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术中肺通气保护性策略降低腹腔镜结直肠癌切除术后并发症：一项随机对照试验

2021

09/29

米勒之声

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术中机械通气中联合应用呼气末正压(PEEP)和膨肺(LRM)(称为肺通气保护性策略，OLS)的作用尚不清楚。

本文由“罂粟花”授权转载

术中肺通气保护性策略降低腹腔镜结直肠癌切除术后并发症：一项随机对照试验

贵州医科大学麻醉与心脏电生理课题组

翻译：佟睿编辑：佟睿审校：曹莹

背景

术中机械通气中联合应用呼气末正压(PEEP)和膨肺(LRM)(称为肺通气保护性策略，OLS)的作用尚不清楚。

目的

旨在于确定中等PEEP(6-8cmH₂O)和重复性LRMs的开肺策略是否能预防低潮气量下腹腔镜结直肠癌切除术高危患者术后并发症的发生。

试验设计

一项前瞻性、评估者盲法、随机对照试验。

范围设置

于2017年1月至2018年10月在单中心的大学附属医院进行。

受试人群

纳入280例有肺部并发症风险的患者，在全麻和低潮气量(6~8ml kg^-¹理想体重)通气下行腹腔镜结直肠癌切除术。

干预因素

将患者随机分为两组(1：1)，PEEP为6~8cmH₂O，LRMs每30min重复一次的OLS组和不加LRMs，PEEP为零的非OLS组。

主要观察指标测定

主要观察指标是术后7天内发生的肺及肺外的主要并发症。次要观察指标包括术中潜在的有害低血压和血管升压药的需求。

结果

每组共130名患者被纳入初步结果分析。有24例(18.5%)和43例(33.1%)发生了主要结局事件[相对危险度为0.46；95%可信区间为0.26~0.82；P=0.009]。有更多的患者出现潜在的危害性低血压(OLS组vs非OLS，15%vs 4.3%；P=0.004)，并且需要血管升压药(25% vs 8.6%；P<0.001)。

结论

在低潮气量通气下接受腹腔镜结直肠癌切除术的高危患者中，PEEP为6-8cmH₂O并重复LRMs的肺开放策略与使用零PEEP且不使用LRMs的策略相比，减少了术后并发症。值得注意的是，在血流动力学不稳定的患者中应谨慎使用LRMs。

原始文献来源

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.

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.