个体化呼气末正压在腹部手术中的应用：系统评价和荟萃分析。

Individualised positive end-expiratory pressure in abdominal surgery: a systematic review and meta-analysis.

机构信息

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Universidad Del Valle, Hospital Universitario Del Valle, Cali, Colombia.

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.

出版信息

Br J Anaesth. 2022 Nov;129(5):815-825. doi: 10.1016/j.bja.2022.07.009. Epub 2022 Aug 26.

DOI:10.1016/j.bja.2022.07.009

PMID:36031417

Abstract

BACKGROUND

Individualised positive end-expiratory pressure (PEEP) may optimise pulmonary compliance, thereby potentially mitigating lung injury. This meta-analysis aimed to determine the impact of individualised PEEP vs fixed PEEP during abdominal surgery on postoperative pulmonary outcomes.

METHODS

Medical databases (PubMed, Embase, Web of Science, ScienceDirect, Google Scholar, and the China National Knowledge Infrastructure) were searched for RCTs comparing fixed vs individualised PEEP. The composite primary outcome of pulmonary complications comprised hypoxaemia, atelectasis, pneumonia, and acute respiratory distress syndrome. Secondary outcomes included oxygenation (PO/FiO) and systemic inflammatory markers (interleukin-6 [IL-6] and club cell protein-16 [CC16]). We calculated risk ratios (RRs) and mean differences (MDs) with 95% confidence interval (CI) using DerSimonian and Laird random effects models. Cochrane risk-of-bias tool was applied.

RESULTS

Ten RCTs (n=1117 patients) met the criteria for inclusion, with six reporting the primary endpoint. Individualised PEEP reduced the incidence of overall pulmonary complications (141/412 [34.2%]) compared with 183/415 (44.1%) receiving fixed PEEP (RR 0.69 [95% CI: 0.51-0.93]; P=0.016; I=43%). Risk-of-bias analysis did not alter these findings. Individualised PEEP reduced postoperative hypoxaemia (74/392 [18.9%]) compared with 110/395 (27.8%) participants receiving fixed PEEP (RR 0.68 [0.52-0.88]; P=0.003; I=0%) but not postoperative atelectasis (RR 0.93 [0.81-1.07]; P=0.297; I=0%). Individualised PEEP resulted in higher PO/FiO (MD 20.8 mm Hg [4.6-36.9]; P=0.012; I=80%) and reduced systemic inflammation (lower plasma IL-6 [MD -6.8 pg ml; -11.9 to -1.7]; P=0.009; I=6%; and CC16 levels [MD -6.2 ng ml; -8.8 to -3.5]; P<0.001; I=0%) at the end of surgery.

CONCLUSIONS

Individualised PEEP may reduce pulmonary complications, improve oxygenation, and reduce systemic inflammation after abdominal surgery.

CLINICAL TRIAL REGISTRATION

CRD42021277973.

摘要

背景

个体化呼气末正压（PEEP）可能优化肺顺应性，从而潜在减轻肺损伤。本荟萃分析旨在确定腹部手术期间个体化 PEEP 与固定 PEEP 相比对术后肺部结局的影响。

方法

检索了比较固定 PEEP 与个体化 PEEP 的随机对照试验（RCT）的医学数据库（PubMed、Embase、Web of Science、ScienceDirect、Google Scholar 和中国知网）。主要复合终点为肺部并发症，包括低氧血症、肺不张、肺炎和急性呼吸窘迫综合征。次要结局包括氧合（PO/FiO）和全身炎症标志物（白细胞介素-6 [IL-6]和克拉细胞蛋白-16 [CC16]）。使用 DerSimonian 和 Laird 随机效应模型计算风险比（RR）和均数差（MD）及 95%置信区间（CI）。应用 Cochrane 偏倚风险工具。

结果

10 项 RCT（n=1117 例患者）符合纳入标准，其中 6 项报告了主要终点。与接受固定 PEEP 的 183/415 例（44.1%）相比，个体化 PEEP 降低了总体肺部并发症的发生率（141/412 [34.2%]）（RR 0.69 [95% CI：0.51-0.93]；P=0.016；I=43%）。风险偏倚分析并未改变这些发现。与接受固定 PEEP 的 110/395 例（27.8%）患者相比，个体化 PEEP 降低了术后低氧血症（74/392 [18.9%]）的发生率（RR 0.68 [0.52-0.88]；P=0.003；I=0%），但未降低术后肺不张的发生率（RR 0.93 [0.81-1.07]；P=0.297；I=0%）。个体化 PEEP 导致更高的 PO/FiO（MD 20.8 mm Hg [4.6-36.9]；P=0.012；I=80%）和降低的全身炎症（更低的血浆 IL-6 [MD -6.8 pg/ml；-11.9 至 -1.7]；P=0.009；I=6%和 CC16 水平[MD -6.2 ng/ml；-8.8 至 -3.5]；P<0.001；I=0%）。