Sergey V. Grigoryev

Highlights This review introduces for the first time an integrative conceptual model of high perioperative cardiac risk, combining three key components: surgical risk, patient vulnerability, and dynamic monitoring, enabling a systematic approach to patient stratification prior to noncardiac surgery. It demonstrates a critical gap between the high predictive accuracy of modern machine learning models (AUROC > 0.90) and the lack of their clinical validation in real-world practice, particularly in the Russian population, highlighting the need for a national risk calculator. For the first time in Russian literature, the role of MINS (myocardial injury after noncardiac surgery) as a major driver of postoperative mortality (contributing 3.9% to overall mortality) is analyzed in detail, justifying the shift from reactive to preventive perioperative cardiac risk management based on routine monitoring of high-sensitivity troponins and natriuretic peptides. Abstract This review focuses on contemporary approaches to the assessment and management of perioperative cardiac risk in patients undergoing non-cardiac surgery. The topic's relevance stems from the high frequency of major adverse cardiovascular events (MACE), a leading cause of perioperative mortality. The work analyzes the paradigm shift from the question “is surgery feasible?” to the strategy “how to improve outcomes?” which includes pre-operative optimization (prehabilitation), active monitoring, and a multidisciplinary approach. Based on a literature search, the epidemiology and key risk factors are reviewed, with detailed classifications and definitions of complications (MACE, myocardial injury after noncardiac surgery (MINS), intraoperative critical incidents). Particular attention is paid to the role of biomarkers (NT-proBNP/BNP for prediction, high-sensitivity troponin for diagnosing MINS) and hemodynamic control in risk stratification and early detection of myocardial injury. A comparative analysis of prognostic tools is conducted: from traditional clinical scales (Lee index, NSQIP) to modern machine learning models demonstrating high accuracy. Problems with validation, clinical interpretability, and the integration of these tools into routine practice are noted. Contemporary recommendations for risk minimization, based on staged personalized assessment, patient optimization, and active postoperative monitoring, are summarized. The conclusion emphasizes the need to develop integrative, transparent, and clinically applicable algorithms that combine data from scales, biomarkers, and dynamic monitoring to transition from reactive to preventive management of perioperative cardiac risk.

Perioperative management of patients receiving anticoagulants and antiplatelet agents is a complex task that requires a balance between the risk of thromboembolic complications and the risk of bleeding. Due to the increasing number of patients taking antithrombotic drugs, the relevance of developing modern recommendations for their perioperative management increases. Particular attention is paid to patients with comorbidities such as atrial fibrillation, ischemic stroke, myocardial infarction and coronary stenting. The article presents the guidelines of the Federation of Anesthesiologists and Reanimatologists and the National Association of Specialists in Thrombosis, Clinical Hemostasis and Hemorheology for the management of patients receiving anticoagulants and antiplatelet agents, revised in 2025. The guidelines for the perioperative management of patients receiving anticoagulants and antiplatelet agents have been updated, taking into account modern concepts of the risks of thromboembolism and bleeding. Particular attention focused to risk stratification, interruption and resumption of antithrombotic therapy, and the safety of regional anesthesia during anticoagulant therapy. The recommendations use data from modern studies, meta-analyses, and clinical trials on the perioperative management of patients receiving anticoagulants and antiplatelet agents. Various methods of thromboprophylaxis are considered, including the use of low molecular weight heparins, fondaparinux, and other anticoagulants. Particular attention is paid to risk stratification using the Caprini, HAS-BLED, and CHA2DS2-VASc scales. Recommendations are proposed for interruption and resumption of antithrombotic therapy depending on the risk of thromboembolism and bleeding. Criteria for the quality of compliance with recommendations, as well as algorithms for patient management during elective and emergency surgeries, are developed. The guidelines provide clinicians with practical tools to manage perioperative risk in patients receiving anticoagulants and antiplatelet agents. An important aspect is the individual approach to each patient, taking into account their clinical situation and risks.

Perioperative management of patients with concomitant heart valve disease is a serious problem considering different hemodynamic changes following valvular lesions. Considering modern data, we updated features of clinical and instrumental preoperative assessment of these patients. Guidelines on prevention of thrombosis, infectious endocarditis and intraoperative monitoring are given. Details on perioperative management of different frequent valvular diseases including preoperative management, goals of anesthesia, choice of optimal anesthesia technique and drugs are presented.

Perioperative management of patients with valvular heart disease is a serious problem considering different hemodynamic changes following various valvular lesions. Considering modern data, we present updated information about preoperative assessment of these patients. Recommendations on prevention of thrombosis and infectious endocarditis, as well as intraoperative monitoring are given. We discuss perioperative management of different valvular diseases including preoperative preparation, goals of anesthesia, choice of optimal technique and drugs.

The article presents the main provisions of clinical guidelines for the diagnosis and treatment of hypovolemic shock in adults, approved by the All-Russian public organization "Federation of Anesthesiologists and Resuscitators" in 2024. The relevance of the problem is associated with a significant prevalence and high mortality rates in hypovolemic shock. The recommendations include issues of etiology, pathogenesis, clinical picture, methods of laboratory and instrumental diagnostics of hypovolemic shock. The features of intensive care for hypovolemic shock are presented, including approaches to the administration of vasopressor and inotropic drugs, recommendations for the choice of infusion and adjuvant therapy, including the correction of coagulopathy in hemorrhagic shock. The issues of resuscitation damage control strategy are discussed. The criteria for the quality of medical care for adult patients with hypovolemic shock and algorithms for the doctor's actions in the diagnosis and intensive care of patients with hypovolemic shock are presented.

The updated guidelines (second revision) for the management patients with concomitant coronary artery disease undergoing non-cardiac surgery are presented. Recent data on epidemiology, pathogenesis, classification and main principles of perioperative management of coronary artery disease are highlighted. The key recommendations on risk stratification and preoperative examination of patients with co-existing coronary artery disease are presented. We describe the peculiarities of anesthesia and intraoperative monitoring, as well as postoperative management of patients with coronary artery disease. Prevention and treatment of postoperative complications, principles of management of perioperative myocardial infarction are discussed in detail. Basic criteria of medical care quality control are presented.

INTRODUCTION: Identification of risk factors that cause a high probability of an unfavorable outcome in the postoperative period is an urgent problem. The creation of national databases (registries) makes it possible to cover a certain patient population by identifying its risk predictors. Existing registries differ in the criteria for inclusion in the study, in the characteristics of the populations studied, and there is often no common view on the classification of postoperative outcomes. OBJECTIVE: Creation of a Russian national calculator for the risk of postoperative complications and mortality. MATERIALS AND METHODS: Two-level observational retrospective-prospective study. Setting: National multicenter study of surgical inpatients. Patients: Adult patients undergoing elective and emergency surgery. Types of interventions: obstetrics, gynecology, mammary gland, urology, endocrine surgery, maxillofacial surgery, orthopedics, traumatology, abdominal surgery, liver and biliary tract, thoracic surgery, vascular surgery, neurosurgery, cardiac surgery, other areas. RESULTS: The design was registered in the ClinicalTrials.gov database, the study was organized by the Federation of Anesthesiologists and Reanimatologists of Russia. Primary (30-day mortality, 30-day complications) and secondary (hospital mortality, hospital complications, length of stay in ICU, length of hospital stay, multiple organ failure (2 or more points on the SOFA scale), 90-day mortality, 90-day complications, post intensive care syndrome, readmission, 1-year mortality) outcomes; six primary and twelve secondary target points; criteria for inclusion, non-inclusion, exclusion. The required sample size and statistical analysis are described. The planned sample size to ensure the required power of the study is determined to be 60,800 observations for elective surgery and 20,000 observations for emergency surgery. The planned duration of the study is 2024–2028. CONCLUSIONS: The study has important scientific and medical-social significance; a Russian national calculator for the risk of postoperative complications and mortality will be developed. In the future, the developed calculator can become the basis for making medical decisions.

INTRODUCTION: The need for an independent assessment of the guidelines before their planned revision based on the third-party opinion of competent specialists is beyond doubt. This analysis allows to adapt the implementation of recommendations in practice, regarding equipment and knowledge of physicians. OBJECTIVE: To analyze the effectiveness, safety and availability of implementation in clinical practice of the guidelines “Application of non-invasive lung ventilation” using the modified Delphi method. MATERIALS AND METHODS: The expertise consisted of three stages. The first stage consisted in the analysis of the guidelines “The use of non-invasive lung ventilation” and the preparation of a questionnaire. At the main stage, a questionnaire was sent out and panel members were asked to evaluate the positions using ten-point Likert scale. The analytical stage consisted in calculating the weighted average, median and mode. The weighted average score were taken into account; the value of the median or mode of criteria for the quality of medical care, weighted average. RESULTS: Fifteen panel members was enrolled. The main remarks and additions were to clarify the terminology, concretize certain recommendations and style. Panel members determined the possibility of implementing the recommendation of the guidelines in practice. The lack of equipment makes therapeutic measures limited. This fact confirms the low results of the weighted average assessment of the criteria for the quality of medical care. CONCLUSIONS: Consensus was reached on 20 of the 21 thesis recommendations, on four of the eight criteria for the quality of medical care, and on the amended wording of certain recommendations. The Delphi analysis made it possible to look at the implementation of the giudelines from the perspective of practicing anesthesiologist and intensive care physician, including in structural units with a low level of material and equipment.

INTRODUCTION: Anesthesia planning for cesarean section requires knowledge of physiological and functional features a pregnant patient has in her gestational age. Proper planning reduced the perioperative critical incidents risk. OBJECTIVE: Search for data on the methods and results of assessing the cardiorespiratory status of pregnant women using methods that involve such key mechanisms of arterial baroreflex (ABR) and peripheral chemoreflex (PCR) mechanisms. MATERIAL AND METHODS: We performed a systematic review of the literature in accordance with the PRISMA guidelines. The bibliographic search was performed in December 2022 in the Medline (Pubmed), RSCI (eLibrary.ru) and Cochrane Library databases. The search keywords were: “pregnancy breath holding test”, “pregnancy chemoreflex”, “pregnancy baroreflex”, “Valsalva test pregnancy”. RESULTS: 110 documents were found, after deleting 68 papers for various reasons 42 full-text sources were analyzed, including a detailed comparative analysis of 8 sources that met totally the inclusion criteria. The design, objectives, methods, data availability, and outcomes of the studies were heterogeneous, so a meta-analysis was not performed. Were extracted and summarized data on functional changes in the work of cardiorespiratory system during pregnancy and changes in the sensitivity of the baroreflex and chemoreflex. CONCLUSIONS: The sensitivity of PCR in pregnant women can be assessed by inhalation of hyperoxic, hypercapnic and isooxic-hypercapnic gas mixtures (rebreathing test). The sensitivity of ABR in pregnant can be assessed by phenylephrine test, Valsalva test, orthostatic test, and spectral analysis of the sequences of blood pressure values and the R-R interval. The sensitivity of PCR in full-term pregnancy increases. The sensitivity of ABR in pregnant progressively decreases from the beginning of pregnancy to the end of the second trimester and increases in the postpartum period to initial level; in the third trimester of pregnancy, changes in ABR sensitivity are individual and do not have a single trend. АКТУАЛЬНОСТЬ: Врачу — анестезиологу-реаниматологу при составлении плана анестезиологического обеспечения операции кесарева сечения необходимо знать о том, какие физиологические и функциональные особенности имеет беременная пациентка в том или ином сроке гестации. Правильное составление плана анестезии и тактики ведения пациенток в периоперационном периоде помогает снизить риск гемодинамических, респираторных и других критических инцидентов. ЦЕЛЬ ИССЛЕДОВАНИЯ: Поиск данных о способах и результатах оценки кардиореспираторного статуса беременных с использованием методов, задействующих такие ключевые механизмы рефлекторной регуляции, как артериальный барорефлекс (АБР) и периферический хеморефлекс (ПХР). МАТЕРИАЛЫ И МЕТОДЫ: Мы провели систематический обзор литературы в соответствии с рекомендациями PRISMA. Поиск был проведен в декабре 2022 г. в базах Medline (Pubmed), «Российский индекс научного цитирования» (РИНЦ, eLibrary.ru) и Cochrane Library. Поиск производился по запросам: «произвольное пороговое апноэ беременность», «хеморефлекс беременность», «барорефлекс беременность», «проба Вальсальвы беременность», «pregnancy breath holding test», «pregnancy chemoreflex», «pregnancy baroreflex», «Valsalva test pregnancy». РЕЗУЛЬТАТЫ: Было найдено 110 работ, после удаления по различным причинам 68 работ было проанализировано 42 полнотекстовых источника, в том числе проведен подробный сравнительный анализ 8 источников, полностью соответствующих критериям включения. Дизайн, цели, методы, доступность данных и конечные результаты исследований были неоднородными, поэтому метаанализ данных не проводился. Были извлечены и обобщены данные о функциональных изменениях в работе кардиореспираторной системы, происходящих при беременности и отражающихся в изменении чувствительности АБР и ПХР. ВЫВОДЫ: Чувствительность ПХР у беременных можно оценивать с помощью вдыхания гипероксической, гиперкапнической и изооксически-гиперкапнической газовой смеси (варианты пробы с возвратным дыханием). Чувствительность АБР у беременных можно оценивать с помощью фенилэфринового теста пробы Вальсальвы, ортостатической пробы, а также спектрального анализа...

In the process of developing the recommendations, the publications of the official websites of the Russian Federation, the electronic databases of the RSCI, PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were analyzed by the developers independently of each other. The date of the last search query was November 1, 2021. To develop the recommendations for the Guidelines, documents were used that directly describe the features of the management of patients with a new coronavirus infection COVID-19 (recommendations and guidelines — 35; randomized clinical trials and Cochrane Reviews — 23; observational and comparative studies — 134; other documents, notes and comments — 72). Compared to the previous, 5th, version of the recommendations, 35 provisions have been corrected in 10 sections. The provisions of the current version of the recommendations highlight the specifics of anesthesia, intensive care, rehabilitation, resuscitation measures, manipulation, transportation, prevention of the spread of COVID-19 in the implementation of these activities. Methods of protecting personnel from infection with COVID-19 during manipulations, anesthesia and intensive care are considered. The features of respiratory support, extracorporeal detoxification, extracorporeal membrane oxygenation, thromboprophylaxis, drug interactions are described. The features of the management of pregnant women, children, patients with concomitant diseases, the principles of the formation of stocks of drugs and consumables are considered. For management of COVID-19 patients, the following were specified and supplemented: 1) indications and contraindications for the administration of drugs (acetaminophen, glucocorticosteroids, remdesevir, tocilizumab, baricitinab, statins, convalescent plasma), depending on the severity of the disease; 2) features of intensive care for concomitant diseases (cardiovascular system, inflammatory bowel disease, cancer, arrhythmia); 3) the timing of elective surgery in patients who survive COVID-19, and post vaccination; 4) thromboprophylaxis and management of coagulation disorders; 5) regulatory and legal documents concerning the activities of healthcare workers facing COVID-19.