心脏手术患者术中机械通气与术后肺部并发症
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Intraoperative Mechanical Ventilation and Postoperative Pulmonary Complications after Cardiac Surgery
背景与目的
与传统的通气策略相比，现阶段肺保护性通气包括低潮气量(VT)、低的驱动压力和呼气末正压(PEEP)的运用。对于旨在减少术后肺部并发症的集中化保护性通气策略，各组成部分的作用在成人心脏外科患者中既没有得到充分的解决，也没有得到全面的评估。作者假设术中集束化保护性通气策略与心脏手术术后肺部并发症的发生率降低独立相关。
方 法
在这项观察性队列研究中，作者回顾了2006年至2017年在三级护理学术医疗中心使用体外循环的非紧急心脏外科手术患者。测试了集束化或组合式术中保护性通气策略（VT低于8ml/kg，改良驱动压力[呼气末正压-PEEP]低于16 cm H2O，PEEP大于或等于5 cm H2O）与术后结局之间的关系，并对先前确定的危险因素进行了调整。主要观察指标为复合性肺部并发症；次要观察指标包括个体性肺部并发症、术后死亡率、机械通气持续时间、重症监护病房和住院时间。
结 果
在4 694例病例中，513例（10.9%）发生肺部并发症。术中肺保护性通气集束化与肺并发症减少相关（调整后比值比，0.56；95% CI，0.42–0.75）。通过敏感性分析，16 cm H2O以下的改良驱动压力与肺部并发症的减少独立相关（校正比值比，0.51；95% CI，0.39–0.66），然而低于8ml/kg的VT和≥5 cm H2 O的PEEP与肺部并发症则不相关。
结 论
作者认为，术中集中化肺保护性通气策略与心脏手术后肺部并发症有关。这一发现为深入了解保护性通气的组成部分与不良预后提供了依据，并可作为未来前瞻性干预研究的目标，以研究特定的保护性通气策略对心脏手术后预后的影响。
原始文献摘要
Mathis MR, Duggal NM, Likosky DS, et al. Intraoperative Mechanical Ventilation and Postoperative Pulmonary Complications after Cardiac Surgery.[J] .Anesthesiology, 2019, 131: 1046-1062.
Background: Compared with historic ventilation strategies, modern lung-protective ventilation includes lower tidal volumes (VT ), lower driving pressures, and application of positive end-expiratory pressure (PEEP). The contributions of each component to an overall intraoperative protective ventilation strategy aimed at reducing postoperative pulmonary complications have neither been adequately resolved, nor comprehensively evaluated within an adult cardiac surgical population. The authors hypothesized that a bundled intraoperative protective ventilation strategy was independently associated with decreased odds of pulmonary complications after cardiac surgery.
Methods: In this observational cohort study, the authors reviewed nonemergent cardiac surgical procedures using cardiopulmonary bypass at a tertiary care academic medical center from 2006 to 2017. The authors tested associations between bundled or component intraoperative protective ventilation strategies (VT below 8ml/kg ideal body weight, modified driving pressure [peak inspiratory pressure − PEEP] below 16 cm H2 O, and PEEP greater than or equal to 5 cm H2 O) and postoperative outcomes, adjusting for previously identified risk factors. The primary outcome was a composite pulmonary complication; secondary outcomes included individual pulmonary complications, postoperative mortality, as well as durations of mechanical ventilation, intensive care unit stay, and hospital stay.
Results: Among 4,694 cases reviewed, 513 (10.9%) experienced pulmonary complications. After adjustment, an intraoperative lung-protective ventilation bundle was associated with decreased pulmonary complications (adjusted odds ratio, 0.56; 95% CI, 0.42–0.75). Via a sensitivity analysis, modified driving pressure below 16 cm H2 O was independently associated with decreased pulmonary complications (adjusted odds ratio, 0.51; 95% CI, 0.39–0.66), but VT below 8ml/kg and PEEP greater than or equal to 5 cm H2 O were not.
Conclusions: The authors identified an intraoperative lung-protective ventilation bundle as independently associated with pulmonary complications after cardiac surgery. The findings offer insight into components of protective ventilation associated with adverse outcomes and may serve as targets for future prospective interventional studies investigating the impact of specific protective ventilation strategies on postoperative outcomes after cardiac surgery.
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贵州医科大学高鸿教授课题组
翻译：何幼芹 编辑：何幼芹 审校：王贵龙