【罂粟摘要】术中呼吸机管理与术后氧合、肺部并发症和死亡率的关联

贵州医科大学 麻醉与心脏电生理课题组

翻译：黄祥   编辑：柏雪   审校：曹莹

背景：“肺保护性通气”是一种通气战略，涉及低潮气量（VT）和/或低驱动压力/平台压力，并已被证明与机械通气后的改善结局有关。我们评估了围手术期通气参数（包括呼气末正压[PEEP]、驱动压力和VT）与三个术后结果之间的关联：PaO2 /吸入氧分压(FIO2)，术后肺部并发症，30天死亡率。

方法：我们回顾性分析了 2006 年至 2015 年在一个美国中心接受重大非心脏手术并在术后保持气管插管的成年患者。使用多变量回归，我们研究了术中呼吸机设置与插管时术后最低 PaO₂/FIO₂、出院诊断确定的肺部并发症以及院内30天死亡率之间的关联。

结果：在 2096 例病例中，PEEP中位数为5cm H₂O（四分位间距=4-6），VT 中位数为520mL（四分位间距=460-580），驱动压中位数为15cmH₂O(四分位间距=13-19)。多变量调整后，术中PEEP中位数（线性回归估计[B]=-6.04；95% CI，-8.22 至 -3.87；P < .001），FIO₂中位数（B=-0.30；95% CI，-0.50 至-0.10；P=0.003）和驱动压>16 cmH₂O的小时数（B = -5.40；95% CI，-7.2 至 -4.2；P<0.001）与术后PaO₂/FIO₂降低相关。较高的术后PaO₂/FIO₂比率与较低的肺部并发症风险（每100mmHg的调整优势比=0.495；95% CI，0.331-0.740；P=0.001，模型C统计量为0.852）和较低的死亡率（调整后的比值比=0.495；95% CI，0.366-0.606；P<0.001，模型C统计量为0.820）相关。术中 VT>500 mL的时间也与发生术后肺部并发症的风险增加有关（调整后的比值比=1.06/小时；95% CI，1.00-1.20；P=0.042）。

结论：在非心脏手术后需要术后插管的患者中，FIO₂中位数增加、PEEP中位数增加和驱动压升高的持续时间可预测术后PaO₂/FIO₂降低。术中VT>500 mL的持续时间与术后肺部并发症增加独立相关。术后较低的PaO₂/FIO₂比值与肺部并发症和死亡率独立相关。我们的研究结果表明，术后PaO₂/FIO₂可能是未来前瞻性试验的潜在目标，以研究特定通气策略对减少呼吸机相关性肺损伤的影响.

原始文献来源: Douville NJ,Jewell ES,Duggal N, et al. Association of Intraoperative Ventilator Management With Postoperative Oxygenation, Pulmonary Complications, and Mortality. Anesth Analg. 2020;130 (1):165-175.

英文原文：

Association of Intraoperative Ventilator Management With Postoperative Oxygenation, Pulmonary Complications, and Mortality  

BACKGROUND: "Lung-protective ventilation" describes a ventilation strategy involving low tidal volumes (VTs) and/or low driving pressure/plateau pressure and has been associated with improved outcomes after mechanical ventilation. We evaluated the association between intraoperative ventilation parameters (including positive end-expiratory pressure [PEEP], driving pressure, and VT) and 3 postoperative outcomes: (1) PaO2/fractional inspired oxygen tension (FIO2), (2) postoperative pulmonary complications, and (3) 30-day mortality.

METHODS: We retrospectively analyzed adult patients who underwent major noncardiac surgery and remained intubated postoperatively from 2006 to 2015 at a single US center. Using multivariable regressions, we studied associations between intraoperative ventilator settings and lowest postoperative PaO2/FIO2 while intubated, pulmonary complications identified from discharge diagnoses, and in-hospital 30-day mortality.

RESULTS: Among a cohort of 2096 cases, the median PEEP was 5 cm H2O (interquartile range = 4-6), median delivered VT was 520 mL (interquartile range = 460-580), and median driving pressure was 15 cm H2O (13-19). After multivariable adjustment, intraoperative median PEEP (linear regression estimate [B] = -6.04; 95% CI, -8.22 to -3.87; P 16 cm H2O (B = -5.40; 95% CI, -7.2 to -4.2; P 500 mL was also associated with an increased likelihood of developing a postoperative pulmonary complication (adjusted odds ratio = 1.06/hour; 95% CI, 1.00-1.20; P = .042).

CONCLUSIONS: In patients requiring postoperative intubation after noncardiac surgery, increased median FIO2, increased median PEEP, and increased time duration with elevated driving pressure predict lower postoperative PaO2/FIO2. Intraoperative duration of VT >500 mL was independently associated with increased postoperative pulmonary complications. Lower postoperative PaO2/FIO2 ratios were independently associated with pulmonary complications and mortality. Our findings suggest that postoperative PaO2/FIO2 may be a potential target for future prospective trials investigating the impact of specific ventilation strategies for reducing ventilator-induced pulmonary injury.

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