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RUSSIAN REANIMATOLOGY TODAY

Дата публикации: 18 ноября 2021
Автор(ы): Viktor MOROZ
Публикатор: Научная библиотека Порталус
Рубрика: МЕДИЦИНА
Источник: (c) Science in Russia, №2, 2014, C.13-19
Номер публикации: №1637242554


Viktor MOROZ, (c)

by Viktor MOROZ, Corresponding Member of the Russian Academy of Medical Sciences, Head of the Negovsky Institute of Reanimatology (Moscow)

 

The problem of life and death has always been vital to people since ancient times. Combating death was their cherished dream that has come true thanks to Vladimir Negovsky (1909-2003), an outstanding scientist, member of the Academy of Medical Sciences of the USSR (elected in 1975), the founder of a new trend in medicine-reanimatology.

 

THE BIRTH AND HISTORY OF THE REANIMATOLOGY INSTITUTE

 

Back in the 1930s Vladimir Negovsky was working as practicing physician and then as research fellow at the laboratory of pathophysiology of the Central Institute of Hematology and Blood Transfusion under Professor Sergei Bryukhonenko who created the world's first artificial circulation device--autojector (blood movement in it was maintained automatically by two diaphragmatic pumps connected to electric motors). Vladimir Negovsky saw that death was not a fact, but a process, which could and should be studied. His ideas captured the interest of several young research fellows of the institute. By using an arterial centripetal (moving directly to the heart) pumping of blood with epinephrine (adrenaline), they revived test animals and even achieved their stable survival. Full of enthusiasm and sure that profound studies in this direction would yield positive results, Negovsky turned the Government of the USSR with a request to create a special laboratory. In 1936 that laboratory was set up, it was to look into the problem formulated as "Recovery of Vital Processes in Death-Like Phenomena". A small group of enthusiasts headed by Negovsky started their struggle for death prevention.

 
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Owing to research done by Negovsky and his followers, it became possible to realize the old human dream of bringing the dead back to life or sustaining life in critical conditions. Such work is going on at the research institute named now after Negovsky.

 

These studies were continued after World War II and the Negovsky laboratory became (in 1948) "Laboratory of Experimental Physiology of Resuscitation" of the Academy of Medical Sciences of the USSR, and in 1977, "Research Laboratory of Reanimatology" of the Academy of Medical Sciences of the USSR. From the very start the laboratory started active research in a new sphere--pathophysiology of vital functions decay and recovery in critical and terminal states. Negovsky put forward a key idea on the role of the brain in the process of dying. He wrote: "For a long time it was assumed that the last contraction of the heart meant the last stroke of life. We no longer say so since for several minutes after cessation of the heart beat, the body status remains reversible in the sense that the central nervous system is capable of recovering its functions. Actually the still persisting signs of brain viability may signal the last "stroke" of life".

 

In the 1940s-1950s the laboratory faced many problems, some of them of technological nature, but the enthusiasm of its workers helped to cope. Although research carried out in those years was mostly experimental yet and aimed at elucidating the pathogenetic mechanisms of critical and terminal states, Negovsky was trying hard to adopt reanimatology methods in clinical practice. In 1946 an intensive care unit was set up at the Bakulev surgery hospital.

 

In 1959 a center involved with shock and terminal states was established at the Botkin Municipal Clinical Hospital. And in 1964 the country's first intensive care department of general profile appeared there, together with the affiliated Moscow mobile intensive care center servicing Moscow hospitals.

 
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Research into the terminal state pathogenesis made it possible to understand many important processes taking place during dying and subsequent resuscitation. Basic data were obtained on the loss and recovery of vital functions during dying because of various causes. Different stages of dying were distinguished, and thus it became possible to validate the possibility of recovery of vital functions during clinical death. For these results Negovsky and his team members Maria Gaevskaya and Yevstolia Smirenskaya as well as Professor Fyodor Alexeyev were awarded a State Prize of the USSR. Extensive experience of Moscow hospitals was used for filing general clinical recommendations. The first instructions "On Introduction into Practice of Methods for Restoration of Vital Functions in a State of Agony or Clinical Death" based on these recommendations were issued in 1952 by the USSR Ministry of Health and re-issued in 1955 and 1959. In 1958 the Ministry of Health distributed instructions for organization of intensive care units at hospitals. Mobile teams of intensive care medics equipped with respiration support, blood transfusion, and heart defibrillation facilities were also organized at that time.

 

HEART FIBRILLATION CONTROL

 

Problems of heart fibrillation control were an important area of research at the Negovsky laboratory. Its medical scientists formulated a theory with respect to processes implicated in ventricular fibrillation and in its arrest by electric pulses; they proved the universal nature of electric pulse therapy for various kinds of cardiac arrhythmia. Our medics were the world's pioneers by suggesting a method of heart defibrillation by bipolar pulses; this method was recognized as most effective and safe in other countries, too. In 1970 for their electric pulse therapy studies laboratory scientists (Vladimir Negovsky and Naum Gurvich) and a team of scientists headed by Alexander Vishnevsky, a famous Russian surgeon, were awarded a State Prize of the USSR.

 

In 1958 US Senator Hubert Humphrey visited the Negovsky laboratory. He was impressed by the depth and scale of our studies of resuscitation. Later he addressed US Congress saying he suggested organizing under the aegis of national health institutes specialized centers involved with the physiology of death, reanimation, and related problems. He said the United States should compete with the USSR in a bold search for approaches to at least a partial victory over death.

 

Proceeding from the findings of his laboratory, in 1961 Vladimir Negovsky presented a report at the International Congress of Traumatologists in Budapest, Hungary. He pointed to the birth of a new medical science--reanimatology with a focus on nonspecific pathological reactions, pathogenesis, therapy, and prevention of terminal states and on life support in critical states. Accordingly, in 1969 the USSR Ministry of Health issued instructions on a national reanimatological service. Professor Peter Safar, a leading American reanimatologist, told Negovsky, he would always be considered a founder of reanimatology by beginning research into dying and resuscitation. He had developed many basic definitions and concepts in this new sci-

 
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ence. The American medic said he had learned much from Negovsky's concepts and views.

 

REANIMATOLOGY TODAY AND TOMORROW

 

Today reanimatology is an important specialization of the three stem lines in medicine: therapy, surgery, and anesthesiology/resuscitation. Anesthesiology/resuscitation investigates problems of life support, provisional replacement of organs and systems (artificial kidney, circulation, liver, ventilation of the lungs) and their functions in critical, terminal, and postresuscitation conditions caused by diseases, injuries, wounds, blood loss, shock, intoxication, and also in various surgical interventions, including transplantations.

 

In 1985 the national Academy of Medical Sciences set up the world's first Institute of Reanimatology on the basis of the Negovsky laboratory. Today we can see Vladimir Negovsky's memorial room there. In 1988-1995 this institute was headed by Viktor Semenov, Corresponding Member of the Russian Academy of Medical Sciences. In 1995 Vladimir Moroz, the au-

 
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thor of the present article, became its head. During the 1990s, a hard time for our country, the institute retained its research collective to become a leading research and clinical center working on problems of anesthesiology and reanimatology. Our scientists are carrying out experimental studies and promoting introduction of their results and new technologies in clinical practice. Our researchers are making a contribution in technological problem-solving related to the manufacture of specialized facilities (defibrillators, resuscitation devices). In 2004 our institute suggested creating a National Council for Reanimation (NCR). One priority task for it involves resuscitation technologies for use at the prehospital stage. NCR--a Russian organization--is a member of the European Council for Resuscitation (ECR).

 

NEW TRENDS

 

The main trends in modern reanimatology concern research into the nature of critical and terminal pathological conditions and postresuscitation diseases at the organic, cellular, subcellular, and molecular levels. We mean studies of the trigger mechanisms of irreversible injuries of the brain, neurological disorders, and abnormalities of circulation and respiration functions, of endocrine and immune systems, and hemostasis in critical states, during dying and subsequent recovery of their functions. Our scientists have brought out formative regularities in postresuscitation abnormalities of the brain and viscera caused by disoxia and toxemia as key components of postresuscitation pathogenesis as well as impairment of the structure of the hydrate membrane enveloping biopolymer molecules, and immune and microcirculatory failures.

 

We also centered on the molecular mechanisms of dying and recovery of vital functions after critical blood losses, on the significance of apoptosis* and necrobiotic processes (necrobiosis--dying) in the pathogenesis of posthypoxic encephalopathy (PE) and visceral dysfunctions. We have detected clinical and extraclinical pneumonia risk genotypes and collected important data on DNA aberrations, apoptosis, and necrosis of blood cells in patients with severe combined injury**, blood loss, and hemodynamic disorders. Thus, we have vali-

 

* Apoptosis--programmed cell death, self-destruction process regulated at the cell level as the cell breaks into apoptotic (dead) bodies enclosed in the plasmatic membrane.--Ed.

 

** Combined injury relates to traumas inflicted on two or more anatomic regions of the body by a traumatic agent.--Ed.

 

dated the role of the genetic factor in the development of critical states and obtained new data on cell membrane injuries at the nanostructural level.

 

Studies of the genetic, metabolic, structural, and functional injuries concomitant to critical states have led to the discovery of mechanisms implicated in critical, terminal, and postresuscitation states. Today the focus is on experimental validation and clinical tests of methods for correction of the critical state hypoxia (oxygen insufficiency). New combination methods for hypoxia correction have been developed on the basis of relevant data. Among other things, the concept of using Perfluothane--a blood plasma substitute with a gas transport function--has been substantiated. Perfluothane is a perfluorocarbon-based drug improving blood microrheology*, microcirculation and oxygen balance. It protects cell membranes, improves the course of the reperfusion (oxygen-dependent) process, and reducing the intensity of degenerative changes in the viscera.

 

A new-generation perfluorocarbon emulsions (dissolving oxygen easily) with better characteristics have been obtained at the Negovsky Institute with the use of a new class of emulsifiers. For basic studies in this sphere, specifically, in creating Perfluorocarbon media for regulating the vital activity of organs, cells and organism at large, Viktor Moroz, Corresponding Member of the Russian Academy of Medical Sciences, was awarded a Prize of the Government of the Russian Federation (1999), and in 2002 he merited a "Vocation Diploma"--the First National Prize for Russia's Best Physicians.

 

The Institute of Reanimatology is playing a leading part in reanimatology research. Thanks to activities of the Biophysical Laboratory (headed by Prof. Alexander Chernysh) at our institute, we have obtained data on the mechanisms of action and cellular effects of Perfluorane. Changes in the erythrocyte membranes nanostructure in health, disease, and during Perfluorane treatment were studied by a new method--atomic force microscopy.

 

Our scientists are focusing on the improvement and experimental and clinical development of methods for preventing organic disorders and for intensive care during the postresuscitation period; they are handling reanimatological technologies and life support systems in critical, terminal and postresuscitation states. Research

 

* Blood microrheology, variable blood viscosity in the microcirculation system, dependent on bloodflow.--Ed.

 
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and practical aspects of extracorporeal detoxication* are studied as a substitute therapy in septic shock, acute renal, hepatic, hepatorenal failures of different etiology. Multistaged uses of low-energy laser technologies and other modern reanimatological methods and technologies are under study as well. Novel systems of life support and modern sophisticated reanimation facilities have been designed and adopted in practice, as well as methods to correct disorders in critical and terminal

 

* Extracorporeal detoxication involves therapeutic methods making use of blood-cleansing devices that eliminate external toxic substances getting in.--Ed.

 

states. High technologies and nanotechnologies are actively introduced in diagnostic and therapeutic procedures.

 

The Negovsky Institute is working to develop and improve the philosophy of the anesthesiological and reanimatological service and to organize intensive care by means of cardiopulmonary resuscitation methods at the prehospital stage. We have devised principles of a universal state system for training the population to be able to give first medical aid and resuscitation procedures in disaster management and have drawn up a Cardiovascular Resuscitation Protocol in Premedical Aid.

 
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MECHANISMS AND METHODS IN ARDS TREATMENT

 

Comprehensive studies of mechanisms and methods for the treatment of acute respiratory failure has become one of the priorities of our research and clinical work in recent years. Experimental studies have demonstrated morphological changes occurring in the lungs due to various destructive factors. Clinical studies in patients with acute respiratory distress syndrome (ARDS)* brought out specific features of the pathogenesis and clinical signs of direct and indirect lung injuries. We detected the accumulation of extravascular liquid in the lungs during various ARDS scenarios and saw the prognostic significance of this parameter. Accordingly, our scientists were the first to develop an algorithm of differential diagnosis, and differentiated therapy for ARDS caused by different factors. Thus, it became possible to create a new classification and adopt it in practice.

 

The introduction of modern technologies has demonstrated the efficiency of differentiated (depending on ARDS causes) intensive care measures. For the first time ever the period of respiratory support and treatment in intensive care units and the mortality rate were brought down.

 

The achievements of the Institute of Reanimatology were honored at the governmental level. Our scientists--Viktor Moroz, Corresponding Member of the Russian Academy of Medical Sciences, heading the team, Gennady Ryabov, Member of the Russian Academy of Medical Sciences, Prof. Arkady Golubev, Prof. Yuri Churlyaev, and Alexei Vlasenko, Cand. Sc. (Med.), were awarded a Prize of the Government of the Russian

 

* Acute respiratory distress syndrome (ARDS) is a deadly inflammatory involvement of the lungs characterized by diffuse infiltration and severe hypoxemia. This pathological condition is caused by many factors directly or indirectly affecting the lungs and after resulting in death (up to 80-90 persent). This syndrome calls for intensive care and forced ventilation of the lungs.--Ed.

 

Federation in Science and Technology "For Improving the Efficiency of Diagnosis and Treatment of Acute Respiratory Distress Syndrome (ARDS) on the Basis of New Most Progressive Medical Technologies".

 

EDUCATION ACTIVITIES

 

The work of our institute cannot be divorced from its education activities. The training of skilled specialists for research, academic, and practical work has been our priority since the very beginning. Certification cycles, theoretical and clinical training (at our clinic, too) is an important part of our activity. Our research results are published in international and Russian journals, presented at international and Russian scientific forums--congresses, conferences, workshops. New technologies developed at the Institute of Reanimatology are confirmed by numerous patents. We are publishing the research and practical journal "General Reanimatology" (since 2005), monographs, research papers, proceedings of conferences, and methodological recommendations. Our specialists are contributing to the filing of normative documents and recommendations of the Federation of Anesthesiologists and Reanimatologists.

 

Russian reanimatologists have scored results of world significance in recent years; a new trend in medicine-- reanimatology--has come to stay. We can say with good reason that the Negovsky Institute of Reanimatology is Russia's only research center specialising in anesthesiology and reanimatology, a leader in this vital area.

Опубликовано на Порталусе 18 ноября 2021 года

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