Andrey V. Diordiev

Ketamine, an N-methyl-D-aspartate receptor antagonist, developed more than 60 years ago as an anesthetic, has experienced a varied history but remains relevant in modern global medical practice. Over the past several decades, it has revealed new potential extending far beyond anesthesia. There is growing interest in the use of subdissociative doses of ketamine to treat various types of acute and chronic pain and depression. Its efficacy is similar to that of opioids, with a low incidence of transient adverse effects. Ketamine can be administered via multiple routes and is nearing the status of an ideal analgesic for the prehospital setting because of its favorable safety profile. In patients with severe trauma, ketamine is likely the optimal analgesic, as it provides hemodynamic stability without an increase in intracranial pressure. Ketamine is particularly useful in patients with opioid dependence, opioid tolerance, or opioid-induced hyperalgesia. The discovery of its multiple molecular targets and related effects enables the use of this unique agent in many areas of clinical and experimental medicine, including anesthesiology, emergency medicine, intensive care, pain management, psychiatry, research on the neurobiological basis of consciousness, and modeling of pathological mental states. This article presents the history of ketamine development and reviews current understanding of its mechanisms of action, methods, and areas of application.

Севофлуран является препаратом выбора при анестезии вне операционной у детей. Существенным недостатком севофлурана является синдром посленаркозной ажитации с частотой возникновения до 90%. Ажитация доставляет выраженный дискомфорт пациенту и может привести к его травматизации, а также значительно снижает удовлетворенность родителей анестезией в целом. ЦЕЛЬ ИССЛЕДОВАНИЯ Определить эффективность медикаментозных методов для профилактики ажитации, снижения ее частоты и выраженности при проведении ингаляционной анестезии севофлураном у детей вне операционной. МАТЕРИАЛ И МЕТОДЫ В ГБУЗ «НПЦ ДП ДЗМ» с марта 2021 г. по январь 2022 г. проведено проспективное сравнительное неинтервенционное рандомизированное исследование, включающее 180 пациентов в возрасте от 4 мес до 18 лет. В зависимости от метода анестезии пациенты разделены на 4 группы: ингаляционная анестезия севофлураном (n=50), севофлуран + пропофол (C+П, n=50), севофлуран + внутривенное введение кетамина (С+К, n=30), севофлуран + внутривенное введение MgSO₄ (С+М, n=50). Реакцию на индукцию оценивали по шкале MAS, наличие или отсутствие ажитации и степень ее выраженности — по шкале Watcha. Время достижения ясного сознания оценивали по шкале Aldrete. РЕЗУЛЬТАТЫ Все методики позволили снизить частоту посленаркозной ажитации: С+П — χ² (1; N=49) = 14,7, p2 (1; N=42) = 7,46, p=0,007; С+М — χ² (1; N=55) = 9,73, p=0,0018. У пациентов подгруппы до 3 лет наиболее эффективно выраженность ажитации по шкале Watcha снижал пропофол (U=42, Uкр=178, p(U=7, Uкр =12, p<0,05). У детей 3—5 лет статистически значимой разницы в уровнях посленаркозного возбуждения между группами анестезии не отмечено. ЗАКЛЮЧЕНИЕ С целью профилактики посленаркозной ажитации после анестезии севофлураном у детей до 3 лет рекомендовано внутривенное введение пропофола за 10 мин до конца исследования, у детей старше 5 лет — кетамина. Пациентам 3—5 лет профилактику ажитации можно не проводить.

Clinical guidelines address malignant hyperthermia, a rare pharmacogenetic syndrome triggered by volatile inhalational anesthetics and suxamethonium. Modern data concerning the mechanism of malignant hyperthermia development are presented, issues of syndrome clinical presentation and diagnosis are highlighted. Practical algorithm for anesthesiologist in case of malignant hyperthermia crisis is given, recommendations for identifying life-threatening syndromes and methods for their correction are presented. Prevention measures are also described. Medical care quality assessment criteria for the management of malignant hyperthermia patients are indicated.

The article discusses current approaches to anesthesia in providing vascular access in children in Russia and the framework of the existing problem and global practice. Several features of the child's body, such as small size, increased flexibility of the punctured vessel, expressed psycho-emotional and the childs motor reaction to a potentially painful invasive procedure create significant additional difficulties in peripheral vein catheterization in children, especially at an early age, compared with adults. This fact until recently caused a high frequency of unsuccessful peripheral vein catheterizations in children and, as a result, a high percentage of punctures and central vein catheterizations, which in turn is associated with the risk of serious potentially life-threatening complications accompanying the puncture and catheterization of the latter. The article describes various, including non-pharmacological methods for inducing adequate sedation and analgesia during vein catheterization. The parents presence in the intensive care unit plays an essential role in non-pharmacological methods of child protection. It is a factor that reduces stress and psycho-emotional stress, both for the child and indirectly for the medical staff. Information from domestic and foreign sources on the use of various administration methods and various pharmacological drugs demonstrate the variety of approaches to solving this urgent problem. This article presents our research results showing the advantages of using a combination of methods and drugs that provide adequate anesthesia, expressed as an increase in successful peripheral vein catheterizations, the corresponding reduction in the unjustified number of central vein catheterizations, and the positive economic effect accompanying this dynamic.

Acute and chronic pain in nonverbal children with severe pathologies of the central nervous system, including infantile cerebral palsy, is the most common and significant problem that is underestimated throughout the life of these patients. The underestimation of the importance of diagnosing pain and its treatment leads to significant damage to their physical, social and mental well-being. Obstacles to the diagnosis and treatment of pain are the uncertainty in the definition of the fact of the presence of acute pain, the degree of its intensity and the lack of reliable tools for assessing the impact of chronic pain on the quality of life of patients with severe neurological diseases. Problems of pain treatment, along with limited experience with the use of analgesics and adjuvants in this category of patients, are also concerns about the legitimacy of the use of certain drugs. In this review, we analyzed the problem of the current state of diagnosis and treatment of acute and chronic pain in nonverbal patients with severe neurological pathology and formed the main solutions.