【原】【罌粟摘要】呼氣末正壓及術(shù)后預(yù)氧合對(duì)減肥手術(shù)患者術(shù)后早期氧合的影響：一項(xiàng)隨機(jī)對(duì)照試驗(yàn)

罌粟花anesthGH 2024-12-23 發(fā)布于貴州

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呼氣末正壓及術(shù)后預(yù)氧合對(duì)減肥手術(shù)患者術(shù)后早期氧合的影響：一項(xiàng)隨機(jī)對(duì)照試驗(yàn)

貴州醫(yī)科大學(xué) 麻醉與心臟電生理課題組

翻譯：王貴龍編輯：周倩審校：曹瑩

背景

呼氣末正壓通氣（PEEP）對(duì)于增加麻醉期間的肺容量和氣道閉合非常重要，特別是在肥胖患者中。然而在手術(shù)結(jié)束預(yù)氧合期間維持PEEP可能會(huì)增加術(shù)后肺不張，因?yàn)檫@會(huì)使易感肺區(qū)充滿高濃度氧氣，在拔管時(shí)PEEP突然撤離導(dǎo)致小氣道塌陷時(shí)，這些氧氣會(huì)被滯留。本研究旨在驗(yàn)證：在預(yù)氧合前停止PEEP可以更好地維持術(shù)后氧合。

方法

該試驗(yàn)為前瞻性隨機(jī)對(duì)照試驗(yàn)，于2019年12月至2023年1月在瑞典一家二級(jí)醫(yī)院完成。共納入60名BMI在35至50kg m^-2的接受腹腔鏡減肥手術(shù)的患者。根據(jù)體重指數(shù)，所有PEEP固定為12或14 cmH ₂O的患者術(shù)中通氣都是一樣的。手術(shù)后，患者在蘇醒前預(yù)氧合期間被分配到維持PEEP組或零PEEP組。主要觀察指標(biāo)為患者蘇醒前到術(shù)后45分鐘的氧合變化，通過(guò)動(dòng)脈血?dú)夥治鲞M(jìn)行估計(jì)血液氧合情況。

結(jié)果

兩組患者術(shù)后氧合均下降；在蘇醒期間維持PEEP的患者中，估計(jì)的未被氧合血液成分平均增加了9.1%，而在蘇醒期間PEEP為零的患者中估計(jì)的未被氧合血液成分平均增加了10.6%，差異為-1.5%（95%CI：-4.6%至1.7%，P?=?0.354）。在整個(gè)麻醉過(guò)程中，與蘇醒狀態(tài)相比，兩組都表現(xiàn)出較低的驅(qū)動(dòng)壓力和較高的氧合水平。

結(jié)論

預(yù)氧合前停用PEEP，不會(huì)改變接受腹腔鏡減肥手術(shù)肥胖患者術(shù)后早期氧合情況。盡管使用了固定的PEEP而沒(méi)有進(jìn)行肺復(fù)張策略，術(shù)中氧合情況依舊良好，但在拔管后氧合情況下降，表明需要進(jìn)一步研究以改進(jìn)通氣策略。

原始文獻(xiàn)：Erland, ?stberg; Alexander, Larsson; Philippe, Wagner; Staffan, Eriksson; Lennart, Edmark；Positive end-expiratory pressure and emergence preoxygenation after bariatric surgery: effect on postoperative oxygenation: A randomised controlled trial.Eur J Anaesthesiol 2025 Jan 1;42(1):54-63；PMID：39325031；DOI：10.1097/EJA.0000000000002071 .

Positive end-expiratory pressure and emergence preoxygenation after bariatric surgery: effect on postoperative oxygenation: A randomised controlled trial

Abstract

BACKGROUND:Positive end-expiratory pressure (PEEP) is important to increase lung volume and counteract airway closure during anaesthesia, especially in obese patients. However, maintaining PEEP during emergence preoxygenation might increase postoperative atelectasis by allowing susceptible lung areas to be filled with highly absorbable oxygen that gets entrapped when small airways collapse due to the sudden loss of PEEP at extubation.

OBJECTIVE:This study aimed to test the hypothesis that withdrawing PEEP just before emergence preoxygenation would better maintain postoperative oxygenation.

DESIGN:Prospective, randomised controlled trial.

SETTING:Single centre secondary hospital in Sweden between December 2019 and January 2023.

PATIENTS: A total of 60 patients, with body mass index between 35 and 50?kg?m-2 , undergoing laparoscopic bariatric surgery.

INTERVENTION:Intraoperative ventilation was the same for all patients with a fixed PEEP of 12 or 14?cmH2O depending on body mass index. No recruitment manoeuvres were used. After surgery, patients were allocated to maintained PEEP or zero PEEP during emergence preoxygenation.

MAIN OUTCOME MEASURES: The primary outcome was change in oxygenation from before awakening to 45?min postoperatively as measured by estimated venous admixture calculated from arterial blood gases. RESULTS: Both groups had impaired oxygenation postoperatively; in the group with PEEP maintained during awakening, estimated venous admixture increased by mean 9.1%, and for the group with zero PEEP during awakening, estimated venous admixture increased by mean 10.6%, difference -1.5% (95% confidence interval -4.6 to 1.7%), P ?=?0.354. Throughout anaesthesia, both groups exhibited low driving pressures and superior oxygenation compared with the awake state.

CONCLUSIONS:Withdrawing PEEP before emergence preoxygenation, did not alter early postoperative oxygenation in obese patients undergoing laparoscopic bariatric surgery. Intraoperative oxygenation was excellent despite using fixed PEEP and no recruitment manoeuvres, but deteriorated after extubation, indicating a need for future studies aimed at improving the emergence procedure.