驱动压指导的呼气末正压通气对腹腔镜或机器人手术患者术后肺部并发症的影响：一项随机对照试验。
Effect of driving pressure-guided positive end-expiratory pressure on postoperative pulmonary complications in patients undergoing laparoscopic or robotic surgery: a randomised controlled trial.
机构信息
Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Republic of Korea.
出版信息
Br J Anaesth. 2023 Nov;131(5):955-965. doi: 10.1016/j.bja.2023.08.007. Epub 2023 Sep 9.
BACKGROUND
Individualised positive end-expiratory pressure (PEEP) improves respiratory mechanics. However, whether PEEP reduces postoperative pulmonary complications (PPCs) remains unclear. We investigated whether driving pressure-guided PEEP reduces PPCs after laparoscopic/robotic abdominal surgery.
METHODS
This single-centre, randomised controlled trial enrolled patients at risk for PPCs undergoing laparoscopic or robotic lower abdominal surgery. The individualised group received driving pressure-guided PEEP, whereas the comparator group received 5 cm HO fixed PEEP during surgery. Both groups received a tidal volume of 8 ml kg ideal body weight. The primary outcome analysed per protocol was a composite of pulmonary complications (defined by pre-specified clinical and radiological criteria) within 7 postoperative days after surgery.
RESULTS
Some 384 patients (median age: 67 yr [inter-quartile range: 61-73]; 66 [18%] female) were randomised. Mean (standard deviation) PEEP in patients randomised to individualised PEEP (n=178) was 13.6 cm HO (2.1). Individualised PEEP resulted in lower mean driving pressures (14.7 cm HO [2.6]), compared with 185 patients randomised to standard PEEP (18.4 cm HO [3.2]; mean difference: -3.7 cm HO [95% confidence interval (CI): -4.3 to -3.1 cm HO]; P<0.001). There was no difference in the incidence of pulmonary complications between individualised (25/178 [14.0%]) vs standard PEEP (36/185 [19.5%]; risk ratio [95% CI], 0.72 [0.45-1.15]; P=0.215). Pulmonary complications as a result of desaturation were less frequent in patients randomised to individualised PEEP (8/178 [4.5%], compared with standard PEEP (30/185 [16.2%], risk ratio [95% CI], 0.28 [0.13-0.59]; P=0.001).
CONCLUSIONS
Driving pressure-guided PEEP did not decrease the incidence of pulmonary complications within 7 days of laparoscopic or robotic lower abdominal surgery, although uncertainty remains given the lower than anticipated event rate for the primary outcome.
CLINICAL TRIAL REGISTRATION
KCT0004888 (http://cris.nih.go.kr, registration date: April 6, 2020).
背景
个体化呼气末正压（PEEP）可改善呼吸力学。然而，PEEP 是否可降低术后肺部并发症（PPCs）尚不清楚。我们研究了驱动压指导的 PEEP 是否可降低腹腔镜/机器人腹部手术后的 PPCs。
方法
这是一项单中心、随机对照试验，纳入了有 PPCs 风险的接受腹腔镜或机器人下腹部手术的患者。个体化组接受驱动压指导的 PEEP，而对照组在手术期间接受 5cmH2O 固定 PEEP。两组均给予 8ml/kg 理想体重的潮气量。主要的按方案分析的结局是术后 7 天内发生的肺部并发症（定义为预先指定的临床和影像学标准）的综合指标。
结果
共纳入 384 例患者（中位年龄：67 岁[四分位间距：61-73]；66[18%]为女性）。随机分至个体化 PEEP 组（n=178）的患者的平均（标准差）PEEP 为 13.6cmH2O（2.1）。与接受标准 PEEP（n=185）的患者相比，个体化 PEEP 组的平均驱动压更低（14.7cmH2O[2.6]）（平均差异：-3.7cmH2O[95%置信区间（CI）：-4.3 至 -3.1cmH2O]；P<0.001）。个体化 PEEP 组（25/178[14.0%]）与标准 PEEP 组（36/185[19.5%]）肺部并发症发生率无差异（风险比[95%CI]，0.72[0.45-1.15]；P=0.215）。随机分至个体化 PEEP 组的患者因低氧饱和度而发生的肺部并发症较不频繁（8/178[4.5%]，而标准 PEEP 组为 30/185[16.2%]，风险比[95%CI]，0.28[0.13-0.59]；P=0.001）。
结论
尽管主要结局的预期事件发生率较低，因此仍存在不确定性，但腹腔镜或机器人下腹部手术后 7 天内，驱动压指导的 PEEP 并未降低肺部并发症的发生率。
临床试验注册
KCT0004888（http://cris.nih.go.kr，注册日期：2020 年 4 月 6 日）。
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