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[JAMA发表论文]:术中小潮气量与传统潮气量对接受大手术患者术后肺部并发症的影响
2020年09月08日 时讯速递, 进展交流 暂无评论

Original Investigation September 1, 2020

Effect of Intraoperative Low Tidal Volume vs Conventional Tidal Volume on Postoperative Pulmonary Complications in Patients Undergoing Major Surgery: A Randomized Clinical Trial

Dharshi Karalapillai, Laurence Weinberg, Philip Peyton, et al

JAMA. 2020;324(9):848-858. doi:10.1001/jama.2020.12866

Abstract 摘要

Importance 背景

In patients who undergo mechanical ventilation during surgery, the ideal tidal volume is unclear.

对于手术中接受机械通气的患者,理想潮气量尚不清楚。

Objective 目的

To determine whether low-tidal-volume ventilation compared with conventional ventilation during major surgery decreases postoperative pulmonary complications.

确定与在大手术中传统通气相比,小潮气量通气能否降低术后肺部并发症。

Design, Setting, and Participants 设计,场景与研究对象

Single-center, assessor-blinded, randomized clinical trial of 1236 patients older than 40 years undergoing major noncardiothoracic, nonintracranial surgery under general anesthesia lasting more than 2 hours in a tertiary hospital in Melbourne, Australia, from February 2015 to February 2019. The last date of follow-up was February 17, 2019.

这是一项单中心、评估者设盲的随机临床实验,在澳大利亚墨尔本一家三级医院中,入选2015年2月至2019年2月期间在全麻下接受非心胸非颅内大手术(超过2个小时)的1236名40岁以上患者。最后随访日期为2019年2月17日。

Interventions 干预措施

Patients were randomized to receive a tidal volume of 6 mL/kg predicted body weight (n = 614; low tidal volume group) or a tidal volume of 10 mL/kg predicted body weight (n = 592; conventional tidal volume group). All patients received positive end-expiratory pressure (PEEP) at 5 cm H2O.

患者接受随机分组,接受潮气量6 ml/kg理想体重(n = 614; 小潮气量组) 或潮气量10 mL/kg理想体重 (n = 592; 传统潮气量组)。所有患者使用 5 cm H2O的PEEP。

Main Outcomes and Measures 主要结局指标

The primary outcome was a composite of postoperative pulmonary complications within the first 7 postoperative days, including pneumonia, bronchospasm, atelectasis, pulmonary congestion, respiratory failure, pleural effusion, pneumothorax, or unplanned requirement for postoperative invasive or noninvasive ventilation. Secondary outcomes were postoperative pulmonary complications including development of pulmonary embolism, acute respiratory distress syndrome, systemic inflammatory response syndrome, sepsis, acute kidney injury, wound infection (superficial and deep), rate of intraoperative need for vasopressor, incidence of unplanned intensive care unit admission, rate of need for rapid response team call, intensive care unit length of stay, hospital length of stay, and in-hospital mortality.

主要预后指标为复合终点,即术后7天内肺部并发症,包括肺炎、支气管痉挛、肺不张、肺充血、呼吸功能衰竭、胸腔积液、气胸或术后非计划性有创或无创机械通气。次要预后指标包括术后肺部并发症,包括肺栓塞,ARDS,全身炎症反应综合征,脓毒症,急性肾损伤,伤口感染(浅表或深部),术中需要升压药物比例,非计划性收入ICU,需要紧急呼叫快速反应小组,ICU住院日,总住院日和住院病死率。

Results 结果

Among 1236 patients who were randomized, 1206 (98.9%) completed the trial (mean age, 63.5 years; 494 [40.9%] women; 681 [56.4%] undergoing abdominal surgery). The primary outcome occurred in 231 of 608 patients (38%) in the low tidal volume group compared with 232 of 590 patients (39%) in the conventional tidal volume group (difference, −1.3% [95% CI, −6.8% to 4.2%]; risk ratio, 0.97 [95% CI, 0.84-1.11]; P = .64). There were no significant differences in any of the secondary outcomes.

共1236名患者接受随机分组,1206名 (98.9%) 患者完成试验 (平均年龄,63.5 岁; 494名 [40.9%] 女性;681名 [56.4%] 接受腹部手术)。小潮气量组608名患者中231 名 (38%) 以及传统潮气量组590名患者中 232 名 (39%) 发生主要研究终点 (差异, −1.3% [95% CI, −6.8% to 4.2%]; 风险比, 0.97 [95% CI, 0.84-1.11]; P = .64)。所有次要预后指标均无显著差异。

Conclusions and Relevance 结论与意义

Among adult patients undergoing major surgery, intraoperative ventilation with low tidal volume compared with conventional tidal volume, with PEEP applied equally between groups, did not significantly reduce pulmonary complications within the first 7 postoperative days.

对于接受大手术的成年患者,与术中传统潮气量通气相比,采用小潮气量通气,且两组PEEP相同,不能显著减少术后7天内的肺部并发症。

Trial Registration 试验注册

ANZCTR Identifier: ACTRN12614000790640

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