基于电阻抗断层成像的个体化呼气末正压引导在机器人辅助腹腔镜根治性前列腺切除术中的应用：一项前瞻性、随机对照临床试验。

Individualised positive end-expiratory pressure guided by electrical impedance tomography for robot-assisted laparoscopic radical prostatectomy: a prospective, randomised controlled clinical trial.

机构信息

Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Leipzig, Germany; Innovation Centre Computer Assisted Surgery, University of Leipzig, Leipzig, Germany.

Clinical Trial Centre, University of Leipzig, Leipzig, Germany; Integrated Research and Treatment Centre (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.

出版信息

Br J Anaesth. 2020 Sep;125(3):373-382. doi: 10.1016/j.bja.2020.05.041. Epub 2020 Jul 19.

DOI:10.1016/j.bja.2020.05.041

PMID:32665059

Abstract

BACKGROUND

Robot-assisted laparoscopic radical prostatectomy requires general anaesthesia, extreme Trendelenburg positioning and capnoperitoneum. Together these promote impaired pulmonary gas exchange caused by atelectasis and may contribute to postoperative pulmonary complications. In morbidly obese patients, a recruitment manoeuvre (RM) followed by individualised PEEP improves intraoperative oxygenation and end-expiratory lung volume (EELV). We hypothesised that individualised PEEP with initial RM similarly improves intraoperative oxygenation and EELV in non-obese individuals undergoing robot-assisted prostatectomy.

METHODS

Forty males (age, 49-76 yr; BMI <30 kg m) undergoing prostatectomy received volume-controlled ventilation (tidal volume 8 ml kg predicted body weight). Participants were randomised to either (1) RM followed by individualised PEEP (RM/PEEP) optimised using electrical impedance tomography or (2) no RM with 5 cm HO PEEP. The primary outcome was the ratio of arterial oxygen partial pressure to fractional inspired oxygen (Pao/Fo) before the last RM before extubation. Secondary outcomes included regional ventilation distribution and EELV which were measured before, during, and after anaesthesia. The cardiovascular effects of RM/PEEP were also assessed.

RESULTS

In 20 males randomised to RM/PEEP, the median PEEP was 14 cm HO [inter-quartile range, 8-20]. The Pao/Fo was 10.0 kPa higher with RM/PEEP before extubation (95% confidence interval [CI], 2.6-17.3 kPa; P=0.001). RM/PEEP increased end-expiratory lung volume by 1.49 L (95% CI, 1.09-1.89 L; P<0.001). RM/PEEP also improved the regional ventilation of dependent lung regions. Vasopressor and fluid therapy was similar between groups, although 13 patients randomised to RM/PEEP required pharmacological therapy for bradycardia.

CONCLUSION

In non-obese males, an individualised ventilation strategy improved intraoperative oxygenation, which was associated with higher end-expiratory lung volumes during robot-assisted laparoscopic prostatectomy.

CLINICAL TRIAL REGISTRATION

DRKS00004199 (German clinical trials registry).

摘要

背景

机器人辅助腹腔镜前列腺根治术需要全身麻醉、极端的特伦德伦堡体位和二氧化碳气腹。这些因素共同导致了由于肺不张引起的气体交换受损，并可能导致术后肺部并发症。在病态肥胖患者中，募集手法（RM）加个体化呼气末正压通气（PEEP）可改善术中氧合和呼气末肺容积（EELV）。我们假设在接受机器人辅助前列腺切除术的非肥胖个体中，初始 RM 加个体化 PEEP 同样可以改善术中氧合和 EELV。

方法

40 名男性（年龄 49-76 岁；BMI<30kg/m）接受前列腺切除术，接受容量控制通气（潮气量 8ml/kg 预测体重）。参与者随机分为以下两组：（1）RM 加个体化 PEEP（RM/PEEP），采用电阻抗断层成像术优化；或（2）无 RM 加 5cmH2O PEEP。主要结局是拔管前最后一次 RM 前的动脉血氧分压与吸入氧分数（Pao/Fo）比值。次要结局包括麻醉前、麻醉中和麻醉后区域性通气分布和 EELV。还评估了 RM/PEEP 的心血管效应。

结果

在随机分为 RM/PEEP 的 20 名男性中，中位 PEEP 为 14cmH2O[四分位间距，8-20]。RM/PEEP 拔管前的 Pao/Fo 高 10.0kPa（95%置信区间[CI]，2.6-17.3kPa；P=0.001）。RM/PEEP 使呼气末肺容积增加 1.49L（95%CI，1.09-1.89L；P<0.001）。RM/PEEP 还改善了依赖肺区的区域性通气。两组间血管加压药和液体治疗相似，但随机分为 RM/PEEP 的 13 名患者需要药物治疗心动过缓。