经鼻持续气道正压通气在小儿腹腔镜手术后改善氧合作用的随机对照试验

Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial.

机构信息

Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt.

Pediatric Surgery Department, Faculty of Medicine, Assiut University, Assiut, Egypt.

出版信息

Acta Anaesthesiol Scand. 2019 May;63(5):620-629. doi: 10.1111/aas.13324. Epub 2019 Feb 14.

DOI:10.1111/aas.13324

PMID:30761530

Abstract

BACKGROUND

Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO ] after pediatric laparoscopic surgery.

METHODS

Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events.

RESULTS

At 1 hour postoperatively, mean [(A-a) DO ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO ] and PaO were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups.

CONCLUSIONS

An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.

摘要

背景

在使用高吸入氧和气道吸引的情况下，术中募集 maneuvers (RMs) 在恢复过程中会失去对氧合和肺顺应性的影响。我们研究了小儿腹腔镜手术后拔管后应用无创 CPAP 面罩对肺泡动脉氧差 [(A-a) DO ] 的影响。

方法

将 60 名患者（1-6 岁）随机分为三组，每组 20 名患者，分别接受零呼气末正压 (ZEEP) 组、仅递减 PEEP 滴定的 RM 组或拔管后 5 分钟内应用 CPAP 的 RM-CPAP 组。主要结局是术后 1 小时 [(A-a) DO ]。次要结局是呼吸力学、动脉血气分析、血液动力学和不良事件。

结果

术后 1 小时，RM-CPAP 组的平均 [(A-a) DO ]（mmHg）（41.5±13.2，[95%CI 37.6-45.8]）低于 ZEEP 组（80.2±13.7，[72.6-87.5]，P<0.0001）和 RM 组（59.2±14.6，[54.8-62.6]，P<0.001）。术后 1 小时 RM-CPAP 组的平均 PaO（mmHg）（156.2±18.3，[95%CI 147.6-164.7]）高于 ZEEP 组（95.9±15.9，[88.5-103.3]，P<0.0001）和 RM 组（129.1±15.9，[121.6-136.5]，P<0.0001）。术后 12 小时，RM-CPAP 组的平均 [(A-a) DO ] 和 PaO 分别为（9.6±2.1，[8.4-10.8]）和（91.9±9.4，[87.5-96.3]），与 ZEEP 组（25.8±5.5，[23.6-27.6]）和（69.9±5.5，[67.4-72.5]）和 RM 组（34.3±13.2，[28.4-40.2]，P<0.0001）和（74.03±9.8，[69.5-78.6]，P<0.0001）。各组围手术期不良反应无显著差异。