围手术期输血、潮气量、气道压力与术后急性呼吸窘迫综合征之间的相互作用：一项个体患者数据荟萃分析。
Interaction between peri-operative blood transfusion, tidal volume, airway pressure and postoperative ARDS: an individual patient data meta-analysis.
作者信息
Serpa Neto Ary, Juffermans Nicole P, Hemmes Sabrine N T, Barbas Carmen S V, Beiderlinden Martin, Biehl Michelle, Fernandez-Bustamante Ana, Futier Emmanuel, Gajic Ognjen, Jaber Samir, Kozian Alf, Licker Marc, Lin Wen-Qian, Memtsoudis Stavros G, Miranda Dinis Reis, Moine Pierre, Paparella Domenico, Ranieri Marco, Scavonetto Federica, Schilling Thomas, Selmo Gabriele, Severgnini Paolo, Sprung Juraj, Sundar Sugantha, Talmor Daniel, Treschan Tanja, Unzueta Carmen, Weingarten Toby N, Wolthuis Esther K, Wrigge Hermann, de Abreu Marcelo Gama, Pelosi Paolo, Schultz Marcus J
机构信息
Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, São Paulo, Brazil.
出版信息
Ann Transl Med. 2018 Jan;6(2):23. doi: 10.21037/atm.2018.01.16.
BACKGROUND
Transfusion of blood products and mechanical ventilation with injurious settings are considered risk factors for postoperative lung injury in surgical Patients.
METHODS
A systematic review and individual patient data meta-analysis was done to determine the independent effects of peri-operative transfusion of blood products, intra-operative tidal volume and airway pressure in adult patients undergoing mechanical ventilation for general surgery, as well as their interactions on the occurrence of postoperative acute respiratory distress syndrome (ARDS). Observational studies and randomized trials were identified by a systematic search of MEDLINE, CINAHL, Web of Science, and CENTRAL and screened for inclusion into a meta-analysis. Individual patient data were obtained from the corresponding authors. Patients were stratified according to whether they received transfusion in the peri-operative period [red blood cell concentrates (RBC) and/or fresh frozen plasma (FFP)], tidal volume size [≤7 mL/kg predicted body weight (PBW), 7-10 and >10 mL/kg PBW] and airway pressure level used during surgery (≤15, 15-20 and >20 cmHO). The primary outcome was development of postoperative ARDS.
RESULTS
Seventeen investigations were included (3,659 patients). Postoperative ARDS occurred in 40 (7.2%) patients who received at least one blood product compared to 40 patients (2.5%) who did not [adjusted hazard ratio (HR), 2.32; 95% confidence interval (CI), 1.25-4.33; P=0.008]. Incidence of postoperative ARDS was highest in patients ventilated with tidal volumes of >10 mL/kg PBW and having airway pressures of >20 cmHO receiving both RBC and FFP, and lowest in patients ventilated with tidal volume of ≤7 mL/kg PBW and having airway pressures of ≤15 cmHO with no transfusion. There was a significant interaction between transfusion and airway pressure level (P=0.002) on the risk of postoperative ARDS.
CONCLUSIONS
Peri-operative transfusion of blood products is associated with an increased risk of postoperative ARDS, which seems more dependent on airway pressure than tidal volume size.
背景
输血制品以及采用有害参数进行机械通气被认为是外科手术患者术后肺损伤的危险因素。
方法
进行了一项系统评价和个体患者数据荟萃分析，以确定围手术期输血制品、术中潮气量和气道压力对接受普通外科机械通气的成年患者的独立影响，以及它们对术后急性呼吸窘迫综合征（ARDS）发生的相互作用。通过系统检索MEDLINE、CINAHL、科学引文索引和考克兰系统评价数据库来识别观察性研究和随机试验，并筛选纳入荟萃分析。个体患者数据从相应作者处获得。患者根据围手术期是否接受输血[红细胞浓缩液（RBC）和/或新鲜冰冻血浆（FFP）]、潮气量大小[≤7 mL/千克预测体重（PBW）、7 - 10和>10 mL/千克PBW]以及手术期间使用的气道压力水平（≤15、15 - 20和>20 cmH₂O）进行分层。主要结局是术后ARDS的发生。
结果
纳入了17项研究（3659例患者）。接受至少一种血液制品的40例（7.2%）患者发生了术后ARDS，而未接受输血的40例患者（2.5%）发生了术后ARDS[校正风险比（HR），2.32；95%置信区间（CI），1.25 - 4.33；P = 0.008]。术后ARDS发生率在潮气量>10 mL/千克PBW且气道压力>20 cmH₂O并接受RBC和FFP输血的患者中最高，在潮气量≤7 mL/千克PBW且气道压力≤15 cmH₂O且未输血的患者中最低。输血与气道压力水平之间在术后ARDS风险上存在显著相互作用（P = 0.002）。
结论
围手术期输血制品与术后ARDS风险增加相关，这似乎更多地取决于气道压力而非潮气量大小。
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