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[JAMA在线发表]:肺保护性通气基础上肺复张对术后肺部并发症的影响
2017年04月08日 时讯速递, 进展交流 暂无评论

Preliminary Communication | Caring for the Critically Ill Patient

March 21, 2017

Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial

Alcino Costa Leme, Ludhmila Abrahao Hajjar, Marcia S. Volpe, et al

JAMA. Published online March 21, 2017. doi:10.1001/jama.2017.2297

Abstract

Importance 背景

Perioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial.

心脏外科手术后推荐围手术期采用肺保护性通气以减少肺部并发症。小潮气量(Vt)的保护性作用已经明确,然而,肺复张策略的额外保护作用尚存在争议。

Objective 目的

To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT.

确定在小Vt的保护性通气基础上,强化肺复张策略能否减少手术后肺部并发症。

Design, Setting, and Participants 设计,场景及研究人群

Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014).

2011年12月至2014年12月间,巴西一个ICU中心脏外科术后低氧血症患者的随机对照试验

Interventions 干预措施

Intensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT.

小Vt保护性通气基础上,强化复张策略(n = 157)或中度复张策略(n = 163)。

Main Outcomes and Measures  主要预后指标

Severity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality.

截止到出院时术后肺部并发症的严重程度,通过共同比数比(OR)分析肺部并发症严重程度评分(评分0-5分,0,无并发症;5,死亡)分布的变化。预先确定的次要指标包括ICU住院日及总住院日,气压伤发生率及住院病死率。

Results 结果

All 320 patients (median age, 62 years; IQR, 56-69 years; 125 women [39%]) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI, 1.7 to 2.0) and a median 1.7 (IQR, 1.0-2.0) pulmonary complications score vs 2.1 (95% CI, 2.0-2.3) and 2.0 (IQR, 1.5-3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI, 1.22 to 2.83; P = .003). The mean hospital stay for the moderate group was 12.4 days vs 10.9 days in the intensive group (absolute difference, −1.5 days; 95% CI, −3.1 to −0.3; P = .04). The mean ICU stay for the moderate group was 4.8 days vs 3.8 days for the intensive group (absolute difference, −1.0 days; 95% CI, −1.6 to −0.2; P = .01). Hospital mortality (2.5% in the intensive group vs 4.9% in the moderate group; absolute difference, −2.4%, 95% CI, −7.1% to 2.2%) and barotrauma incidence (0% in the intensive group vs 0.6% in the moderate group; absolute difference, −0.6%; 95% CI, −1.8% to 0.6%; P = .51) did not differ significantly between groups.

总共320 名患者(中位年龄 62 岁;IQR, 56-69 岁;125 名女性 [39%])完成了试验。强化复张策略组肺部并发症评分均值为 1.8 (95% CI, 1.7 to 2.0) 中位数为 1.7 (IQR, 1.0-2.0),中等复张策略组分别为 2.1 (95% CI, 2.0-2.3) 和 2.0 (IQR, 1.5-3.0)。 总体而言,强化策略组肺部并发症评分分布显著降低,共同OR 1.86 (95% CI, 1.22 to 2.83; P = .003)。中等策略组平均住院日12.4 天vs 强化组10.9 天(绝对差异,−1.5 天;95% CI, −3.1 to −0.3; P = .04)。中等组平均ICU住院日 4.8 天 vs 强化组 3.8 天(绝对差异,−1.0 天;95% CI, −1.6 to −0.2; P = .01)两组间住院病死率(强化组2.5% vs 中等组 4.9% ;绝对差异 −2.4%, 95% CI, −7.1% to 2.2%)及气压伤发生率(强化组0% vs 中等组 0.6%;绝对差异 −0.6%; 95% CI, −1.8% to 0.6%; P = .51)无显著差异。

Conclusions and Relevance 结论与意义

Among patients with hypoxemia after cardiac surgery, the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital.

对于心脏外科术后低氧血症患者,采用强化肺复张策略,与中等复张策略相比,能够显著降低住院期间肺部并发症的严重程度。

Trial Registration

clinicaltrials.gov Identifier: NCT01502332

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