Almonacid-Cardenas Federico, Saab Remie, Nemirovsky Eitan Scher, Rivas Eva, Araujo-Duran Jorge, Mao Guangmei, Esa Wael Ali Sakr, Ruetzler Kurt, Argalious Maged, Turan Alparslan
Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain.
Acta Anaesthesiol Scand. 2023 Nov;67(10):1348-1355. doi: 10.1111/aas.14314. Epub 2023 Aug 31.
To test whether higher intraoperative PEEP levels and/or higher TV levels are associated with higher incidence of postoperative AKI within the first postoperative week, in adult patients having orthopedic surgeries under general anesthesia.
We conducted a sub analysis of a non-randomized alternating intervention cross over study performed in patients undergoing orthopedic surgery under general anesthesia at Cleveland Clinic, Cleveland, OH. We included four different combinations of PEEP (5 or 8 cm H O) and TV (6 or 10 mL/kg of PBW) that alternated each week in the six orthopedic operating rooms. Our primary outcome was postoperative AKI defined by the KDIGO criteria with baseline creatinine as the closest preoperative value to the time of surgery obtained within 30 days and postoperative value as the highest creatinine value within 7 days after surgery. Secondary outcome was the maximum postoperative in-hospital creatinine level within seven postoperative days.
A total of 1933 patients were included in the analysis. The incidence of AKI was 6.8% in the study population and similar in high TV versus low TV group and high PEEP versus low PEEP group. Neither TV nor PEEP significantly impacted AKI incidence. The estimated odds ratio of AKI comparing TV = 6 mL/kg to TV = 10 mL/kg was 0.96 (97.5% CI: 0.63, 1.46; p = .811); while the estimated odds ratio of AKI comparing PEEP = 5cm H O to PEEP = 8cm H O was 0.92 (97.5% CI: 0.60, 1.39; p = .623). No interaction was found between TV and PEEP on AKI. Additionally, neither TV nor PEEP had a significant effect on the seven postoperative day creatinine levels.
Higher levels of PEEP or TV during mechanical ventilation in adult patients undergoing orthopedic surgeries under general anesthesia do not increase the odds of developing postoperative AKI within the narrow limits studied.
为了检测在全身麻醉下接受骨科手术的成年患者中，术中较高的呼气末正压（PEEP）水平和/或较高的潮气量（TV）水平是否与术后第一周内急性肾损伤（AKI）的较高发生率相关。
我们对在俄亥俄州克利夫兰市克利夫兰诊所接受全身麻醉的骨科手术患者进行的一项非随机交替干预交叉研究进行了亚组分析。我们纳入了呼气末正压（5或8cmH₂O）和潮气量（6或10mL/kg预计体重）的四种不同组合，这些组合在六个骨科手术室中每周交替。我们的主要结局是根据改善全球肾脏病预后组织（KDIGO）标准定义的术后急性肾损伤，基线肌酐为术前30天内最接近手术时间的值，术后值为术后7天内的最高肌酐值。次要结局是术后7天内的术后最高院内肌酐水平。
共有1933例患者纳入分析。研究人群中急性肾损伤的发生率为6.8%，高TV组与低TV组以及高PEEP组与低PEEP组相似。潮气量和呼气末正压均未显著影响急性肾损伤的发生率。将潮气量=6mL/kg与潮气量=10mL/kg比较时，急性肾损伤的估计比值比为0.96（97.5%可信区间：0.63，1.46；p=0.811）；而将呼气末正压=5cmH₂O与呼气末正压=8cmH₂O比较时，急性肾损伤的估计比值比为0.92（97.5%可信区间：0.60，1.39；p=0.623）。在急性肾损伤方面，未发现潮气量和呼气末正压之间存在相互作用。此外，潮气量和呼气末正压对术后7天的肌酐水平均无显著影响。
在全身麻醉下接受骨科手术的成年患者机械通气期间，较高水平的呼气末正压或潮气量在所研究的狭窄范围内不会增加发生术后急性肾损伤的几率。
