Background. Pain syndrome due to thoracotomy is one of the most intense in surgery. Thoracic epidural anesthesia (TEA) is considered to be the “gold standard” of regional anesthesia for thoracic operations. Technical difficulties in applying this method can be a problem for the anesthesiologist. Goal of the study was to identify and analyze the difficulties associated with the use of TEA in thoracic surgery, to determine the percentage of effective use of TEA in the postoperative period. Materials and methods. Over a 10-month period, attempts to place an epidural catheter for analgesia of various thoracic operations were registered at the National Cancer Institute (a total of 204 patients during the observation period). During the study, the technical characteristics of the manipulation (level, patient position, duration of the procedure) were noted and the success of the attempts and the effectiveness of TEA for postoperative analgesia were evaluated, as well as the dependence of these results on the experience of the anesthesiologist performing the manipulation. Results. It was determined that out of 204 attempts to place an epidural catheter, 43 (21 %) were unsuccessful. The success of manipulation depended directly on the experience of the anesthesiologist who performed it: the lowest percentage of failures (9.3 %) was in doctors who had experience in thoracic surgery of more than 10 years, and the highest (35.9 %) was in residents. The effectiveness of postoperative analgesia in thoracic patients provided with TEA was also assessed — in 28 out of 161 patients (17.4 %), the analgesia was ineffective or insufficiently effective. The effectiveness of TEA in thoracic and gastric surgery did not differ significantly. The use of TEA was not associated with a large number of complications (6.4 %) and they were not life-threatening. Conclusions. TEA is a recognized effective method of regional anesthesia for thoracic operations, which is at the same time technically difficult to perform and has a fairly high failure rate. The success of TEA largely depends on the experience of the doctor performing the manipulation. Also, even in case of successful placement of an epidural catheter, TEA is not always effective.

Background. Currently, clinical and expert characteristics, legal consequences of inadequate medical care in anesthesio­logy and intensive care in Ukraine have been studied insufficiently. Objective: to analyze court decisions and conclusions of forensic medical examinations in criminal proceedings initiated in Ukraine in recent years against anesthesiologists and intensive care physicians for professional negligence. Materials and methods. Official statistical data from the Unified State Register of Court Decisions for 2018–2024 were analyzed in cases concerning improper professional activity of healthcare workers. In addition, 123 reports of forensic medical examination regarding the prosecution of anesthesiologists from various regions of Ukraine from 2007 to 2024 were reviewed. Statistical processing was performed using multivariate regression analysis. Results. Ukrainian courts proved the guilt of anesthesiologists and intensive care physicians in the professional negligence in 81.2 % of legal proceedings against these doctors. According to forensic medical conclusions, different lacks of health care provision were identified in 71.5 % of the cases examined. Professional errors were most often committed in severe clinical situations related to respiratory or cardiovascular pathology, as well as trauma. The main types of errors included diagnostic (32.0 %), low quality medical treatment (26.0 %), institutional (14.0 %) and ethical (6.0 %) mistakes. Errors in medical records were detected in 22.0 % of the cases. Inadequate medical care in anesthesiology was predominantly insufficient (49.0 %) or delayed (37.0 %). Diagnostic errors most frequently occurred during associated management of patients with therapists and resulted in failur6e to provide timely care. Tactical errors were one of the main causes leading to criminal liability. The study proposes to distinguish the following categories of errors in anesthesiology and resuscitation: technical defects in the performance of anesthesia, preoperative, medication, perioperative, and postoperative errors. Conclusions. Anesthesiologists and intensive care physicians belong to the group of medical professionals with the highest risk of criminal prosecution. Diagnostic errors and improper performance of medical procedures or medication errors seemed to be most frequent in malpractice cases against anesthe­siologists. Increasing clinicians’ awareness of the types, causes, and consequences of medical errors is crucial for preventing adverse outcomes of medical practice.

Background. Electrical injuries are among the most common public health problems and are frequently associated with high morbidity and mortality. Evidence acquisition. Literature sources were included in the study if they: 1) were published in Ukrainian, Spanish, or English; 2) reported on cardiac arrhythmias associated with electrical injury; 3) provided data on the prevalence of cardiac arrhythmias in electrical injury; 4) used an observational study design (cohort or cross-sectional). A retrospective literature search was conducted using a spatial-vector descriptive model, supplemented by a manual review of the referenced articles. Evidence synthesis. The heart is affected more frequently than other internal organs because electrical current usually follows the path of least resistance in the body — along blood vessels and nerves, toward the heart. Extensive surface burns and a vertical current pathway through the torso indicate an increased risk of cardiac damage. The most common manifestation of cardiac injury due to electrical exposure is arrhythmia, which typically occurs immediately after the electric shock. Conduction disturbances may result from alterations in myocytes surrounding the sinoatrial and atrioventricular nodes and are not necessarily related to myocardial ischemia or arterial injury. The most frequent ECG findings upon hospital admission were sinus bradycardia and sinus tachycardia. Other documented arrhythmias included newly diagnosed atrial fibrillation, frequent multifocal atrial complexes, sinus node arrest with atrial escape rhythm, prehospital-resolved ventricular fibrillation, ventricular bigeminy, and recurrent nonsustained ventricular tachycardia. Arrhythmias caused by electrical injury are mostly functional in nature, generally benign, and tend to resolve within the first few hours after hospitalization. Ventricular fibrillation is the most common fatal arrhythmia, occurring in 60 % of patients in whom the electrical current passes transthoracically. Alternating current has a greater propensity to induce ventricular fibrillation, whereas direct current more often causes asystole. Conclusions. Cardiac arrhythmias are the leading and most dangerous complications of electrical injury. Their incidence is directly dependent on the characteristics of the electrical current, its pathway through the body, the duration of exposure, body mass, and the extent of myocardial structural damage. In some cases, arrhythmias resulting from electrical injury may resolve spontaneously. Cardiac arrhythmias following electrical trauma can also occur in a delayed manner. Timely resuscitation measures can restore normal cardiac rhythm.

Background. Combined clavicle and rib fractures account for 18.6–29.1 % of cases among patients with polytrauma. Blunt chest trauma is one of the main causes of mortality. Clavicle and rib fractures are considered markers of injury severity and independently increase the risk of mortality. These lesions are characterized by multifaceted clinical manifestations and polysymptomatic presentation. Objective of the study: to improve the level of diagnosis for combined fractures of the clavicle and ribs by determining the informativeness of instrumental examination methods and creating a clinical and instrumental diagnostic algorithm. Materials and methods. Literature sources from PubMed, Embase databases were analyzed using keywords: polytrauma, fractures of the clavicle and ribs, injuries of the chest organs, clinical and instrumental diagnosis. Results. In terms of mechanism of injury, road accidents prevail (57.1–80 % of cases). Among clavicle fractures, fractures of the middle third prevail — 72.2 %. Fracture of two ribs was diagnosed in 40.7 % of cases, three — in 16.7 %, more than three — in 42.6 %, lung damage: lung contusion — in 33.3 %, pneumothorax — in 22.2 %, hemothorax — in 44.5 %. The nature of the clinical and instrumental examination depends on the general condition of the patient. In those with severe or extremely severe condition, the priority is to conduct chest ultrasound, which is characterized by sufficiently high sensitivity of 92.45 %, specificity of 99.07 % and diagnostic accuracy of 96.88 %. Conclusions. Combined fractures of the clavicle and ribs are characterized by polymorphism of the lesion and multifaceted symptoms, which requires a multidisciplinary differential approach to diagnosis. The proposed clinical and instrumental diagnostic algorithm for combined injuries of the clavicle and chest provides a rational approach to diagnosis and helps reduce the number of diagnostic errors.

Background. Ovarian cancer is one of the most lethal gynecological malignancies. Primary cytoreductive surgery remains the standard treatment, but in high-risk patients the complication rate is substantial. Multimodal prehabilitation within ERAS protocols is a promising approach to optimize patients’ condition before surgery. The purpose was to evaluate the impact of multimodal prehabilitation on perioperative outcomes in patients with advanced ovarian cancer undergoing primary cytoreduction. Materials and methods. In this prospective observational study (2022–2024), 150 patients with FIGO stage IIIC–IV ovarian cancer and ASA III–IV status were included. Seventy-five patients completed a 7–14-day prehabilitation program (nutritional support, anemia correction, exercise, psychological counseling), while 75 historical controls received standard ERAS care only. Primary endpoints were postoperative complications; secondary endpoints included hospital stay and time to chemotherapy initiation. Results. Prehabilitation significantly improved nutritional and functional parameters, reduced hospital stay (8 vs. 14 days; p < 0.005), accelerated chemotherapy initiation (8 vs. 15 days; p < 0.005), lowered the incidence of severe complications and 30-day mortality (1 vs. 10 %). Optimal benefit was achieved with ~ 10-day programs. Conclusions. Multimodal prehabilitation improves functional status, reduces morbidity, and shortens recovery in patients with advanced ovarian cancer, supporting its integration into ERAS pathways.

The use of agents such as hyoscine and scopolamine for premedication has led anesthesiologists to consider central anticholinergic syndrome (ACS) as one of the important causes of delirium due to the previous anticholinergic effects of these agents. Not only antimuscarinic agents like atropine and scopolamine but also various other anesthetic drugs with anticholinergic effects can induce ACS, which may cause from 1 to 40 % of episodes of delayed awakening in the postoperative period. The frequency of ACS depends on the choice and dose of the anesthetic, the type of surgery, the patient’s condition, and diagnostic criteria. ACS after general anesthesia occurs in 8–12 % of patients, and after regional anesthesia combined with sedation, its frequency is 3.3–4 %. In sedated patients on prolonged mechanical ventilation, the syndrome occurs in about 5 % of cases. This syndrome is polyetiologic and can be caused by many drugs with different mechanisms of action. Most patients with central anticholinergic syndrome in the immediate postoperative period experience central nervous system depression, while those who present to emergency or psychiatric departments typically show agitation or delirium. The spectrum of anticholinergic delirium is a common complication after drug overdose. Patients with severe toxicity may experience significant distress and behavioral problems that often require pharmacological treatment. Seizures occur in about 2.5 % of patients, and cardiotoxic effects are sometimes also observed. In elderly patients, delirium is a common and serious side effect of surgical intervention and anesthesia, occurring at frequencies from 10.1 to 51 %. Postoperative delirium in older adults is often associated with persistent cognitive dysfunction, dementia, higher rates of institutionalization, and increased morbidity and mortality. Anticholinergic syndrome during the perioperative period is often undiagnosed and therefore inadequately treated. This toxidrome can manifest in polypharmacy, especially in the elderly, in neuro-muscular diseases, and hereditary predispositions. Perioperative ACS can be caused by many anesthetic drugs and especially their combinations. Trigger factors for ACS may include medications that can cause other toxidromes. Currently, our ability to treat ACS is significantly limited by the low availability of well-known antidotes and hemodialysis agents, which encourages the use of alternative intensive therapy options.

Background. An increase in spinal cord injuries due to military operations requires a comprehensive approach to rehabilitation, including interdisciplinary cooperation of specialists and the use of modern methods. The importance of the neuropsychological approach lies in analyzing the impact of stress on the physical state and ensuring a balance between mental and physical health of the patients. The purpose of the article is to study the significance and practical implementation of neuropsychological care for war victims, emphasizing its role in comprehensive recovery, and to identify effective rehabilitation strategies based on the understanding of neuropsychological consequences of spinal cord injuries, considering an interdisciplinary approach to the restoration of mental and physical health in relation to modern challenges of human life support. Materials and methods. The following psychodiagnostic methods have been used: “Change in quality of life” questionnaire, visual analogue scale for pain assessment, and MMPI-2 for evaluating psychological status. The dynamics was analyzed by the outpatient R. Waters index (0–3 points) and statistical methods (SPSS, version 22) for ensuring the reliability of the results. RCS, PCAT, CNC and PICUPS scales have been used to determine rehabilitation needs. The signs of injury were determined using medical diagnostic methods. Results. According to the findings, aggression on the MMPI-2 was at medium and high levels. Back pain and headaches are observed at a high level. A comprehensive approach to rehabilitation, namely physical rehabilitation and psychocorrection, helps significantly improve motor activity, reduce pain and improve the quality of life of patients with spinal cord injuries. Conclusions. The results of the study prove the effectiveness of an integrated approach, including physical rehabilitation and psychocorrection, for the recovery of patients with spinal cord injuries. A significant increase in the Hauser index (from 3.18 ± 0.13 to 4.9 ± 0.63 points) indicates the improvement in motor activity, which allows patients to move without assistance after 10–12 months of treatment. The authors emphasize the importance of coordinated treatment that not only relieves pain but also restores patients’ functional activity, significantly improving their quality of life.

Background. The goal is to demonstrate the possibilities of using various methods to stop bleeding from the liver due to a thoracoabdominal gunshot wound. Materials and methods. Male patient aged 25 years was wounded in the chest during mortar shelling. An hour after the wound, he was taken to the advanced surgical group in serious condition, and the right thoracocentesis, drainage of the pleural cavity according to Blau, and primary surgical treatment (PST) of the wounds were performed. After 2 hours, the patient was taken to the Military Medical Clinical Center of the Northern Region of the Military Medical Service of the Armed Forces of Ukraine, and hospitalized in the emergency department. The diagnosis was: combined gunshot shrapnel wound of the chest, abdomen, and extremities. Blind thoracoabdominal wound on the right with a comminuted fracture of the VIII rib, damage to the lower lobe of the right lung, right lobe of the liver, right kidney with the presence of a foreign body (metal fragment) in the retroperitoneal space. Right-sided hemopneumothorax, pneumonitis. Hemoperitoneum. Blind wound of the soft tissues of the right shoulder and the presence of a foreign body (metal fragment). Operations: thoracocentesis, drainage of the right pleural cavity according to Blau. PST of gunshot wounds. The patient was examined, laboratory tests were performed: general clinical blood, urine tests, biochemical blood test, blood coagulogram, blood group and Rh factor, thromboelastography, blood electrolytes, alkaline-base composition and blood gases, ultrasound examination of the chest and abdominal organs according to the FAST protocol, multislice computed tomography (MSCT) of the head, chest, abdominal organs and pelvis with and without contrast, radiographic examinations of the head, chest and abdominal organs, electrocardiography, angiographic diagnosis and final stoppage of bleeding, removal of a foreign body using a multifunctional magnetic instrument for the diagnosis and removal of metallic ferromagnetic foreign bodies. Hemostasis from the liver wound was achieved by suturing the liver wound, Pringle maneuver, tamponade with gauze, using a Bowa ARC 303 high-frequency electrosurgical device, an isolated output electrosurgical generator Valleylab™ LS10, and a Medtronic AEX™ generator Aquamantys. Surgical interventions were performed using the (DCS) technique. Results. Upon admission, chest and abdominal ultrasound using the FAST protocol was done: fluid in the right pleural cavity and abdominal cavity. MSCT of the head, chest, abdominal organs and pelvis was also performed, which revealed a gunshot fracture of the right VIII rib, post-traumatic pneumonitis of the lower lobe of the right lung, signs of damage to Sg6, Sg7, Sg8 of the liver, gauge in the liver, foreign body (metal fragment) in the area of the upper pole of the right kidney, pleural drainage in the pleural cavity, signs of small hemopneumothorax, signs of hemoperitoneum. On the first day, 3 hours after the injury, DCS I was performed. Laparotomy, revision of the abdominal organs and the right extraperitoneal space. Atypical resection of Sg6, Sg7, Sg8 of the liver. Suturing and hemostasis of the liver. Suturing of the right dome of the diaphragm. Removal of a foreign body (metal fragment) using a multifunctional magnetic instrument for the diagnosis and removal of metal ferromagnetic foreign bodies. “Sandwich” liver tamponade. Suturing of the upper pole of the right kidney. Sanitation and drainage of the abdominal cavity. Closed laparostomy. Revision of the abdominal organs, hemostasis and suturing of the liver, “sandwich” liver tamponade, sanitation and re-drainage of the abdominal cavity. Closed laparostomy. The diagnosis was established: combined gunshot shrapnel wound of the chest, abdomen, and extremities. Blind thoracoabdominal wound on the right with a comminuted fracture of the VIII rib, damage to the lower lobe of the right lung, right lobe of the liver (AAST IV), right kidney (AAST III) with the presence of a foreign body (metal fragment) in the retroperitoneal space. Right-sided hemopneumothorax, pneumonitis. Hemoperitoneum. Blind wound of the soft tissues of the right shoulder and the presence of a foreign body (metal fragment). Operation: thoracocentesis, drainage of the right pleural cavity according to Blau. PST of gunshot wounds. Signs of intra-abdominal bleeding appeared the next day with blood being removed from the abdominal cavity through drainage. MSCT of the head, chest, abdominal and pelvic organs with contrast was performed, signs of extravasation of contrast material into the abdominal cavity were detected. The next day, due to the presence of intra-abdominal bleeding from the liver, a re-look, revision of the abdominal organs, hemostasis and re-tamponade of the liver, sanitation, re-drainage of the abdominal cavity, and laparostomy were performed. Twelve hours after a re-look, intra-abdominal bleeding relapsed. The operation was performed: revision of the abdominal organs, hemostasis and re-tamponade of the liver, sanitation, re-drainage of the abdominal cavity, laparostomy. A day after the injury, endovascular embolization of the branches of the right hepatic artery was performed due to recurrence of intra-abdominal bleeding from the liver. Diagnostic angiography of the liver vessels was performed, during which the source of bleeding was identified as a pseudoaneurysm from one of the branches of the right hepatic artery. The right hepatic artery originates from the superior mesenteric artery. Superselective catheterization of the damaged branch of the right hepatic artery and its embolization were performed. Hemostasis was achieved. Two days after the injury, a re-look, revision of the abdominal organs, liver detamponade, sanitation, re-drainage of the abdominal cavity, and a closed laparostomy were performed. Four days after the injury, left re-thoracocentesis and drainage of the pleural cavity according to Blau were conducted due to an increase in the amount of fluid in the pleural cavity. On the fifth day after the injury, the patient was transferred to the next level of medical care. It is known that subsequently, on the 10th day, an atypical liver re-resection was performed with laparostomy closure, and the patient was discharged on the 21st day with presentation to the military medical commission and provision of sick leave for 30 calendar days. Conclusions. The presented clinical case of endovascular hemostasis in the comprehensive treatment of gunshot wounds of the liver complicated by abdominal bleeding using the damage control surgery against the background of anatomical features of the right hepatic artery origin showed its high effectiveness.

Background. Extended epidural analgesia is widely used for postoperative pain control in oncological surgery. However, prolonged catheterization carries a risk of microbial colonization and infectious complications. In cancer patients, these risks are exacerbated by immunosuppression and impaired skin barrier function, underscoring the need to study the microbial spectrum and clinical implications of catheter colonization. Objective: to determine the frequency of bacterial colonization of epidural catheters, the spectrum of isolated microorganisms, and the clinical significance of these findings in patients undergoing oncological surgery. Materials and methods. A prospective study was conducted involving 51 patients who underwent prolonged epidural analgesia after oncological surgery. Demographic characteristics, somatic status, catheterization duration, incidence of infectious complications, and microbial culture results from catheter tips were analyzed. Statistical methods included descriptive analysis, Pearson’s test, Mann-Whitney U test, logistic regression, and Spearman correlation. Results. Positive cultures were found in 41.18 % of patients, with Staphylococcus epidermidis being the most common isolate. Clinical signs of infection were absent in 98 % of cases. No clinical-demographic variable showed a statistically significant association with colonization (p > 0.05), although body mass index had the strongest (nonsignificant) inverse correlation ( = –0.223). Colonization rates increased after more than 72 hours of catheterization. Conclusions. Epidural catheter colonization is common among cancer patients but rarely leads to clinically significant infections. Adherence to aseptic techniques and regular monitoring allow for the safe use of prolonged analgesia. Further research is needed to determine the optimal duration of catheterization and effective prevention strategies.

Background. The role of intraoperative nerve monito­ring (IONM) in thyroid surgery remains a controversial issue for surgeons regardless of their training and experience. This monitoring method is not intended to visualize the recurrent laryngeal nerve, but rather to assess its function intraoperatively and to help make a prognosis in patients who develop recurrent laryngeal nerve paralysis. Because of its simplicity and cost-effectiveness, electromyography recording of the vocal cords using surface electrodes integrated into or attached to the endotracheal tube is probably the most commonly used IONM method. Full functionality of IONM depends on near-complete laryngeal relaxation and reflex inhibition without the use of neuromuscular blocking agents. The depth of anesthesia required to meet these criteria often results in hemodynamic instability. During our study, we used intravenous lidocaine infusion, which allowed for good operating and monitoring conditions without significant hemodynamic fluctuations. The purpose of the study is to evaluate the effect of lidocaine administered intravenously in estimated doses on the IONM and laryngotracheal reflexes during surgical interventions on the thyroid and parathyroid glands. Materials and methods. Forty-six patients were randomly assigned to group 1 where lidocaine was administered and group 2 with no lidocaine was used. All patients were anesthetized with a narcotic analgesic and inhalation anesthetic. The loading dose of lidocaine was administered at the rate of 1 mg/kg intravenously, and the maintenance dose was calculated at 1.5 mg/kg/hour. For IONM, a Dragonfly single-channel laryngeal surface electrode (Electrode LSE 500Ms; Neurovision Medical Products, Ventura, CA, USA) attached to a cuffed endotracheal tube 7.0 (Medicare, China) was used during surgery according to the manufacturer’s instructions. Results. The number of patients who required stimulating current at 0.5 mA (the manufacturer’s recommended strength is 1.5 mA) was significantly higher in the lidocaine group (P = 0.001) than in the no lidocaine group (P = 0.00006). Similarly, the proportion of patients with < 50 % drop in aggregate impedance level at the end of surgery was significantly higher in group 1 than in group 2. In addition, the proportion of patients with hypotensive episodes and need to correct blood pressure with medications more than twice during surgery was significantly lower in group 1 than in group 2 (P < 0.05). ­Conclusions. Patients who were prescribed lidocaine intravenously were more resistant to laryngotracheal irritation during surgery, and this made it possible to maintain such a condition of the larynx, which was necessary to ensure its increased relaxation and suppression of reflexes when using IONM. Our ability to elicit a positive signal with stimulating current of 0.5 mA intraoperatively and provide a drop in aggregate impedance level < 50 % before the end of surgery was statistically significant in the intravenous lidocaine group.