive therapy (I and II complexes) of a patient undergoing surgery.

An anesthesiologist or resuscitator should not act on 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 conditions 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. With regard to the division of physiology into sections, the definition of the boundaries of these sections, opinions are not the same. There are general and particular physiology, normal and pathological, clinical, experimental, comparative, age, sports, underwater, aviation, etc.

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

What is clinical physiology?

We consider clinical physiology as a branch of applied medicine, with the help of 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, only beginning and ending with functional research, but necessarily including physiological therapy, restoring 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 ability of various systems of the human body with the exact localization of the function 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 variety of his individual characteristics and concomitant diseases.

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

4. Functional control of the effectiveness of therapy.

The question may arise: isn't the restoration of the body's natural autoregulation the ultimate goal of any section 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. Tasks 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 is to be done (III) and what will be (IV).

Clinical medicine uses any means of etiological, pathogenetic and symptomatic therapy to achieve the ultimate goal - recovery. It can equally address its efforts to different systems and organs on the principle of urgent indication "to everyone, to everyone, to everyone", and the disappearance of the symptoms of the disease, the restoration of working capacity is the main criterion for its success.

Clinical physiology uses etiological factors and symptomatic treatment only to the extent that they help to 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 believe that physiological analysis in the clinic should be called clinical pathophysiology, not 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 is not yet present, and in the last there is no longer. Thus, pathophysiology should be called physiological analysis, relating to only one of the three main components of clinical practice. Secondly, traditionally, pathophysiology is used to mean the study of experimental animal models. Although the term "clinical" emphasizes the application of physiological analysis to the sick person, we still prefer the term "clinical physiology", while at the same time considering the term "clinical pathophysiology" completely unacceptable.

Thus, we conditionally distinguish three related areas of physiology and medicine that do not have clear boundaries, and sometimes, on the contrary, are intricately intertwined: 1) theoretical (normal and pathological) physiology of models - one of the foundations for obtaining medical knowledge and 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 critical care therapy, which, unfortunately, does not yet have a name adequate to its purpose. .

There is no sensible and generally recognized name of the specialty, which will inevitably be divided in the future, but there is a single principle that is preserved wherever an anesthesiologist or resuscitator works: management, artificial substitution and restoration of vital functions in conditions of aggression of such a degree that it exceeds the possibilities of autoregulation of body functions .

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

Everyday clinical and physiological analysis, which in a critical condition is performed by a doctor, no matter how he is called and no matter what position he holds on the staffing table, should consist of four stages: determining the mechanism and degree of function damage, predicting pathology development paths, choosing means of replacing the function or control it and immediately monitor its effectiveness. In other words, physiological analysis should contribute to the solution of the following questions: what is it, why is it, what to do and what will happen.

Rice. 4. The 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 "Medicina" published the book "Clinical Physiology for the Anesthesiologist", in which clinical and physiological materials were presented in accordance with the functional systems of the body, i.e. its construction was fundamentally different from the structure of this manual. The desire to place as many new materials as possible on the clinical physiology of critical states forced us to abandon such an examination of a number of important problems outlined in the previous book and which have not undergone significant changes over the past years.

What is the structure of leadership? 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 medical actions. The three parts of the book can be summarized as follows: physiology of syndromes (I), physiology of methods (II), and physiological correction in various branches of public health (III). All three parts belong to 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 control the vital functions of the body in a critical state of the patient, making ITAR applied (clinical) physiology.

The author sees the main goal of this book in showing the complexity of the physiological processes in which the anesthesiologist and resuscitator constantly interfere, to substantiate therapeutic actions that allow the body to restore the autoregulation of functions disturbed by a critical state. In other words, in this book, the interested specialist should look for a physiological justification for the fact that necessary to do to a critically ill patient and what to do it is forbidden.

Part I

CLINICAL PHYSIOLOGY OF THE MAIN SYNDROMES OF CRITICAL CONDITIONS

The materials of 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 the second part of the book is devoted to it.

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 and Technical Academy, as well as the Academy of Security, Defense and Law Enforcement Problems of the Russian Federation.

Achievements

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

Silber and the respiratory system

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

In 1959, he created one of the first departments of the 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 of generalized 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 out such scientific works as:

• "The concept of critical care medicine (ISS 1989)",
• "Operating 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-standard - this list can be continued indefinitely! Zilber went down in history as a talented physician - a scientist who saved many lives, literally pulling the straw out of the clutches of death.

I created this project to tell you about anesthesia and anesthesia in simple language. If you received an answer to your question and the site was useful to you, I will be glad to support it, it will help to 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

A. P. ZILBER 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 in relation 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 resuscitation of the Central Order of Lenin Institute for the Improvement of Doctors.

4113000000-118 039(01)-84

Publishing house "Medicina" 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 guide seems to be the most appropriate for considering clinical and physiological problems. We have systematized in three parts of the book the physiology of the main syndromes, methods of intensive therapy and the principles of particular physiological analysis. Such a plan for building a guide 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 an Anesthesiologist (M., 1977) and the volume of the book, but also to the principle justified in the introduction to the guide.

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 activity of the reader in the perception of the material, his agreement and disagreement with the position of the author and, therefore, makes him think about the problem, and not thoughtlessly trust someone's authority. In such a little studied branch 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 tried to ensure that the drawings not only illustrate the text, but also arouse the reader's desire to reflect.

It would seem that the very name of the manual defines 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, neuropathologist, pediatrician in intensive care units). But if we manage the patient together with different specialties, schools, traditions, then we should develop a single clinical and physiological platform for action.

INTRODUCTION

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

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

In the future, 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 an infection, hemostasis in response to vessel damage, edema or necrosis in a burn, inhibition of nerve cells under the action 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 defenses. 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 work of the liver, kidneys 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, the consumption of enzymatic factors, the displacement of electrolytes and fluids in the cellular, extracellular and intravascular spaces, hyperthermia, etc. Such a 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 go into a critical state and does not require the intervention of resuscitators. Despite the similarity of the physiological mechanisms of the general post-aggressive reaction with 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 led by a surgeon, a cardiologist, a neuropathologist - a specialist who "belongs" this disease in terms of its etiology and pathogenesis.

But too much or prolonged aggression, imperfect reactivity of the organism, concomitant pathology of any functional systems make the general post-aggressive reaction inharmonious and inadequate. If any function is depleted, the rest are inevitably violated and the general post-aggressive reaction turns from protective into a killing organism: pathogenesis becomes thanatogenesis. Now, previously useful hyperventilation leads to respiratory alkalosis and a decrease in cerebral blood flow, the centralization of hemodynamics disrupts the rheological properties of blood and reduces its volume. The hemostatic reaction turns into disseminated intravascular coagulation with dangerous thrombus formation or uncontrolled bleeding. Immune and inflammatory reactions do not just block the microbe, but cause anaphylactic shock or bronchospasm and pneumonitis. Now not only reserves of energy substances are burned, but also structural proteins, lipoproteins and polysaccharides, reducing the functionality of organs. There comes a decompensation of the acid-base and electrolyte state, in connection with which enzymatic systems and information transfer are inactivated. This is the terminal (critical) state.

Rice. 1. Three states of vital functions: health (1), illness (2), critical (terminal) state (3), in which only a lifebuoy with the inscription "ITAR" gives the patient the opportunity to "not drown".
We have 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 the central regulatory mechanisms (nervous and hormonal) are damaged, but also tissue (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: violation of the rheological properties of blood, hypovolemia, coagulopathy, metabolic damage (the second vicious circle). The third circle - organ disorders: acute functional insufficiency 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 these disorders always exist, so any critical condition should be considered as a multiorgan failure.

Unfortunately, today there is no universal objective criterion that makes it possible to distinguish between a disease and a 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) state 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 momentary tactics, but also for subsequent analysis. However, after 3 years, D. J. Cullen (1977) considered it necessary to evaluate not only syndromes and therapeutic actions, but also the third important component - functional tests characterizing the respiratory, circulatory, blood systems and various metabolic parameters.

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

For 20 years, the Karelian ASSR has been using a five-point risk scale for a patient requiring 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 skill and capabilities of the team that will work with the patient. The risk assessment is applied to a working punch card, in which the procedures performed and indicators of various vital functions are recorded.

Currently, our department is testing a new risk objectification scale, which details the functional state of seven systems (respiration, blood circulation, blood, liver, kidneys, central nervous system, digestive system) 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 risk gradations according to the old scale, makes it possible to objectively judge the state of severity of patients and the risk that awaits them. It is designed to: 1) rationalize the work of ITAR department staff by dividing the services required by patients into four complexes discussed below; 2) predicting complications for their timely prevention; 3) a retrospective analysis of the effectiveness of ITAR in various pathologies, different teams, etc. It should be noted that a quantitative assessment of the severity of the patient's condition and risk facilitates the processing of materials using a computer, including monitoring functions (see Chapter 18).

At this stage of the 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 the autoregulation of functions disappears and an inadequate inharmonious post-aggressive reaction begins to kill the organism, a methodologically uniform artificial replacement of the vital functions of the organism 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 the management of body functions during illness in general, then resuscitation manages them in critical conditions. The task is to bring 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. I complex - the main and most time-consuming. This is intensive therapy, i.e. artificial substitution of the vital functions of the body or their management. Complex II, which may precede or complete the first one, is intensive observation and care, when monitoring of vital functions is required, if the nature of the pathology is such that they may need to be managed, i.e., intensive care. Complex III - resuscitation, which can be defined as intensive therapy in case of circulatory and respiratory arrest. Complex IV - an anesthetic benefit - is, in fact, the use of complex I and II in connection with surgical intervention. In anesthesia management, pain management is only a small component of complex I (intensive care), and the anesthesiologist must work so that the patient does not need complex III. Thus, the IV complex (anesthesiological benefit) is only intensive observation and intensive therapy (I and II complexes) of a patient undergoing surgery.

An anesthesiologist or resuscitator should not act on 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 conditions 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. With regard to the division of physiology into sections, the definition of the boundaries of these sections, opinions are not the same. There are general and particular physiology, normal and pathological, clinical, experimental, comparative, age, sports, underwater, aviation, etc.

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

What is clinical physiology?

We consider clinical physiology as a branch of applied medicine, with the help of 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, only beginning and ending with functional research, but necessarily including physiological therapy, restoring 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 ability of various systems of the human body with the exact localization of the function 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 variety of his individual characteristics and concomitant diseases.

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

4. Functional control of the effectiveness of therapy.

The question may arise: isn't the restoration of the body's natural autoregulation the ultimate goal of any section 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. Tasks 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 is to be done (III) and what will be (IV).

Clinical medicine uses any means of etiological, pathogenetic and symptomatic therapy to achieve the ultimate goal - recovery. It can equally address its efforts to different systems and organs on the principle of urgent indication "to everyone, to everyone, to everyone", and the disappearance of the symptoms of the disease, the restoration of working capacity is the main criterion for its success.

Clinical physiology uses etiological factors and symptomatic treatment only to the extent that they help to 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 believe that physiological analysis in the clinic should be called clinical pathophysiology, not 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 is not yet present, and in the last there is no longer. Thus, pathophysiology should be called physiological analysis, relating to only one of the three main components of clinical practice. Secondly, traditionally, pathophysiology is used to mean the study of experimental animal models. Although the term "clinical" emphasizes the application of physiological analysis to the sick person, we still prefer the term "clinical physiology", while at the same time considering the term "clinical pathophysiology" completely unacceptable.

Thus, we conditionally distinguish three related areas of physiology and medicine that do not have clear boundaries, and sometimes, on the contrary, are intricately intertwined: 1) theoretical (normal and pathological) physiology of models - one of the foundations for obtaining medical knowledge and educating 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 critical care therapy, which, unfortunately, does not yet have a name adequate to its purpose. .

There is no sensible and generally recognized name of the specialty, which will inevitably be divided in the future, but there is a single principle that is preserved wherever an anesthesiologist or resuscitator works: management, artificial substitution and restoration of vital functions in conditions of aggression of such a degree that it exceeds the possibilities of autoregulation of body functions .

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

Everyday clinical and physiological analysis, which in a critical state is performed by a doctor, no matter how he is called and no matter what position he holds on the staffing table, should consist of four stages: determining the mechanism and degree of damage to the function, predicting the pathology development paths, choosing the means of replacing the function or control it and immediately monitor its effectiveness. In other words, physiological analysis should contribute to the solution of the following questions: what is it, why is it, what to do and what will happen.

^ Rice. 4. The 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 "Medicina" published the book "Clinical Physiology for the Anesthesiologist", in which clinical and physiological materials were presented in accordance with the functional systems of the body, i.e. its construction was fundamentally different from the structure of this manual. The desire to place as many new materials as possible on the clinical physiology of critical states forced us to abandon such an examination of a number of important problems outlined in the previous book and which have not undergone significant changes over the past years.

What is the structure of leadership? 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 medical actions. The three parts of the book can be summarized as follows: physiology of syndromes (I), physiology of methods (II), and physiological correction in various branches of public health (III). All three parts belong to 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 control the vital functions of the body in a critical state of the patient, making ITAR applied (clinical) physiology.

The author sees the main goal of this book in showing the complexity of the physiological processes in which the anesthesiologist and resuscitator constantly interfere, to substantiate therapeutic actions that allow the body to restore the autoregulation of functions disturbed by a critical state. In other words, in this book, the interested specialist should look for a physiological justification for the fact that necessary to do to a critically ill patient and what to do it is forbidden.

Part I

^ CLINICAL PHYSIOLOGY OF THE MAIN SYNDROMES OF CRITICAL CONDITIONS

The materials of 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 the second part of the book is devoted to it.

Anatoly Petrovich Zilber(born in 1931) - Soviet and Russian doctor, organizer of the first intensive care unit in Russia (1989), then the respiratory center (2001). Author of the concept of critical care medicine (ISS) (1989). Doctor of Medical Sciences (1969), professor (1973), full member of the public academies of the Russian Medical and Technical Academy (1997) and the Academy of Security, Defense and Law Enforcement Problems of the Russian Federation (2007).

Honorary and full member of the Board of the Federation of Anesthesiologists and Resuscitators of the Russian Federation, Honored Scientist of the RSFSR (1989), Honorary Worker of Higher Professional Education of the Russian Federation, People's Doctor of the Republic of Karelia, holder of the Orders of Friendship and Honor.

Biography

In 1948 he graduated from school in Tashkent. Graduated in 1954. From the year - a surgeon, and then () an anesthesiologist of the Republican Hospital of Karelia. In 1959 he created one of the first branches of ITAR in the country. Since this year - the chief anesthesiologist of the Ministry of Health of the KASSR. In the city, he organized the first independent course in anesthesiology and resuscitation in the USSR (since - the department) in the Petrozavodsk State. University, became its head.

Organizer of the Petrozavodsk annual educational and methodological seminars of the ISS (since 1964). The main areas of scientific work: clinical physiology and intensive care of critical conditions, clinical physiology of respiration, promotion of the humanitarian foundations of the education and practice of doctors, studying the activities of doctors who have become famous outside of medicine (the so-called medical truentism).

Scientific activity

Author of more than 400 publications, 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 respiration in anesthesiology." The subject of his research is the reaction of the respiratory system in any critical condition. The respiratory system for A.P. Zilber is not only a structure that provides the entire body with the necessary amount of oxygen and rids 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 work - the non-standard approach to the problems studied or the unexpectedness of the findings and revealed patterns. A clear proof of this is the main works of the professor 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 time", is their clinical and physiological orientation and validity. This is probably why none of the fundamental provisions derived by A.P. Zilber from his research has been refuted or, at least, reasonably rejected.

Year of issue: 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 service, current trends in the sections of the ISS, problems of monitoring, multiple organ failure, cardiopulmonary resuscitation and post-resuscitation management of patients. The role of the immunoreactive system in the organization of the body's vital activity in a state of 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 Intensive Care with the postgraduate course of Petrozavodsk State University. The material is presented and illustrated in a non-standard style, justified by the author's desire to give the reader not only medical information on the issues under discussion, but also to expand his humanitarian horizons.
For anesthesiologists, intensivists (resuscitators), emergency physicians, senior medical students, as well as clinicians, in whose practice critically ill patients are often encountered.

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 of the ISS?
Anesthesiologist-resuscitator or anesthesiologist and resuscitator?
Establishment of recovery wards in the operating block
Rationalism in the organization of service
Specific Features of Critical Care Medicine
Extremeness of the situation
Presence of multiple organ dysfunction
The need for monitoring and technicalism
Lack of psychological contact
Invasiveness of research and treatment methods
Interdisciplinarity of pathology
Specificity of ethical and legal norms
Chapter 2 Current trends in the ISS: 1 - anesthesiology and other sections of the ISS
ANESTHESIOLOGY
Profiling anesthesiologists
Regional anesthesia as a component of anesthetic management
"Proactive" analgesia and "memory of pain"
Maintaining consciousness under anesthesia
Depth of anesthesia
Explicit and implicit memory
Causes of too superficial anesthesia
Consequences of maintaining consciousness during surface anesthesia
Diagnostics and monitoring
How common is this pathology?
What to do?
"Therapeutic" anesthesia
Preoperative gradation of the severity of the condition and assessment of anesthetic risk
Preliminary assessment of anesthetic risk
INTENSIVE CARE (REANIMATOLOGY)
Growth and profiling of intensive care beds
Cost-benefit analysis
NICU - Intensive Care Unit Syndrome
Risk Factors for ICU Syndrome
Early signs of SSIT
Prevention and treatment of SSIT
Optimal level of sedation
EMERGENCY MEDICINE
System of paramedics and specialized teams
Hospital emergency departments
Improving Patient Transportation
Urgent telephone consultations
EMERGENCY MEDICINE
Classification and structure
Principles of medical support
Planned training of staff and funds
"Global Perestroika" and the ISS
Chapter 3 Current trends in the ISS: 2 - medicine without blood, without pain, without delusions
MEDICINE WITHOUT DONOR BLOOD
Reduction of allotransfusions
Principal disadvantages of allohemotransfusions
Manifestation of immune incompatibility
Acute transfusion 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
Blockade technique
Preparations for interpleural analgesia
Clinical practice
Contraindications
Complications
MEDICINE WITHOUT MISTAKE
Principles and methods of evidence-based medicine in the ISS
Archie Cochrane and Evidence Based Medicine
Principles of randomization
Efficiency mark
HRQOL - health-related quality of life
Stages of evidence-based medicine implementation
I - compiling DM reviews
II - access to reviews via the Internet
III - assessment of reviews and decision making
Specificity of DM in critical care medicine
Objective difficulties on the way to the implementation of evidence-based medicine
Dangers of forced introduction of DM
Chapter 4 Clinical Physiology - Applied Section of the ISS
What is physiological analysis
Physiology as a section of fundamental sciences
The difference between clinical physiology and normal and pathological
Clinical Physiology - the main basis of the ISS
Practical complexes ISS
ISS Specialist as a Clinical Physiologist Autoregulation of Functions and Ways of Medical Development
Instruction or clinical-physiological analysis?
Organization of clinical physiology service 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
Control of the patient's functions
Control of therapeutic actions
Environmental control
Monitoring Technology
Invasiveness and non-invasiveness of methods
Accuracy and speed of evaluation
Complexity of assessment
Controlled parameters
Circulation
Breath
Blood system
Liver and kidneys
Metabolism
central nervous system
Muscular system
Complex monitoring
Diagnosis of PE
Depth and quality of anesthesia
Switching from artificial lung ventilation to spontaneous ventilation
Condition severity monitoring
Ethical and legal aspects of monitoring

Monitoring standards
Chapter 6 Objectification of the severity of the condition of patients
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
The main functional systems of the body
Immunoreactive system in phylogenesis
Tasks of immunity
The life and death of Paul Langerhans
Pradoxes of infection at the turn of the II and III millennia
Causes of infectious paradoxes
Intensive care units are the main source of nosocomial infection
Infections from a vascular catheter
Antibiotic resistance
Dysbacteriosis
Invasive mycoses
Luminaries are not against infection, but for IRS
RTIS - General Reactive Inflammation Syndrome
Critical condition 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
Defeat of hemodynamics
Respiratory damage
Other PON components
Intensive Care for Septic Shock
Ideological preamble
Hemodynamic correction
Breath Correction
Correction of coagulopathy
Impact on IRS functions
Correction of the digestive tract
Correction of other PON components
Elimination of the focus of infection
ANAPHILACTIC 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 with anesthesia
Intensive care and prevention
Ideological preamble
Blockade of mastocytes and basophils
Blockade of mediators and receptors
Syndrome correction
Prevention
IRS AND ISS: FUTUROLOGICAL ASPECT
Why was the role of the IRS in physiology and pathology appreciated so late?
And PC in critical conditions
Visible perspectives and rules of conduct today
Chapter 9 Multiple organ dysfunction (MOD) and insufficiency (POF): 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
Control theories of a multicellular organism

Etiology of multiple organ failure
Iatrogenicity in modern medicine
Patho- and thanatogenesis
Endothelial physiology and mediator mechanism of PON
Functions of the endothelium
Nitric oxide (N0) and blood flow
Distal, paracrine and autocrine effects
Cytokines and eicosanoids
Microcirculatory and reperfusion mechanisms
Hypovolemic vicious circle
Reperfusion paradoxes
Digestive tract - PON engine and infectious mechanism
Selective intestinal decontamination (SID)
Abdominal Compression Syndrome
Autoimmune defeat and the double whammy phenomenon
Iatrogenic Double Strike
Clinic: parallelism or sequence of syndromes?
Summary of patho- and thanatogenesis
Chapter 10 Multiple organ dysfunction (MOD) and insufficiency (POF): 2 - strategy and tactics
Principles of case management: strategy
Objectification of damage to functions and severity of the condition
Assessment of the severity of the condition
It is necessary to warn PON at the stage of POD
Staged actions
Antimediator effect
Normalization of energy production
Detoxification
Syndromic therapy
Reducing the invasiveness of actions
Patient management methods: 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: cardiac or thoracic pump?
Indirect methods of artificial blood flow
Compression of the chest at the same time as artificial inspiration
Vest (vest) CPR
Inserted abdominal compression (IAC)
Active Compression-Decompression (ACD)
DPTwith inspiratory resistance
Cough autoresuscitation
CPR in the prone position (compression of 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 ventilation methods
Air ducts with artificial dead space
Single and double lumen obturators-air ducts
Laryngeal mask airway
Invasive ventilation methods
Tracheal intubation
Coniotomy
Manual respirators
Automatic respirators
Translaryngeal jet ventilation
Chapter 12 Specialized CPR complex: 2 - auxiliary methods, tactics, prognosis
Medical therapy
Optimal route of drug administration
Adrenaline or vasopressin?
Lidocaine or amiodarone?
Should sodium bicarbonate be used?
Whether to enter calcium preparations?
Place of atropine in CPR
Electrical defibrillation of the heart
The main rule: EMF must be early
Procedure
Monitoring and prognostic criteria
CPR monitoring
Outcome Prediction
Prevention of brain damage
Mechanisms of brain damage
Preventive and curative measures
Post-resuscitation illness
Mistakes, 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?
Termination of CPR
Chapter 13 Terminal state cognition (PTS phenomenon)
Problem history
Manifestations of the PTS phenomenon
Physiological mechanisms of the phenomenon
Theory of phase states of the brain
Drug intoxication
Analyzers at terminal state
Parapsychological mechanisms
What distinguishes man from animals?
The future of cardiopulmonary resuscitation
ISS in the healthcare system (instead of the Conclusion)
Content and summary in English
Literature