不同通气策略对开腹手术大鼠的驱动压、机械功率和生物标志物的影响。

Impact of Different Ventilation Strategies on Driving Pressure, Mechanical Power, and Biological Markers During Open Abdominal Surgery in Rats.

机构信息

From the *Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil; †Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany; ‡Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil; §Laboratory of Cellular and Molecular Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil; ‖Department of Intensive Care Medicine and the Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Centre at the University of Amsterdam, Amsterdam, the Netherlands; and ¶Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy.

出版信息

Anesth Analg. 2017 Oct;125(4):1364-1374. doi: 10.1213/ANE.0000000000002348.

DOI:10.1213/ANE.0000000000002348

PMID:28759484

Abstract

BACKGROUND

Intraoperative mechanical ventilation may yield lung injury. To date, there is no consensus regarding the best ventilator strategy for abdominal surgery. We aimed to investigate the impact of the mechanical ventilation strategies used in 2 recent trials (Intraoperative Protective Ventilation [IMPROVE] trial and Protective Ventilation using High versus Low PEEP [PROVHILO] trial) on driving pressure (ΔPRS), mechanical power, and lung damage in a model of open abdominal surgery.

METHODS

Thirty-five Wistar rats were used, of which 28 were anesthetized, and a laparotomy was performed with standardized bowel manipulation. Postoperatively, animals (n = 7/group) were randomly assigned to 4 hours of ventilation with: (1) tidal volume (VT) = 7 mL/kg and positive end-expiratory pressure (PEEP) = 1 cm H2O without recruitment maneuvers (RMs) (low VT/low PEEP/RM-), mimicking the low-VT/low-PEEP strategy of PROVHILO; (2) VT = 7 mL/kg and PEEP = 3 cm H2O with RMs before laparotomy and hourly thereafter (low VT/moderate PEEP/4 RM+), mimicking the protective ventilation strategy of IMPROVE; (3) VT = 7 mL/kg and PEEP = 6 cm H2O with RMs only before laparotomy (low VT/high PEEP/1 RM+), mimicking the strategy used after intubation and before extubation in PROVHILO; or (4) VT = 14 mL/kg and PEEP = 1 cm H2O without RMs (high VT/low PEEP/RM-), mimicking conventional ventilation used in IMPROVE. Seven rats were not tracheotomized, operated, or mechanically ventilated, and constituted the healthy nonoperated and nonventilated controls.

RESULTS

Low VT/moderate PEEP/4 RM+ and low VT/high PEEP/1 RM+, compared to low VT/low PEEP/RM- and high VT/low PEEP/RM-, resulted in lower ΔPRS (7.1 ± 0.8 and 10.2 ± 2.1 cm H2O vs 13.9 ± 0.9 and 16.9 ± 0.8 cm H2O, respectively; P< .001) and less mechanical power (63 ± 7 and 79 ± 20 J/min vs 110 ± 10 and 120 ± 20 J/min, respectively; P = .007). Low VT/high PEEP/1 RM+ was associated with less alveolar collapse than low VT/low PEEP/RM- (P = .03). E-cadherin expression was higher in low VT/moderate PEEP/4 RM+ than in low VT/low PEEP/RM- (P = .013) or high VT/low PEEP/RM- (P = .014). The extent of alveolar collapse, E-cadherin expression, and tumor necrosis factor-alpha correlated with ΔPRS (r = 0.54 [P = .02], r = -0.48 [P = .05], and r = 0.59 [P = .09], respectively) and mechanical power (r = 0.57 [P = .02], r = -0.54 [P = .02], and r = 0.48 [P = .04], respectively).

CONCLUSIONS

In this model of open abdominal surgery based on the mechanical ventilation strategies used in IMPROVE and PROVHILO trials, lower mechanical power and its surrogate ΔPRS were associated with reduced lung damage.

摘要

背景

术中机械通气可能导致肺损伤。迄今为止，对于腹部手术最佳通气策略尚无共识。我们旨在研究最近两项试验（术中保护性通气[IMPROVE]试验和保护性通气使用高与低呼气末正压[PROVHILO]试验）中使用的机械通气策略对开腹手术模型中驱动压（ΔPRS）、机械功率和肺损伤的影响。

方法

使用 35 只 Wistar 大鼠，其中 28 只麻醉并进行标准的肠操作开腹。术后，动物（每组 7 只）随机接受 4 小时的通气：（1）潮气量（VT）= 7 mL/kg，呼气末正压（PEEP）= 1 cm H2O，无复张手法（RMs）（低 VT/低 PEEP/RM-，模拟 PROVHILO 的低-VT/低-PEEP 策略）；（2）VT = 7 mL/kg，PEEP = 3 cm H2O，开腹前和此后每小时进行 RMs（低 VT/中 PEEP/4 RM+，模拟 IMPROVE 的保护性通气策略）；（3）VT = 7 mL/kg，PEEP = 6 cm H2O，仅在开腹前进行 RMs（低 VT/高 PEEP/1 RM+，模拟 PROVHILO 中气管插管和拔管后使用的策略）；或（4）VT = 14 mL/kg，PEEP = 1 cm H2O，无 RMs（高 VT/低 PEEP/RM-，模拟 IMPROVE 中常规通气）。7 只大鼠未进行气管切开、手术或机械通气，构成健康非手术和非通气对照组。

结果

与低 VT/低 PEEP/RM-和高 VT/低 PEEP/RM-相比，低 VT/中 PEEP/4 RM+和低 VT/高 PEEP/1 RM+导致较低的 ΔPRS（分别为 7.1 ± 0.8 和 10.2 ± 2.1 cm H2O 与 13.9 ± 0.9 和 16.9 ± 0.8 cm H2O；P<.001）和较低的机械功率（分别为 63 ± 7 和 79 ± 20 J/min 与 110 ± 10 和 120 ± 20 J/min；P =.007）。与低 VT/低 PEEP/RM-相比，低 VT/高 PEEP/1 RM+与较少的肺泡塌陷相关（P =.03）。与低 VT/低 PEEP/RM-或高 VT/低 PEEP/RM-相比，低 VT/中 PEEP/4 RM+中 E-钙黏蛋白表达更高（P =.013）。肺泡塌陷程度、E-钙黏蛋白表达和肿瘤坏死因子-α与 ΔPRS（r = 0.54 [P =.02]、r = -0.48 [P =.05]和 r = 0.59 [P =.09]）和机械功率（r = 0.57 [P =.02]、r = -0.54 [P =.02]和 r = 0.48 [P =.04]）相关。