術(shù)中肺開放通氣策略降低腹腔鏡結(jié)直腸癌切除術(shù)后并發(fā)癥：一項隨機對照試驗

貴州醫(yī)科大學(xué) 麻醉與心臟電生理課題組  

翻譯：佟睿  編輯：陳銳 審校：曹瑩

背景 

術(shù)中機械通氣中  聯(lián)合應(yīng)用  呼氣末正壓(PEEP)和肺復(fù)張(LRM)(稱為  肺開放  策略，OLS)的作用尚不清楚。 

目的 旨在于  確定中等PEEP(6-8cmH  2  O)和重復(fù)  性  LRM  s  的開肺策略是否能預(yù)防低潮氣量下腹腔鏡結(jié)直腸癌切除術(shù)高�；颊咝g(shù)后并發(fā)癥的發(fā)生。 試驗設(shè)計 一項前瞻性、評估者盲法、隨機對照試驗。 范圍設(shè)置 于2017年1月至2018年10月在單中心的大學(xué)附屬醫(yī)院進行。 干預(yù)因素

將患者隨機分為兩組(1：1)，PEEP為6~8cmH2O，LRMs每30min重復(fù)一次(OLS組)和不加LRMs的PEEP為零(非OLS組)。

主要觀察指標(biāo)測定 主要  觀察指標(biāo)  是術(shù)后7天內(nèi)發(fā)生  的  肺  及  肺外  的主要  并發(fā)癥。次要  觀察指標(biāo)  包括術(shù)中潛在的有害低血壓和血管  升壓藥的需求  。

結(jié)果

每組共130名患者被納入初步結(jié)果分析。有24例(18.5%)和43例(33.1%)發(fā)生了主要結(jié)果事件[相對危險度為0.46；95%可信區(qū)間為0.26~0.82；P  =  0.009]。有更多的患者出現(xiàn)潛在的危害性低血壓(  OLS組  vs非  OLS  ，15%vs 4.3%；P  =  0.004)，并且需要血管升壓劑(25%     vs 8.6%；P<0.001)。

結(jié)論 在低潮氣量通氣下接受腹腔鏡結(jié)直腸癌切除術(shù)的高危患者中，PEEP為6-8cmH2O并重復(fù)LRM  s  的  肺開放  策略與使用零PEEP  且  不使用LRM  s  的策略相比，減少了術(shù)后并發(fā)癥。值得注意的是，在血流動力學(xué)不穩(wěn)定的患者中應(yīng)謹(jǐn)慎使用LRM  s  。 

原始文獻來源 Hong LiM, Zhi-Nan ZhengM, Nan-Rong Zhang  ,  et al. Intra-operative open-lung ventilatory strategy reduces postoperative complications after laparoscopic colorectal cancer resection  :   A randomised controlled trial.[J].Eur J Anaesthesiol2021;38:1042–1051  .

Intra-operative open-lung ventilatory strategy reduces postoperative complications after laparoscopic colorectal cancer resection: A randomised controlled trial

Abstract

BACKGROUND The role of the positive end-expiratory pressure (PEEP) and lung recruitment manoeuvre (LRM) combination (termed open-lung strategy, OLS) during intraoperative mechanical ventilation is not clear. OBJECTIVETo determine whether an open-lung strategy constituting medium PEEP (6–8 cmH2O) and repeated LRMs protects against postoperative complications in at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation.

DESIGN A prospective, assessor-blinded, randomised controlled trial.

SETTING Single university-affiliated hospital, conducted from January 2017 to October 2018. PATIENTSA total of 280 patients at risk of pulmonary complications, scheduled for laparoscopic colorectal cancer resection under general anaesthesia and low-tidal-volume (6–8 ml kg-1 predicted body weight) ventilation.

INTERVENTION The patients were randomly assigned (1 : 1) to a PEEP of 6–8 cmH2O with LRMs repeated every 30 min (OLS group) or a zero PEEP without LRMs (non-OLS group).

MAIN OUTCOME MEASURES The primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within 7 days after surgery. The secondary outcomes included intra-operative potentially harmful hypotension and the need for vasopressors.

RESULTS A total of 130 patients from each group were included in the primary outcome analysis. Primary outcome events occurred in 24 patients (18.5%) in the OLS group and 43 patients (33.1%) in the non-OLS group [relative risk, 0.46; 95% confidenceinterval(CI),0.26to0.82;P=0.009). More patients in the OLS group developed potentially harmful hypotension (OLS vs. non-OLS, 15% vs. 4.3%; P=0.004) and needed vasopressors (25% vs. 8.6%; P<0.001).

CONCLUSION Among at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation, an open-lung strategy with a PEEP of 6–8 cmH2O and repeated LRMs reduced postoperative complications compared with a strategy using zero PEEP without LRMs. Of note, LRMs should be used with caution in patients with haemodynamic instability.