Vladimir Viktorovich Pichugin

Objective: To assess the economic burden and resource utilization associated with an increasing number of postoperative organ dysfunctions defined according to the SOFA score after cardiac surgery with cardiopulmonary bypass (CPB). Materials and methods: This single-center retrospective cohort study included 681 adult patients who underwent cardiac surgery with CPB in 2025. The primary analysis included 676 patients with complete data for the assessment of organ dysfunction during the first 72 h after surgery. Organ dysfunction was assessed using the original SOFA score, and patients were stratified into groups with no organ dysfunction, dysfunction of one organ system, and multiple organ dysfunction syndrome (MODS), defined as dysfunction of two or more organ systems. Resource utilization, in-hospital mortality, and direct medical costs calculated using a micro-costing approach were assessed. A generalized linear model with a gamma distribution and log link was used to evaluate independent associations with costs. The robustness of the findings was assessed in sensitivity analyses using the maximum SOFA score throughout the ICU stay and after excluding patients with preoperative organ dysfunction. Results: During the first 72 h after surgery, dysfunction of one organ system was identified in 11.2% (76/676) of patients, and MODS occurred in 6.1% (41/676). The length of ICU stay increased from 2 [2; 3] days in patients without organ dysfunction to 4 [3; 7] days in those with single-organ dysfunction and 8 [5; 17] days in those with MODS ( p < 0.001). Patients with MODS accounted for 66.7% of all in-hospital deaths (4/6). The median total hospitalization cost was 125 [107; 146], 285 [235; 355], and 640 [465; 910] thousand RUB, respectively ( p < 0.001 for all pairwise comparisons). After adjustment for age, EuroSCORE II, urgency and type of surgery, CPB duration, and preoperative organ dysfunction, MODS was independently associated with higher hospitalization costs (Cost Ratio 3.1; 95% CI, 2.4–4.0; p < 0.001). In the MODS group, 60.2% of total costs were attributable to ICU stay. When the maximum SOFA score throughout the ICU stay was used, the incidence of MODS was 7.3%, and the Cost Ratio was 3.3 (95% CI, 2.6–4.3). Conclusion: An increasing number of postoperative organ dysfunctions was associated with progressively greater resource utilization and hospitalization costs. Despite its relatively low incidence, MODS was characterized by disproportionately high resource utilization and remained independently associated with higher costs after adjustment for baseline severity and surgical characteristics. These findings highlight the economic importance of preventing and reducing the severity of postoperative organ dysfunction.

INTRODUCTION: Hyperlactatemia after cardiac surgery with cardiopulmonary bypass (CPB) occurs in 20–40 % of patients and is associated with adverse outcomes. However, distinguishing hypoperfusion from metabolic hyperlactatemia remains difficult because simple routine diagnostic criteria are lacking. OBJECTIVE: To identify clinical phenotypes of postoperative hyperlactatemia, develop routine diagnostic criteria, and assess their association with escalation of inotropic and/or vasopressor support and clinical outcomes. MATERIALS AND METHODS: In this prospective cohort (January–December 2025), 221 of 733 adults undergoing cardiac surgery with CPB developed hyperlactatemia (arterial lactate ≥ 3.0 mmol/L within 6 h); after 41 exclusions, 180 were analyzed. Central venous oxygen saturation (ScvO2), the venous-to-arterial carbon dioxide partial pressure difference (Pv-aCO2), and lactate clearance were assessed. Hyperlactatemia was classified as ischemic or metabolic. Oxygen delivery index (DO2I) was measured in 126 patients. Receiver operating characteristic (ROC) analysis, multivariable logistic regression, and decision curve analysis (DCA) were performed. RESULTS: Hyperlactatemia occurred in 30.2 % of patients; 180 were analyzed. The ischemic phenotype was identified in 92 (51.1 %) patients and the metabolic phenotype in 88 (48.9 %). The ischemic phenotype was associated with higher peak lactate, lower lactate clearance, and more frequent escalation of inotropic and/or vasopressor support (all p < 0.001). In the exploratory ROC analysis, the internal discriminatory performance of a lactate threshold > 4.8 mmol/L was AUC 0.83, while the combination of lactate and ScvO2 yielded an AUC of 0.86. Independent predictors of support escalation were peak lactate, lactate clearance < 10 %, and ScvO2 < 65 %. The proposed criteria agreed with reduced DO2I (< 450 mL/min/m²; κ = 0.78; p < 0.001). Hospital mortality was higher in the ischemic group (7.6 vs 1.1 %; p = 0.03). CONCLUSIONS: Approximately half of patients with postoperative hyperlactatemia exhibited a hypoperfusion phenotype associated with worse outcomes. The combination of lactate > 4.8 mmol/L, ScvO2 < 65 %, Pv-aCO2 > 6 mmHg, and lactate clearance < 10 % may help stratify the probability of a hypoperfusion phenotype.

Background. Cardiac surgery and cardiopulmonary bypass (CPB) cause ischemia-reperfusion injury, leading to endothelial dysfunction, systemic inflammation and, in some cases, multiple organ failure (MOF), which worsens the prognosis. Aim. To study the effect of nitric oxide (NO) and molecular hydrogen (H ₂ ) on endothelial dysfunction, myocardial contractility during surgery, and postoperative multiple organ failure. Materials and methods. The study included 123 patients randomized into 4 groups: 1 ^st (n = 30) – control; 2 ^nd (n = 33) – isolated supply of NO (40 ppm) in the CPB circuit; 3 ^rd (n = 30) – isolated supply of H2 (2 vol%) into the CPB circuit; 4th (n = 30) – combined supply of NO (40 ppm) and H ₂ (2 vol%) into the CPB circuit. During surgery, the functional parameters of the heart were studied using transesophageal echocardiography; the state of endothelial cells – by analysis of circulating endothelial cells (CECs); after surgery – biochemical blood parameters and clinical outcomes. Results. The action of NO and H ₂ improved the contractile function of the myocardium, reduced the increase in AST and ALT activity, reduced the urea content compared with the control, maintaining bilirubin (with the combined action of gases) and creatinine within the initial values, which indicates a multi-organ protective effect. Against the background of the action of NO and H ₂ , a more pronounced decrease in circulating endothelial cells was noted, associated with a lower incidence of postoperative complications and MOF. The combined use of NO and H ₂ caused a multi-organ protective effect superior to the effect of each gas. Conclusion. Extracorporeal administration of NO and H ₂ is an effective strategy for correcting myocardial and endothelial dysfunction, which helps prevent the development of multiple organ failure in cardiac surgery patients.

A medical plasma-chemical apparatus for synthesizing nitric oxide (NO) has been developed for the first time. It is designed to deliver it directly into the extracorporeal circuit of heart-lung machine and extracorporeal membrane oxygenation (ECMO) machines. This paper presents the technical characteristics of the apparatus, the results of its experimental use, and clinical studies during CPB surgeries. In the apparatus’s plasma-chemical reactor, the primary synthesis of NO was achieved in the plasma of diffuse low-current (<1 A) microsecond-duration discharges uniformly distributed within the annular discharge gap. This ensured a long service life of the electrode system—up to 6.000 hours—and low levels of unwanted impurities. Experimental results showed that the oxygenator with a polypropylene hollow fiber membrane retained its mass-transfer properties in the presence of NO at a concentration of 500 ppm for 6 hours, with no signs of chemical interaction between polypropylene and NO. Analysis of the surface condition of hollow fiber membrane samples from oxygenators revealed a significantly lower incidence of fibrin deposits when NO was administered via CPB. Clinical studies have shown that administering NO to the extracorporeal circuit exerted an antioxidant effect, reduced oxidative stress, maintained high ATP levels in red blood cells, effectively prevented increased red blood cell aggregation, and had a protective effect on endothelial function during prolonged CPB. Perioperative administration of NO was associated with a statistically significant reduction in the incidence of acute kidney injury within 7 days postoperatively and a protective effect on the myocardium.

The objective was to evaluate the association between the volume of intraoperative fluid therapy and the risk of postoperative hyperlactatemia in patients undergoing cardiac surgery with cardiopulmonary bypass. Materials and methods . This single-center prospective cohort study included 733 adult patients who underwent cardiac surgery with cardiopulmonary bypass between 2024 and 2025. The total intraoperative fluid volume (crystalloids and colloids), normalized to body weight (mL/kg), was used as the exposure variable; the priming volume of the cardiopulmonary bypass circuit was excluded from the analysis. Patients were stratified according to quartiles of fluid volume distribution: the first quartile (Q1) represented the low-volume («restrictive») group, the second and third quartiles (Q2–Q3) represented the moderate-volume group, and the fourth quartile (Q4) represented the high-volume («liberal») group. The quartile boundaries were calculated based on the distribution of infusion volume in the entire study cohort. Hyperlactatemia was defined as a lactate level ≥3 mmol/L within the first 6 hours after admission to the intensive care unit. The type of hyperlactatemia (ischemic or metabolic) was determined using a predefined algorithm incorporating lactate level, ScvO ₂ , Pv-aCO₂, and lactate clearance at 6 hours. Indicators of tissue hypoperfusion included ScvO₂ < 65%, Pv–aCO₂ > 6 mmHg, and lactate clearance < 10%. Multinomial logistic regression was used to evaluate the independent association between fluid volume and hyperlactatemia type (no hyperlactatemia, ischemic type, metabolic type). Results . The overall incidence of postoperative hyperlactatemia (lactate ≥3.0 mmol/L within 6 hours after ICU admission) in the general cohort occurred in 30.2% of patients (n = 733). The median intraoperative fluid volume differed significantly between groups (p < 0.001). The incidence of ischemic hyperlactatemia demonstrated a U-shaped relationship with fluid volume: the lowest rate was observed in the moderate-volume group (9.5% per the entire group of patients), whereas in the low-volume («restrictive») group, the frequency increased (13.1%), and the probability of this type of hyperlactatemia also increased according to regression analysis (OR 1.52; 95% CI 1.01–2.29; p = 0.04), peaking in the high-volume («liberal») group (18.0%; OR 1.95; 95% CI 1.28–2.98; p = 0.002). When fluid volume was analyzed as a continuous variable, the lowest predicted risk of ischemic hyperlactatemia corresponded to an infusion range of approximately 35–45 mL/kg. The incidence of metabolic hyperlactatemia differed between groups (p = 0,001), but without a consistent pattern and without a nonlinear association. Conclusion . In patients undergoing cardiac surgery with cardiopulmonary bypass, a U-shaped association was observed between the volume of intraoperative fluid therapy and the risk of ischemic hyperlactatemia following cardiac surgery with cardiopulmonary bypass. The lowest risk of hypoperfusion-related hyperlactatemia was observed with a moderate fluid volume of approximately 35–45 mL/kg. These findings suggest that a moderate intraoperative fluid strategy may be associated with a more favorable postoperative tissue perfusion profile in cardiac surgical patients.

Background. Patients with acute heart failure (AHF) and cardiogenic shock requiring cardiac surgery represent the cohort of the highest risk with extremely poor perioperative outcomes. Standard risk stratification tools (EuroSCORE II, STS scores) consistently underestimate mortality in this population, necessitating integration of additional prognostic modalities including biomarkers and dynamic hemodynamic assessment. Objective. To analyze current evidence on optimizing perioperative management of patients with AHF and cardiogenic shock. Material and methods. A systematic review was performed across PubMed, Embase, Cochrane Library, and Google Scholar databases (2000—2025). Systematic reviews, meta-analyses, randomized controlled trials, and large cohort studies addressing perioperative management of adults with AHF or cardiogenic shock undergoing cardiac surgery were included. Among 410 initially identified records, 35 studies met inclusion criteria after screening and full-text assessment. Results. In addition to EuroSCORE II, modern approach includes assessment of biomarkers (ST2 protein, galectin-3, NT-proBNP), perfusion parameters (lactate, central venous saturation (ScvO2), and cardiogenic shock-specific assessment (SCAI). The choice of anesthesia is driven by the need for hemodynamic stability, not by a debate about support methods. Hybrid and minimally invasive procedures instead of open surgery are justified. Perfusion modification (MECC, pulsatile mode) reduces inflammatory response and improves organ perfusion. Intensive care strategy should be preemptive with early planning of mechanical circulatory support (extracorporeal membrane oxygenation) and multiple organ support. Conclusion. Perioperative management of cardiac surgery patients with acute heart failure should be based on a multidisciplinary approach including advanced risk assessment, individual choice of surgical tactics and anesthesia, modified perfusion and preventive intensive care.

The historical paradigm of cardiac anesthesia, reliant on high-dose opioids, carries inherent risks of prolonged mechanical ventilation, increased complications, and extended hospital stays. The contemporary shift towards minimally invasive surgery and the widespread adoption of Enhanced Recovery After Surgery (ERAS) protocols necessitates a move from deep sedation towards the active control of the perioperative stress response, thereby redefining the role of regional anesthesia (RA). This review aims to provide a detailed analysis of the evolution, evidence base, and clinical significance of regional anesthesia techniques within multimodal ERAS strategies in cardiac anesthesia practice. A systematic literature search was conducted following PRISMA guidelines across PubMed/MEDLINE, Embase, Cochrane CENTRAL, and other databases (January 2000 — March 2025). After a two-stage screening process, 46 publications were included for final analysis. Due to significant clinical heterogeneity among the studies, a structured narrative synthesis was performed. The results show that regional anesthesia has evolved from an adjunct analgesic technique into a strategic pillar of anesthetic management. Its fundamental advantage — the preemptive blockade of nociceptive afferentation — enables effective modulation of the surgical stress response. The integration of RA into ERAS protocols demonstrably promotes hemodynamic stability, reduces pulmonary complications, provides effective analgesia with minimal opioid use, shortens extubation time and ICU stay, and ultimately accelerates functional patient recovery. Thus, regional anesthesia serves as a cornerstone of modern multimodal cardiac anesthesia aligned with the ERAS philosophy, and the proactive use of contemporary ultrasound-guided RA techniques is helping to establish a new standard of care focused on improving perioperative outcomes, patient safety, and quality of life following cardiac surgery.

The objective was to assess the impact of postoperative respiratory complications (RC) on the development of multiple organ dysfunction syndrome (MODS) and in-hospital mortality after cardiac surgery, and to identify independent predictors of these complications. Materials and methods . We performed a single-center retrospective cohort study included 1514 consecutive patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The diagnosis of acute respiratory distress syndrome (ARDS) was established according to the Berlin criteria. Organ dysfunction was assessed using the Sequential Organ Failure Assessment (SOFA) score. The association between RC and the incidence of MODS, dynamics of SOFA score, duration of mechanical ventilation, ICU length of stay, and mortality was evaluated. Multivariate logistic regression was used to identify independent risk factors. Results . The overall incidence of RC was 14.4% ( n = 219). ARDS was diagnosed in 1.7% ( n = 26) of patients. The development of RC significantly increased the risk of MODS: 46.2% in the RC group versus 3.8% in the group without RC ( p < 0.001). The mean maximum SOFA score was significantly higher in the RC group [9 (7; 11)]; p < 0.001). All patients with ARDS developed MODS. Mortality in the MODS group reached 53.9% and correlated with the maximum SOFA score (r = 0.84) and its change (r = 0.79). Independent predictors of RC were age > 65 years, emergency surgery, CPB duration > 120 minutes, and obesity. ARDS was the strongest independent predictor of MODS (OR 15.4). Conclusion . Postoperative respiratory complications, particularly ARDS, are critical triggers of multiple organ dysfunction and are responsible for high mortality rates. The SOFA score is a valuable tool for assessing the severity of the condition and the prognosis. Proactive prevention of RC by controlling modifiable risk factors is a key strategy to reduce the incidence of MODS and improve survival.

Objective : To determine the incidence and structure of postoperative pulmonary complications (PPCs) and to identify independent risk factors for their development in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Materials and Methods : A retrospective single-center study included 658 patients who underwent cardiac surgery in 2024. Demographic, anamnestic, intra- and postoperative data were analyzed. Univariate and multivariate logistic regression analyses were used to identify risk factors for postoperative complications. Results : PPCs were observed in 71 (10.8%) patients. Atelectasis was the most common complication (7.9%). The incidence of PPCs among smokers was 24.5% (compared to 4.1% among non-smokers), and among obese patients – 21.8% (compared to 6.3% in patients with BMI 65 years (OR 6.14; 95% CI 3.38–11.16), CPB duration >120 min (OR 5.86; 95% CI 3.57–9.60), smoking history (OR 5.92; 95% CI 2.89– 12.15), obesity (BMI ≥30 kg/m²; OR 5.12; 95% CI 2.70–9.81), and combined surgery (OR 4.69; 95% CI 2.46–8.94). The presence of chronic obstructive pulmonary disease (OR 1.94; 95% CI 1.11–3.39) and pulmonary hypertension (OR 2,14; 95% CI 1.79–5.52) was also associated with an increased risk (all p < 0.001). Conclusions : The identified modifiable risk factors (smoking, obesity) highlight the importance of preoperative optimization. Nonmodifiable factors (age, type of surgery) define a high-risk group requiring increased attention and early prevention of PPC. The findings may contribute to the development of risk stratification algorithms in cardiac surgery practice.

Исследованы агрегация и электрофоретическая подвижность эритроцитов у пациентов при операциях на клапанах сердца при подаче молекулярного водорода (1,2 ppm) и оксида азота (40 ppm) в экстракорпоральный контур в условиях искусственного кровообращения с продолжительностью перфузии менее и более 90 мин. Использование медицинских газов вызывало снижение агрегации эритроцитов, усиливающееся в контрольной группе. Уменьшение агрегации при действии медицинских газов сопровождалось увеличением электрофоретической подвижности эритроцитов по сравнению со значениями контрольной группы, в которой данный показатель снижался. Продолжительность перфузии более 90 мин характеризовалась увеличением дезагрегирующего эффекта оксида азота и молекулярного водорода, наиболее выраженного при их сочетании, что доказывает эффективность использования медицинских газов при длительных хирургических операциях.