冠状动脉搭桥手术期间及术后适度高氧与接近生理氧目标的比较：一项随机对照试验
Moderate hyperoxic versus near-physiological oxygen targets during and after coronary artery bypass surgery: a randomised controlled trial.
作者信息
Smit Bob, Smulders Yvo M, de Waard Monique C, Boer Christa, Vonk Alexander B A, Veerhoek Dennis, Kamminga Suzanne, de Grooth Harm-Jan S, García-Vallejo Juan J, Musters Rene J P, Girbes Armand R J, Oudemans-van Straaten Heleen M, Spoelstra-de Man Angelique M E
机构信息
Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
出版信息
Crit Care. 2016 Mar 10;20:55. doi: 10.1186/s13054-016-1240-6.
BACKGROUND
The safety of perioperative hyperoxia is currently unclear. Previous studies in patients undergoing coronary artery bypass surgery suggest reduced myocardial damage when avoiding extreme perioperative hyperoxia (>400 mmHg). In this study we investigated whether an oxygenation strategy from moderate hyperoxia to a near-physiological oxygen tension reduces myocardial damage and improves haemodynamics, organ dysfunction and oxidative stress.
METHODS
This was a single-blind, single-centre, open-label, randomised controlled trial in patients undergoing elective coronary artery bypass surgery. Fifty patients were randomised to a partial pressure of oxygen in arterial blood (PaO2) target of 200-220 mmHg during cardiopulmonary bypass and 130-150 mmHg during intensive care unit (ICU) admission (control group) versus lower targets of 130-150 mmHg during cardiopulmonary bypass and 80-100 mmHg at the ICU (conservative group). Primary outcome was myocardial injury (CK-MB and Troponin-T) at ICU admission and 2, 6 and 12 hours thereafter.
RESULTS
Weighted PaO2 during cardiopulmonary bypass was 220 mmHg (interquartile range (IQR) 211-233) vs. 157 (151-162) in the control and conservative group, respectively (P < 0.0001). During ICU admission, weighted PaO2 was 107 mmHg (86-141) vs. 90 (84-98) (P = 0.03), respectively. Area under the curve of CK-MB was median 23.5 μg/L/h (IQR 18.4-28.1) vs. 21.5 (15.8-26.6) (P = 0.35) and 0.30 μg/L/h (0.25-0.44) vs. 0.39 (0.24-0.43) (P = 0.81) for Troponin-T. Cardiac index, systemic vascular resistance index, creatinine, lactate and F2-isoprostane levels were not different between groups.
CONCLUSIONS
Compared to moderate hyperoxia, a near-physiological oxygen strategy does not reduce myocardial damage in patients undergoing coronary artery bypass surgery. Conservative oxygen administration was not associated with increased lactate levels or hypoxic events.
TRIAL REGISTRATION
Netherlands Trial Registry NTR4375, registered on 30 January 2014.
背景
围手术期高氧的安全性目前尚不清楚。先前对冠状动脉搭桥手术患者的研究表明，避免围手术期极端高氧（>400 mmHg）时心肌损伤会减轻。在本研究中，我们调查了从中度高氧到接近生理氧张力的氧合策略是否能减少心肌损伤并改善血流动力学、器官功能障碍和氧化应激。
方法
这是一项针对择期冠状动脉搭桥手术患者的单盲、单中心、开放标签随机对照试验。50例患者被随机分为两组，一组在体外循环期间动脉血氧分压（PaO2）目标为200 - 220 mmHg，在重症监护病房（ICU）入院期间为130 - 150 mmHg（对照组）；另一组在体外循环期间目标较低，为130 - 150 mmHg，在ICU为80 - 100 mmHg（保守组）。主要结局指标是ICU入院时以及此后2、6和12小时的心肌损伤（肌酸激酶同工酶MB和肌钙蛋白T）。
结果
体外循环期间加权PaO2在对照组为220 mmHg（四分位间距（IQR）211 - 233），在保守组为157（151 - 162）（P < 0.0001）。在ICU入院期间，加权PaO2分别为107 mmHg（86 - 141）和90（84 - 98）（P = 0.03）。肌酸激酶同工酶MB曲线下面积中位数在对照组为23.5 μg/L/h（IQR 18.4 - 28.1），在保守组为21.5（15.8 - 26.6）（P = 0.35）；肌钙蛋白T曲线下面积中位数在对照组为0.30 μg/L/h（0.25 - 0.44），在保守组为0.39（0.24 - 0.43）（P = 0.81）。两组间心脏指数、全身血管阻力指数、肌酐、乳酸和F2 - 异前列腺素水平无差异。
结论
与中度高氧相比，接近生理氧策略在冠状动脉搭桥手术患者中并未减少心肌损伤。保守给氧与乳酸水平升高或低氧事件无关。
试验注册
荷兰试验注册中心NTR4375，于2014年1月30日注册。
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