術(shù)中肺通氣保護(hù)性策略降低腹腔鏡結(jié)直腸癌切除術(shù)后并發(fā)癥：一項(xiàng)隨機(jī)對(duì)照試驗(yàn)
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：佟睿 審校：曹瑩
術(shù)中機(jī)械通氣中聯(lián)合應(yīng)用呼氣末正壓(PEEP)和膨肺(LRM)(稱(chēng)為肺通氣保護(hù)性策略，OLS)的作用尚不清楚。
旨在于確定中等PEEP(6-8cmH2O)和重復(fù)性LRMs的開(kāi)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)高危患者術(shù)后并發(fā)癥的發(fā)生。
一項(xiàng)前瞻性、評(píng)估者盲法、隨機(jī)對(duì)照試驗(yàn)。
于2017年1月至2018年10月在單中心的大學(xué)附屬醫(yī)院進(jìn)行。
納入280例有肺部并發(fā)癥風(fēng)險(xiǎn)的患者，在全麻和低潮氣量(6~8ml kg-1理想體重)通氣下行腹腔鏡結(jié)直腸癌切除術(shù)。
將患者隨機(jī)分為兩組(1：1)，PEEP為6~8cmH2O，LRMs每30min重復(fù)一次的OLS組和不加LRMs，PEEP為零的非OLS組。
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。
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)局事件[相對(duì)危險(xiǎn)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)，并且需要血管升壓藥(25% vs 8.6%；P<0.001)。
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)LRMs的肺開(kāi)放策略與使用零PEEP且不使用LRMs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(dòng)力學(xué)不穩(wěn)定的患者中應(yīng)謹(jǐn)慎使用LRMs。
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.
SETTINGSingle 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.
