Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.
Anesthesia and Intensive Care, University Hospital of Padua, Via Giustiniani 2, Padova, Italy.
BMC Anesthesiol. 2021 Jun 30;21(1):184. doi: 10.1186/s12871-021-01404-8.
Post-operative pulmonary complications (PPC) can develop in up to 13% of patients undergoing neurosurgical procedures and may adversely affect clinical outcome. The use of intraoperative lung protective ventilation (LPV) strategies, usually including the use of a low V, low PEEP and low plateau pressure, seem to reduce the risk of PPC and are strongly recommended in almost all surgical procedures. Nonetheless, feasibility of LPV strategies in neurosurgical patients are still debated because the use of low Vt during LPV might result in hypercapnia with detrimental effects on cerebrovascular physiology. Aim of our study was to determine whether LPV strategies would be feasible compared with a control group in adult patients undergoing cranial or spinal surgery.
This single-centre, pilot randomized clinical trial was conducted at the University Hospital "Maggiore della Carità" (Novara, Italy). Adult patients undergoing major cerebral or spinal neurosurgical interventions with risk index for pulmonary post-operative complications > 2 and not expected to need post-operative intensive care unit (ICU) admission were considered eligible. Patients were randomly assigned to either LPV (Vt = 6 ml/kg of ideal body weight (IBW), respiratory rate initially set at 16 breaths/min, PEEP at 5 cmH2O and application of a recruitment manoeuvre (RM) immediately after intubation and at every disconnection from the ventilator) or control treatment (Vt = 10 ml/kg of IBW, respiratory rate initially set at 6-8 breaths/min, no PEEP and no RM). Primary outcomes of the study were intraoperative adverse events, the level of cerebral tension at dura opening and the intraoperative control of PaCO Secondary outcomes were the rate of pulmonary and extrapulmonary complications, the number of unplanned ICU admissions, ICU and hospital lengths of stay and mortality.
A total of 60 patients, 30 for each group, were randomized. During brain surgery, the number of episodes of intraoperative hypercapnia and grade of cerebral tension were similar between patients randomized to receive control or LPV strategies. No difference in the rate of intraoperative adverse events was found between groups. The rate of postoperative pulmonary and extrapulmonary complications and major clinical outcomes were similar between groups.
LPV strategies in patients undergoing major neurosurgical intervention are feasible. Larger clinical trials are needed to assess their role in postoperative clinical outcome improvements.
registered on the Australian New Zealand Clinical Trial Registry ( www.anzctr.org.au ), registration number ACTRN12615000707561.
术后肺部并发症（PPC）可发生于多达 13%的神经外科手术患者，可能对临床结局产生不利影响。术中肺保护性通气（LPV）策略的应用，通常包括使用低潮气量、低呼气末正压和低平台压，似乎可以降低 PPC 的风险，几乎所有手术都强烈推荐使用。尽管如此，LPV 策略在神经外科患者中的可行性仍存在争议，因为 LPV 期间使用低潮气量可能导致高碳酸血症，对脑血管生理学产生不利影响。我们的研究目的是确定 LPV 策略与对照组相比，在接受颅或脊柱手术的成年患者中是否可行。
这是一项单中心、前瞻性随机临床试验，在意大利马焦雷大学医院（诺瓦拉）进行。具有术后肺部并发症风险指数>2 的高危患者，预计不需要术后重症监护病房（ICU）入院，接受主要脑或脊柱神经外科干预的成年患者被认为符合条件。患者被随机分配到 LPV 组（Vt=6ml/kg 理想体重（IBW），初始呼吸频率设置为 16 次/分钟，呼气末正压 5cmH2O，并在插管后和每次与呼吸机断开连接时立即进行复张手法（RM））或对照组（Vt=10ml/kg IBW，初始呼吸频率设置为 6-8 次/分钟，无呼气末正压和 RM）。该研究的主要结局为术中不良事件、硬脑膜切开时颅内压水平和 PaCO2 的术中控制。次要结局为肺部和肺外并发症发生率、计划外 ICU 入院、ICU 和住院时间及死亡率。
共纳入 60 例患者，每组 30 例。在脑外科手术中，接受对照组或 LPV 策略治疗的患者术中高碳酸血症发作次数和颅内压分级相似。两组间术中不良事件发生率无差异。术后肺部和肺外并发症及主要临床结局发生率两组间相似。
在接受大型神经外科干预的患者中，LPV 策略是可行的。需要更大的临床试验来评估其在改善术后临床结局方面的作用。
在澳大利亚和新西兰临床试验注册中心（ www.anzctr.org.au ）注册，注册号为 ACTRN12615000707561。
