颅内占位病变开颅术后早期驱动压对肺气体分布影响的随机对照研究。

Effect of driving pressure on early postoperative lung gas distribution in supratentorial craniotomy: a randomized controlled trial.

机构信息

Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, China.

Department of Anesthesiology, Beijing Fangshan Liangxiang Hospital, Beijing, China.

出版信息

BMC Anesthesiol. 2023 May 22;23(1):176. doi: 10.1186/s12871-023-02144-7.

DOI:10.1186/s12871-023-02144-7

PMID:37217882

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10201743/

Abstract

BACKGROUND

Neurosurgical patients represent a high-risk population for postoperative pulmonary complications (PPCs). A lower intraoperative driving pressure (DP) is related to a reduction in postoperative pulmonary complications. We hypothesized that driving pressure-guided ventilation during supratentorial craniotomy might lead to a more homogeneous gas distribution in the lung postoperatively.

METHODS

This was a randomized trial conducted between June 2020 and July 2021 at Beijing Tiantan Hospital. Fifty-three patients undergoing supratentorial craniotomy were randomly divided into the titration group or control group at a ratio of 1 to 1. The control group received 5 cmHO PEEP, and the titration group received individualized PEEP targeting the lowest DP. The primary outcome was the global inhomogeneity index (GI) immediately after extubation obtained by electrical impedance tomography (EIT). The secondary outcomes were lung ultrasonography scores (LUSs), respiratory system compliance, the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO/FiO) and PPCs within 3 days postoperatively.

RESULTS

Fifty-one patients were included in the analysis. The median (IQR [range]) DP in the titration group versus the control group was 10 (9-12 [7-13]) cmHO vs. 11 (10-12 [7-13]) cmHO, respectively (P = 0.040). The GI tract did not differ between groups immediately after extubation (P = 0.080). The LUS was significantly lower in the titration group than in the control group immediately after tracheal extubation (1 [0-3] vs. 3 [1-6], P = 0.045). The compliance in the titration group was higher than that in the control group at 1 h after intubation (48 [42-54] vs. 41 [37-46] ml·cmHO, P = 0.011) and at the end of surgery (46 [42-51] vs. 41 [37-44] ml·cmHO, P = 0.029). The PaO/FiO ratio was not significantly different between groups in terms of the ventilation protocol (P = 0.117). At the 3-day follow-up, no postoperative pulmonary complications occurred in either group.

CONCLUSIONS

Driving pressure-guided ventilation during supratentorial craniotomy did not contribute to postoperative homogeneous aeration, but it may lead to improved respiratory compliance and lower lung ultrasonography scores.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT04421976.

摘要

背景

神经外科患者是术后肺部并发症（PPCs）的高危人群。术中较低的驱动压（DP）与术后肺部并发症的减少有关。我们假设，在幕上开颅术中使用驱动压指导通气可能会导致术后肺部的气体分布更加均匀。

方法

这是一项 2020 年 6 月至 2021 年 7 月在北京天坛医院进行的随机试验。53 例接受幕上开颅术的患者以 1:1 的比例随机分为滴定组或对照组。对照组给予 5cmH2O PEEP，滴定组给予针对最低 DP 的个体化 PEEP。主要结局是使用肺部电阻抗断层成像（EIT）获得的拔管后即刻的全局不均匀指数（GI）。次要结局包括肺超声评分（LUSs）、呼吸系统顺应性、动脉血氧分压与吸入氧分数比值（PaO/FiO）和术后 3 天内的 PPCs。

结果

51 例患者纳入分析。滴定组和对照组的中位（IQR [范围]；[7-13]）DP 分别为 10（9-12）cmH2O 与 11（10-12）cmH2O（P=0.040）。拔管后两组 GI 无差异（P=0.080）。拔管后即刻，滴定组的 LUS 明显低于对照组（1[0-3] 比 3[1-6]，P=0.045）。与对照组相比，插管后 1 小时（48[42-54]比 41[37-46]ml·cmH2O，P=0.011）和手术结束时（46[42-51]比 41[37-44]ml·cmH2O，P=0.029），滴定组的顺应性更高。根据通气方案，两组间 PaO/FiO 比值无显著差异（P=0.117）。在 3 天的随访中，两组均未发生术后肺部并发症。