大手术中低潮气量通气并不能降低术后肺部并发
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大手术中低潮气量通气并不能降低术后肺部并发
2017-10-15

本期文章:《美国医学会杂志》:Vol 324 No 9

澳大利亚奥斯汀医院Daryl A. Jones团队分析了术中低潮气量与常规潮气量通气相比,对大手术患者术后肺部并发症的影响。2020年9月1日,该研究发表在《美国医学会杂志》上。

在手术期间进行机械通气的患者中,理想潮气量尚不清楚。

为了确定大手术期间低潮气量通气与常规通气相比是否能减少术后肺部并发症,研究组进行了一项单中心、评估者盲、随机临床试验,2015年2月至2019年2月,研究组在澳大利亚墨尔本的一家三级医院招募了1236例年龄超过40岁,接受重大非心胸、非颅外科手术,全身麻醉持续2小时以上的患者。

将其随机分组,其中614例接受6 mL/kg预测体重的潮气量(低潮气量组),592例接受10 mL/kg预测体重的潮气量(常规潮气量组)。所有患者均在5 cm H2O处接受呼气末正压(PEEP)。主要结局为术后7天内合并的肺部并发症,包括肺炎、支气管痉挛、肺不张、肺充血、呼吸衰竭、胸腔积液、气胸或术后有创或无创通气的计划外需求。

最终有1206名(98.9%)参与者完成试验,平均年龄为63.5岁,40.9%为女性,56.4%接受腹部手术。低潮气量组608例患者中有231例(38%)发生主要结局,而常规潮气量组590例患者中有232例(39%),差异无统计学意义。任何次要结局均无显著差异。

总之,对于接受大手术的成年患者,两组间应用PEEP无差异时,术中低潮气量与常规潮气量通气相比,在术后7天内并未显著降低肺部并发症的风险。

附:英文原文

Title: Effect of Intraoperative Low Tidal Volume vs Conventional Tidal Volume on Postoperative Pulmonary Complications in Patients Undergoing Major Surgery: A Randomized Clinical Trial

Author: Dharshi Karalapillai, Laurence Weinberg, Philip Peyton, Louise Ellard, Raymond Hu, Brett Pearce, Chong O. Tan, David Story, Mark O’Donnell, Patrick Hamilton, Chad Oughton, Jonathan Galtieri, Anthony Wilson, Ary Serpa Neto, Glenn Eastwood, Rinaldo Bellomo, Daryl A. Jones

Issue&Volume: 2020/09/01

Abstract: Importance  In patients who undergo mechanical ventilation during surgery, the ideal tidal volume is unclear.

Objective  To determine whether low-tidal-volume ventilation compared with conventional ventilation during major surgery decreases postoperative pulmonary complications.

Design, Setting, and Participants  Single-center, assessor-blinded, randomized clinical trial of 1236 patients older than 40 years undergoing major noncardiothoracic, nonintracranial surgery under general anesthesia lasting more than 2 hours in a tertiary hospital in Melbourne, Australia, from February 2015 to February 2019. The last date of follow-up was February 17, 2019.

Interventions  Patients were randomized to receive a tidal volume of 6 mL/kg predicted body weight (n=614; low tidal volume group) or a tidal volume of 10 mL/kg predicted body weight (n=592; conventional tidal volume group). All patients received positive end-expiratory pressure (PEEP) at 5 cm H2O.

Main Outcomes and Measures  The primary outcome was a composite of postoperative pulmonary complications within the first 7 postoperative days, including pneumonia, bronchospasm, atelectasis, pulmonary congestion, respiratory failure, pleural effusion, pneumothorax, or unplanned requirement for postoperative invasive or noninvasive ventilation. Secondary outcomes were postoperative pulmonary complications including development of pulmonary embolism, acute respiratory distress syndrome, systemic inflammatory response syndrome, sepsis, acute kidney injury, wound infection (superficial and deep), rate of intraoperative need for vasopressor, incidence of unplanned intensive care unit admission, rate of need for rapid response team call, intensive care unit length of stay, hospital length of stay, and in-hospital mortality.

Results  Among 1236 patients who were randomized, 1206 (98.9%) completed the trial (mean age, 63.5 years; 494 [40.9%] women; 681 [56.4%] undergoing abdominal surgery). The primary outcome occurred in 231 of 608 patients (38%) in the low tidal volume group compared with 232 of 590 patients (39%) in the conventional tidal volume group (difference, 1.3% [95% CI, 6.8% to 4.2%]; risk ratio, 0.97 [95% CI, 0.84-1.11]; P=.64). There were no significant differences in any of the secondary outcomes.

Conclusions and Relevance  Among adult patients undergoing major surgery, intraoperative ventilation with low tidal volume compared with conventional tidal volume, with PEEP applied equally between groups, did not significantly reduce pulmonary complications within the first 7 postoperative days.

DOI: 10.1001/jama.2020.12866

Source: https://jamanetwork.com/journals/jama/article-abstract/2770010

期刊信息

JAMA-Journal of The American Medical Association:《美国医学会杂志》,创刊于1883年。隶属于美国医学协会,最新IF:51.273
官方网址:https://jamanetwork.com/
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