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

貴州醫(yī)科大學 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 

術中機械通氣中  聯合應用  呼氣末正壓(PEEP)和肺復張(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  性  LRM  s  的開肺策略是否能預防低潮氣量下腹腔鏡結直腸癌切除術高危患者術后并發(fā)癥的發(fā)生。 試驗設計 一項前瞻性、評估者盲法、隨機對照試驗。 范圍設置 于2017年1月至2018年10月在單中心的大學附屬醫(yī)院進行。 干預因素

將患者隨機分為兩組(1：1)，PEEP為6~8cmH2O，LRMs每30min重復一次(OLS組)和不加LRMs的PEEP為零(非OLS組)。

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

結果

每組共130名患者被納入初步結果分析。有24例(18.5%)和43例(33.1%)發(fā)生了主要結果事件[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)。

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