Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France.
Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France.
Can J Anaesth. 2024 Feb;71(2):224-233. doi: 10.1007/s12630-023-02644-7. Epub 2023 Nov 28.
Intraoperative alveolar recruitment maneuvers (ARM) used during protective ventilation strategy may have severe adverse hemodynamic effects, reported mainly during abrupt continuous positive airway pressure (CPAP). Stepwise increase and decrease in positive end expiratory pressure (PEEP) may be used. We compared the hemodynamic effects of these two maneuvers.
We enrolled patients scheduled for intermediate to high-risk surgery with continuous arterial pressure and stroke volume (esophageal Doppler) monitoring in a prospective, single-centre, randomized, double-blind study. After induction of anesthesia, we ensured preload independence of stroke volume before an ARM was randomly performed: 30 cm HO CPAP for 30 sec (CPAP group) or stepwise increase in PEEP from 8 to 20 cm HO with inspiratory pressure of 10 cm HO followed by a stepwise decrease in PEEP from 20 to 8 cm HO (STEP group). The primary outcome was the relative variation in stroke volume.
Thirty-five patients were included in the CPAP and STEP groups. Mean (standard deviation) relative variation in stroke volume was -57 (24)% in the CPAP group and -32 (24)% in the STEP group (difference, -25; 95% confidence interval, -37 to -14; P < 0.001). Changes in systolic, mean, and diastolic arterial pressure over time were not different between groups. The ARM was stopped because of a systolic arterial pressure < 70 mm Hg in four patients in the CPAP group and in one patient in the STEP group.
Alveolar recruitment maneuvers through stepwise increase and decrease in PEEP have a better hemodynamic tolerance than transient CPAP.
ClinicalTrials.gov (NCT04802421); first submitted 15 March 2021.
在保护性通气策略中使用术中肺泡复张手法（ARM）可能会产生严重的不良血液动力学效应，主要在突然的持续气道正压通气（CPAP）时报告。可以逐步增加和减少呼气末正压（PEEP）。我们比较了这两种手法的血液动力学效应。
我们在一项前瞻性、单中心、随机、双盲研究中纳入了接受中高危手术且连续动脉压和每搏量（食管多普勒）监测的患者。在麻醉诱导后，我们确保在 ARM 随机进行之前每搏量的前负荷独立：30 cm H2O CPAP 持续 30 秒（CPAP 组）或逐步从 8 至 20 cm H2O 增加 PEEP，吸气压力为 10 cm H2O，然后逐步从 20 至 8 cm H2O 降低 PEEP（STEP 组）。主要结局是每搏量的相对变化。
CPAP 和 STEP 组各纳入 35 例患者。CPAP 组每搏量的相对变化为-57（24）%，STEP 组为-32（24）%（差异，-25；95%置信区间，-37 至-14；P<0.001）。两组之间随时间变化的收缩压、平均动脉压和舒张压的变化没有差异。CPAP 组有 4 例患者和 STEP 组有 1 例患者的收缩压<70 mmHg，因此停止了 ARM。
通过逐步增加和减少 PEEP 进行的肺泡复张手法具有更好的血液动力学耐受性，优于短暂的 CPAP。
ClinicalTrials.gov（NCT04802421）；首次提交日期为 2021 年 3 月 15 日。
