肺保护性通气策略在急诊腹部手术患者中的应用： 多中心、前瞻性、观察性研究
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Adoption of Lung Protective ventilation IN patients undergoing Emergency laparotomy: the ALPINE study. A prospective multicentre observational study
背景与目的
急诊腹部手术与术后肺部并发症(PPCs)的发生密切相关。本研究的主要目的是观察急诊腹部手术的患者是否使用肺保护性通气(LPV策略)（潮气量 ≤ 8ml/kg、PEEP > 5cmH2O以及肺复张）；次要目的是探讨通气因素[LPV策略、术中吸入氧浓度（FiO2）、吸气峰压（peak inspiratory pressure，PIP）]与PPCs发生之间的关系。
方 法
本研究收集了伦敦28家医院急诊腹部手术的患者资料。根据NELA指南进行急诊腹部手术的所有年龄 ≥ 18岁的患者。包括所有开放、腹腔镜或腹腔镜辅助的胃肠道手术。记录患者的身高、体重、麻醉时间、通气模式、潮气量、PEEP、PIP、是否使用肺复张（每30min采用CPAP模式气道压 30cmH2O 维持30s）以及术中FiO2。每日记录PPCs的发展直至术后第7天。根据欧洲的围术期临床结果定义PPCs，其包括呼吸衰竭、呼吸道感染、肺不张、支气管痉挛、气胸和吸入性肺炎。
结 果
本研究共纳入568例患者。潮气量的中位数（IQR）为500ml（450~540ml），相对应的理想体重潮气量中位数（IQR）为8 ml/kg IBW（7.1~9ml）。潮气量采用≤ 8ml/kg IBW 的通气患者共265例（50.5%）。绝大多数患者（n = 523；92%) 使用中位数为5cmH2O（IQR：5~6 cmH2O）的PEEP。只有10%的患者（n = 54）采用肺复张（每30min采用CPAP模式气道压 30cmH2O 维持30s）。共有28例患者（4.9%）达到了上述所定义的LPV标准。大多数患者的PIP(n＝516; 91%) ≤30cmH2O。FiO2的中位数为0.5（IQR：0.44~0.53）。
结 论
术中气道压值和FiO2均为因急诊腹部手术患者术后肺部并发症的独立因素，但需要进一步的研究证实其临床作用及意义。
原始文献摘要
X. Watson1, M. Chereshneva，P. M. Odor,etl; Adoption of Lung Protective ventilation IN patients undergoing Emergency laparotomy: the ALPINE study. A prospective multicentre observational study. Br J Anaesth. 2018 Oct;121(4):909-917. doi: 10.1016/j.bja.2018.04.048. Epub 2018 Jun 29.
Background: Emergency abdominal surgery is associated with a high risk of postoperative pulmonary complications (PPCs). The primary aim of this study was to determine whether patients undergoing emergency laparotomy are ventilated using a lung-protective ventilation strategy employing tidal volume ＜8 ml kg-1 ideal body weight-1, PEEP >5cm H2O, and recruitment manoeuvres. The secondary aim was to investigate the association between ventilation factors(lung-protective ventilation strategy, intraoperative FiO2, and peak inspiratory pressure) and the occurrence of PPCs.
Methods: Data were collected prospectively in 28 hospitals across London as part of routine National Emergency Laparotomy Audit (NELA). Patients were followed for 7 days. Complications were defined according to the European Perioperative Clinical Outcome definition.
Results: Data were collected from 568 patients. The median [inter-quartile range (IQR)] tidal volume observed was 500 ml(450-540 ml), corresponding to a median tidal volume of 8 ml kg-1 ideal body weight-1 (IQR: 7.2-9.1 ml). A lungprotectiveventilation strategy was employed in 4.9% (28/568) of patients, and was not protective against the occurrence of PPCs in the multivariable analysis (hazard ratio¼1.06; P¼0.69). Peak inspiratory pressure of <30 cm H2O was protective against development of PPCs (hazard ratio¼0.46; confidence interval: 0.30-0.72; P¼0.001). Median FiO2 was 0.5 (IQR:0.44-0.53), and an increase in FiO2 by 5% increased the risk of developing a PPC by 8% (2.6-14.1%; P¼0.008).
Conclusions: Both intraoperative peak inspiratory pressure and FiO2 are independent factors significantly associated with development of a postoperative pulmonary complication in emergency laparotomy patients. Further studies are required to identify causality and to demonstrate if their manipulation could lead to better clinical outcomes.
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