术中肺开放通气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

术中肺开放通气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：陈锐 审校：曹莹

背景 

术中机械通气中  联合应用  呼气末正压(PEEP)和肺复张(LRM)(称为  肺开放  策略，OLS)的作用尚不清楚。 

目的 旨在于  确定中等PEEP(6-8cmH  2  O)和重复  性  LRM  s  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。 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(OLS组)和不加LRMs的PEEP为零(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%)发生了主要结果事件[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)，并且需要血管升压剂(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LRM  s  的  肺开放  策略与使用零PEEP  且  不使用LRM  s  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LRM  s  。 

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.

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.