心脏手术后的术中机械通气和术后肺部并发症。
Intraoperative Mechanical Ventilation and Postoperative Pulmonary Complications after Cardiac Surgery.
机构信息
From the Departments of Anesthesiology (M.R.M., N.M.D., N.J.D., M.T.V., M.D.M., D.A.C., A.M.J., S.K., M.C.E.) Cardiac Surgery (D.S.L., J.W.H., R.J.S.), University of Michigan Medical School Department of Biostatistics, University of Michigan (M.Z.), Ann Arbor, Michigan Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia (R.S.B.).
出版信息
Anesthesiology. 2019 Nov;131(5):1046-1062. doi: 10.1097/ALN.0000000000002909.
BACKGROUND
Compared with historic ventilation strategies, modern lung-protective ventilation includes lower tidal volumes (VT), lower driving pressures, and application of positive end-expiratory pressure (PEEP). The contributions of each component to an overall intraoperative protective ventilation strategy aimed at reducing postoperative pulmonary complications have neither been adequately resolved, nor comprehensively evaluated within an adult cardiac surgical population. The authors hypothesized that a bundled intraoperative protective ventilation strategy was independently associated with decreased odds of pulmonary complications after cardiac surgery.
METHODS
In this observational cohort study, the authors reviewed nonemergent cardiac surgical procedures using cardiopulmonary bypass at a tertiary care academic medical center from 2006 to 2017. The authors tested associations between bundled or component intraoperative protective ventilation strategies (VT below 8 ml/kg ideal body weight, modified driving pressure [peak inspiratory pressure - PEEP] below 16 cm H2O, and PEEP greater than or equal to 5 cm H2O) and postoperative outcomes, adjusting for previously identified risk factors. The primary outcome was a composite pulmonary complication; secondary outcomes included individual pulmonary complications, postoperative mortality, as well as durations of mechanical ventilation, intensive care unit stay, and hospital stay.
RESULTS
Among 4,694 cases reviewed, 513 (10.9%) experienced pulmonary complications. After adjustment, an intraoperative lung-protective ventilation bundle was associated with decreased pulmonary complications (adjusted odds ratio, 0.56; 95% CI, 0.42-0.75). Via a sensitivity analysis, modified driving pressure below 16 cm H2O was independently associated with decreased pulmonary complications (adjusted odds ratio, 0.51; 95% CI, 0.39-0.66), but VT below 8 ml/kg and PEEP greater than or equal to 5 cm H2O were not.
CONCLUSIONS
The authors identified an intraoperative lung-protective ventilation bundle as independently associated with pulmonary complications after cardiac surgery. The findings offer insight into components of protective ventilation associated with adverse outcomes and may serve as targets for future prospective interventional studies investigating the impact of specific protective ventilation strategies on postoperative outcomes after cardiac surgery.
背景
与历史通气策略相比，现代肺保护性通气包括更低的潮气量（VT）、更低的驱动压和应用呼气末正压（PEEP）。每个组件对旨在减少术后肺部并发症的整体术中保护性通气策略的贡献既没有得到充分解决，也没有在成人心脏手术人群中得到全面评估。作者假设，捆绑式术中保护性通气策略与心脏手术后肺部并发症的几率降低独立相关。
方法
在这项观察性队列研究中，作者回顾了 2006 年至 2017 年在一家三级保健学术医疗中心使用体外循环的非紧急心脏手术。作者测试了捆绑式或组件术中保护性通气策略（VT 低于 8ml/kg 理想体重、改良驱动压[吸气峰压-PEEP]低于 16cmH2O 和 PEEP 大于或等于 5cmH2O）与术后结果之间的关联，并对先前确定的风险因素进行了调整。主要结果是复合肺部并发症；次要结果包括单个肺部并发症、术后死亡率以及机械通气、重症监护病房停留和住院时间。
结果
在审查的 4694 例病例中，513 例（10.9%）发生肺部并发症。调整后，术中肺保护性通气捆绑与肺部并发症减少相关（调整后的优势比，0.56；95%CI，0.42-0.75）。通过敏感性分析，改良驱动压低于 16cmH2O 与肺部并发症减少独立相关（调整后的优势比，0.51；95%CI，0.39-0.66），但 VT 低于 8ml/kg 和 PEEP 大于或等于 5cmH2O 则不然。
结论
作者发现术中肺保护性通气捆绑与心脏手术后肺部并发症独立相关。这些发现为保护性通气的相关组件提供了深入了解，这些组件与不良结果相关，并且可能成为未来前瞻性干预性研究的目标，这些研究调查心脏手术后特定保护性通气策略对术后结果的影响。
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