机器人辅助根治性前列腺切除术期间肺保护性通气的血液动力学、肾脏和激素效应：一项随机对照试验的次要结局分析。
Hemodynamic, renal and hormonal effects of lung protective ventilation during robot-assisted radical prostatectomy, analysis of secondary outcomes from a randomized controlled trial.
机构信息
University Clinic in Nephrology and Hypertension, Gødstrup Hospital and Aarhus University, 7400 Herning, Denmark.
Department of Anesthesiology, Gødstrup Hospital, 7400 Herning, Denmark.
出版信息
BMC Anesthesiol. 2021 Aug 5;21(1):200. doi: 10.1186/s12871-021-01401-x.
BACKGROUND
Lung protective ventilation with low tidal volume (TV) and increased positive end-expiratory pressure (PEEP) can have unfavorable effects on the cardiovascular system. We aimed to investigate whether lung protective ventilation has adverse impact on hemodynamic, renal and hormonal variables.
METHODS
In this randomized, single-blinded, placebo-controlled study, 24 patients scheduled for robot-assisted radical prostatectomy were included. Patients were equally randomized to receive either ventilation with a TV of 6 ml/IBW and PEEP of 10 cm HO (LTV-h.PEEP) or ventilation with a TV of 10 ml/IBW and PEEP of 4 cm HO (HTV-l.PEEP). Before, during and after surgery, hemodynamic variables were measured, and blood and urine samples were collected. Blood samples were analyzed for plasma concentrations of electrolytes and vasoactive hormones. Urine samples were analyzed for excretions of electrolytes and markers of nephrotoxicity.
RESULTS
Comparable variables were found among the two groups, except for significantly higher postoperative levels of plasma brain natriuretic peptide (p = 0.033), albumin excretion (p = 0.012) and excretion of epithelial sodium channel (p = 0.045) in the LTV-h.PEEP ventilation group compared to the HTV-l.PEEP ventilation group. In the combined cohort, we found a significant decrease in creatinine clearance (112.0 [83.4;126.7] ml/min at baseline vs. 45.1 [25.4;84.3] ml/min during surgery) and a significant increase in plasma concentrations of renin, angiotensin II, and aldosterone.
CONCLUSION
Lung protective ventilation was associated with minor adverse hemodynamic and renal effects postoperatively. All patients showed a substantial but transient reduction in renal function accompanied by activation of the renin-angiotensin-aldosterone system.
TRIAL REGISTRATION
ClinicalTrials, NCT02551341 . Registered 13 September 2015.
背景
采用小潮气量（TV）和增加呼气末正压（PEEP）的肺保护性通气可能对心血管系统产生不利影响。我们旨在研究肺保护性通气是否对血流动力学、肾脏和激素变量有不良影响。
方法
在这项随机、单盲、安慰剂对照研究中，纳入了 24 名计划行机器人辅助根治性前列腺切除术的患者。患者被随机等分为接受潮气量为 6ml/IBW 和 PEEP 为 10cmH2O（LTV-h.PEEP）的通气或潮气量为 10ml/IBW 和 PEEP 为 4cmH2O（HTV-l.PEEP）的通气。在手术前、手术中和手术后，测量血流动力学变量，并采集血液和尿液样本。分析血液样本中电解质和血管活性激素的血浆浓度。分析尿液样本中电解质和肾毒性标志物的排泄量。
结果
两组间除了 LTV-h.PEEP 通气组的术后血浆脑利钠肽（p=0.033）、白蛋白排泄（p=0.012）和上皮钠通道排泄（p=0.045）水平显著升高外，其他变量均无显著差异。在联合队列中，我们发现肌酐清除率（基础值为 112.0[83.4；126.7]ml/min，手术期间为 45.1[25.4；84.3]ml/min）显著下降，并且血浆肾素、血管紧张素 II 和醛固酮浓度显著升高。
结论
肺保护性通气术后与轻微的不良血流动力学和肾脏效应相关。所有患者的肾功能均出现明显但短暂的下降，同时肾素-血管紧张素-醛固酮系统被激活。
试验注册
ClinicalTrials，NCT02551341。于 2015 年 9 月 13 日注册。
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