正压呼气末策略对非肥胖患者腹腔镜手术中氧合、呼吸顺应性和血流动力学的影响：系统评价和随机对照试验的荟萃分析。

Impact of a positive end-expiratory pressure strategy on oxygenation, respiratory compliance, and hemodynamics during laparoscopic surgery in non-obese patients: a systematic review and meta-analysis of randomized controlled trials.

机构信息

National Research Oncology Center, Astana, Kazakhstan.

Karaganda Medical University, Karaganda, Kazakhstan.

出版信息

BMC Anesthesiol. 2023 Nov 11;23(1):371. doi: 10.1186/s12871-023-02337-0.

BACKGROUND

Higher positive end-expiratory pressure (PEEP) during laparoscopic surgery may increase oxygenation and respiratory compliance. This meta-analysis aimed to compare the impact of different intraoperative PEEP strategies on arterial oxygenation, compliance, and hemodynamics during laparoscopic surgery in non-obese patients.

METHODS

We searched RCTs in PubMed, Cochrane Library, Web of Science, and Google Scholar from January 2012 to April 2022 comparing the different intraoperative PEEP (Low PEEP (LPEEP): 0-4 mbar; Moderate PEEP (MPEEP): 5-8 mbar; high PEEP (HPEEP): >8 mbar; individualized PEEP - iPEEP) on arterial oxygenation, respiratory compliance (Cdyn), mean arterial pressure (MAP), and heart rate (HR). We calculated mean differences (MD) with 95% confidence intervals (CI), and predictive intervals (PI) using random-effects models. The Cochrane Bias Risk Assessment Tool was applied.

RESULTS

21 RCTs (n = 1554) met the inclusion criteria. HPEEP vs. LPEEP increased PaO (+ 29.38 [16.20; 42.56] mmHg, p < 0.0001) or PaO/FiO (+ 36.7 [+ 2.23; +71.70] mmHg, p = 0.04). HPEEP vs. MPEEP increased PaO (+ 22.00 [+ 1.11; +42.88] mmHg, p = 0.04) or PaO/FiO (+ 42.7 [+ 2.74; +82.67] mmHg, p = 0.04). iPEEP vs. MPEEP increased PaO/FiO (+ 115.2 [+ 87.21; +143.20] mmHg, p < 0.001). MPEEP vs. LPEP, and HPEEP vs. MPEEP increased PaO or PaO/FiO significantly with different heterogeneity. HPEEP vs. LPEEP increased Cdyn (+ 7.87 [+ 1.49; +14.25] ml/mbar, p = 0.02). MPEEP vs. LPEEP, and HPEEP vs. MPEEP did not impact Cdyn (p = 0.14 and 0.38, respectively). iPEEP vs. LPEEP decreased driving pressure (-4.13 [-2.63; -5.63] mbar, p < 0.001). No significant differences in MAP or HR were found between any subgroups.

CONCLUSION

HPEEP and iPEEP during PNP in non-obese patients could promote oxygenation and increase Cdyn without clinically significant changes in MAP and HR. MPEEP could be insufficient to increase respiratory compliance and improve oxygenation. LPEEP may lead to decreased respiratory compliance and worsened oxygenation.

PROSPERO REGISTRATION

CRD42022362379; registered October 09, 2022.

背景

腹腔镜手术中较高的呼气末正压（PEEP）可能会增加氧合和呼吸顺应性。本荟萃分析旨在比较非肥胖患者腹腔镜手术中不同术中 PEEP 策略对动脉氧合、顺应性和血流动力学的影响。

方法

我们在 PubMed、Cochrane 图书馆、Web of Science 和 Google Scholar 中检索了 2012 年 1 月至 2022 年 4 月期间的 RCT，比较了不同的术中 PEEP（低 PEEP（LPEEP）：0-4 mbar；中 PEEP（MPEEP）：5-8 mbar；高 PEEP（HPEEP）：>8 mbar；个体化 PEEP - iPEEP）对动脉氧合、呼吸顺应性（Cdyn）、平均动脉压（MAP）和心率（HR）的影响。我们使用随机效应模型计算了均值差（MD）及其 95%置信区间（CI）和预测区间（PI）。使用 Cochrane 偏倚风险评估工具进行评估。

结果

21 项 RCT（n=1554）符合纳入标准。HPEEP 与 LPEEP 相比，增加了 PaO（+29.38[16.20；42.56]mmHg，p<0.0001）或 PaO/FiO（+36.7[+2.23；+71.70]mmHg，p=0.04）。HPEEP 与 MPEEP 相比，增加了 PaO（+22.00[+1.11；+42.88]mmHg，p=0.04）或 PaO/FiO（+42.7[+2.74；+82.67]mmHg，p=0.04）。iPEEP 与 MPEEP 相比，增加了 PaO/FiO（+115.2[+87.21；+143.20]mmHg，p<0.001）。MPEEP 与 LPEEP 以及 HPEEP 与 MPEEP 显著增加了 PaO 或 PaO/FiO，存在不同程度的异质性。HPEEP 与 LPEEP 相比，增加了 Cdyn（+7.87[+1.49；+14.25]ml/mbar，p=0.02）。MPEEP 与 LPEEP 以及 HPEEP 与 MPEEP 对 Cdyn 无影响（p=0.14 和 0.38，分别）。iPEEP 与 LPEEP 相比，降低了驱动压（-4.13[-2.63；-5.63]mbar，p<0.001）。任何亚组之间的 MAP 或 HR 均无显著差异。