背景:腹腔镜手术期间较高的呼气末正压(PEEP)可能会增加氧合和呼吸顺应性。这项荟萃分析旨在比较不同术中PEEP策略对动脉氧合的影响,合规,非肥胖患者腹腔镜手术期间的血流动力学。
方法:我们在PubMed中搜索了RCT,科克伦图书馆,WebofScience,和谷歌学者从2012年1月至2022年4月比较不同的术中PEEP(低PEEP(LPEEP):0-4mbar;中等PEEP(MPEEP):5-8mbar;高PEEP(HPEEP):>8mbar;个性化PEEP-iPEEP)动脉氧合,呼吸顺应性(Cdyn),平均动脉压(MAP),心率(HR)我们用95%置信区间(CI)计算平均差(MD),和使用随机效应模型的预测间隔(PI)。应用Cochrane偏差风险评估工具。
结果:21项RCT(n=1554)符合纳入标准。HPEEPvs.LPEEP增加PaO2(+29.38[16.20;42.56]mmHg,p<0.0001)或PaO2/FiO2(+36.7[+2.23;+71.70]mmHg,p=0.04)。HPEEPvs.MPEEP升高PaO2(+22.00[+1.11;+42.88]mmHg,p=0.04)或PaO2/FiO2(+42.7[+2.74;+82.67]mmHg,p=0.04)。iPEEPvs.MPEEP增加PaO2/FiO2(+115.2[+87.21;+143.20]mmHg,p<0.001)。MPEEPvs.LPEP,和HPEEPvs.MPEEP显着增加PaO2或PaO2/FiO2,具有不同的异质性。HPEEPvs.LPEEP增加了Cdyn(+7.87[+1.49;+14.25]ml/mbar,p=0.02)。MPEEPvs.LPEEP,和HPEEPvs.MPEEP不影响Cdyn(分别为p=0.14和0.38)。iPEEPvs.LPEEP降低驱动压力(-4.13[-2.63;-5.63]mbar,p<0.001)。在任何亚组之间均未发现MAP或HR的显着差异。
结论:非肥胖患者PNP期间的HPEEP和iPEEP可促进氧合并增加Cdyn,而MAP和HR无临床意义的变化。MPEEP可能不足以增加呼吸顺应性和改善氧合。LPEEP可能导致呼吸顺应性降低和氧合恶化。
■CRD42022362379;2022年10月9日注册。
Higher positive end-expiratory pressure (PEEP) during laparoscopic surgery may increase oxygenation and respiratory compliance. This meta-analysis aimed to compare the impact of different intraoperative PEEP strategies on arterial oxygenation, compliance, and hemodynamics during laparoscopic surgery in non-obese patients.
We searched RCTs in PubMed, Cochrane Library, Web of Science, and Google Scholar from January 2012 to April 2022 comparing the different intraoperative PEEP (Low PEEP (LPEEP): 0-4 mbar; Moderate PEEP (MPEEP): 5-8 mbar; high PEEP (HPEEP): >8 mbar; individualized PEEP - iPEEP) on arterial oxygenation, respiratory compliance (Cdyn), mean arterial pressure (MAP), and heart rate (HR). We calculated mean differences (MD) with 95% confidence intervals (CI), and predictive intervals (PI) using random-effects models. The Cochrane Bias Risk Assessment Tool was applied.
21 RCTs (n = 1554) met the inclusion criteria. HPEEP vs. LPEEP increased PaO2 (+ 29.38 [16.20; 42.56] mmHg, p < 0.0001) or PaO2/FiO2 (+ 36.7 [+ 2.23; +71.70] mmHg, p = 0.04). HPEEP vs. MPEEP increased PaO2 (+ 22.00 [+ 1.11; +42.88] mmHg, p = 0.04) or PaO2/FiO2 (+ 42.7 [+ 2.74; +82.67] mmHg, p = 0.04). iPEEP vs. MPEEP increased PaO2/FiO2 (+ 115.2 [+ 87.21; +143.20] mmHg, p < 0.001). MPEEP vs. LPEP, and HPEEP vs. MPEEP increased PaO2 or PaO2/FiO2 significantly with different heterogeneity. HPEEP vs. LPEEP increased Cdyn (+ 7.87 [+ 1.49; +14.25] ml/mbar, p = 0.02). MPEEP vs. LPEEP, and HPEEP vs. MPEEP did not impact Cdyn (p = 0.14 and 0.38, respectively). iPEEP vs. LPEEP decreased driving pressure (-4.13 [-2.63; -5.63] mbar, p < 0.001). No significant differences in MAP or HR were found between any subgroups.
HPEEP and iPEEP during PNP in non-obese patients could promote oxygenation and increase Cdyn without clinically significant changes in MAP and HR. MPEEP could be insufficient to increase respiratory compliance and improve oxygenation. LPEEP may lead to decreased respiratory compliance and worsened oxygenation.
CRD42022362379; registered October 09, 2022.