Anesthesiology:肥胖患者术中机械通气的个体化与固定化呼气末正压的比较:一项二次分析

2021-06-25 “罂粟花”公众号 “罂粟花”公众号

身麻醉可能导致肥胖患者肺不张和氧合恶化。作者假设,与固定的呼气末正压(PEEP)相比,个体化呼气末正压可改善术中氧合和通气分布。

背景

全身麻醉可能导致肥胖患者肺不张和氧合恶化。作者假设,与固定的呼气末正压(PEEP)相比,个体化呼气末正压可改善术中氧合和通气分布。

方法

这项二次分析包括在莱比锡大学医院进行的肥胖患者多中心术中保护性通气(PROBESE)试验(n=42)和本地单中心试验(n=54)的所有肥胖患者。两项试验的入选标准均为选择性腹腔镜腹部手术,体重指数大于或等于35kg/m2,在PROBESE研究中,患者被随机分为4cmH2O的PEEP组(n=19)和12cmH2O的PEEP组(n=21)。在单中心研究中,他们被随机分为5cmH2O的PEEP(n=25)或遵循依靠电阻抗断层扫描确定个体化PEEP(n=25)的招募策略。主要观察指标为拔管前PaO2/吸入氧分数,次要观察指标为依赖肺的分布和驱动压的术中潮气量。

结果

90例患者在合并两个较低PEEP组后分为三组进行评估。个体化PEEP的中位数为18(四分位间距16~22;范围,10~26)cmH2O。拔管前PaO2/吸氧分数分别为515(个体PEEP)、370(固定PEEP为12cmH2O)和305(固定PEEP为4~5cmH2O)mmHg(与个体PEEP差异为145;95%CI,91~200;12cmH2O和210的固定PEEP值P<0.001;对于4~5cmH2O的固定PEEP的95%CI,164~257;P<0.001。依赖肺区术中潮气量分别为43.9%(个体化PEEP)、25.9%(固定PEEP为12cmH2O)和26.8%(固定PEEP为4~5cmH2O)(与个体化PEEP差异18.0%;95%CI,8.0~20.7;固定PEEP为12cmH2O时P<0.001,17.1%;对于4~5cmH2O的固定PEEP,95%CI,10.0~20.6;P<0.001。术中平均驱动压为9.85cmH2O(个体化PEEP)、14.45cmH2O(固定PEEP为12cmH2O)和18.85cmH2O(固定PEEP为4~5cmH2O),P<0.001。

结论

这项对接受腹腔镜手术的肥胖患者的二次分析发现,通过使用个性化PEEP电阻抗断层扫描测量,可以获得更好的氧合,更低的驱动压力,以及通气量向依赖肺区的重新分布。但这对患者预后的影响尚不清楚。

原始出处:

Philipp Simon, et al. Individualized versus Fixed Positive End-expiratory Pressure for Intraoperative Mechanical Ventilation in Obese Patients: A Secondary Analysis. Anesthesiology, June 2021; 1346:887–900.

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