围术期个体化开放式肺通气策略中氧浓度对术后感染的影响：随机对照试验

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Effects of oxygen on post-surgical infections during an individualised perioperative open-lung ventilatory strategy: a randomised controlled trial

背景与目的

手术部位感染（SSIs）是手术后患者常见的并发症，对临床预后和医疗费用都有一定影响。WHO、美国外科医师学会、美国CDC建议围术期使用FiO₂为0.80的吸入氧和其他干预措施，以降低SSIs发生率。然而，这一建议缺乏有力的科学证据。肺开放策略（OLA）是一种呼气末正压（PEEP）与肺复张（RMs）相结合的通气策略，通过最小化肺内分流来逆转和预防肺塌陷，并随着时间推移保持正常的气体交换，因此即使在低FiO₂下也能保持正常的PaO₂：FiO₂。本研究旨在探讨术中和术后个体化肺开放通气中吸入高浓度氧气是否可减少择期腹部手术患者手术部位感染发生率。

方  法

本项研究是一项前瞻性、多中心、随机对照、双臂平行试验，自2017年6月6日至2018年7月19日在21所大学医院进行多中心随机对照临床试验。接受腹部手术的患者被随机分为两组，术中和术后3h接受高FiO₂（0.80）或常规FiO₂（0.30）通气，主要指标是术后7d内SSIs的发生率；次要指标包括全身并发症、重症监护时间和住院时间以及6个月死亡率。

结 果  

最终分析共纳入717例患者：高FiO₂组362例，低FiO₂组355例。术后第1周高FiO₂组（n=31;8.9%）和低FiO₂组（n=34;9.4%）SSIs发生率无差异（RR：0.94；95%CI：0.59-1.50；P=0.90）；术后30d内SSI的发生率无统计学差异（RR：1.03；95%CI：0.78-1.37；P=0.89）。在高FiO₂组（42%；n=149）和常规FiO₂组（45%；n=165）组之间，术后并发症的发病率非常相似。总体并发症也无统计学差异（表3）。此外，高FiO₂组和常规FiO₂组在任何并发症上无显著差异，例如肺不张（7.7% vs 9.8%；RR：0.77；95%CI：0.48-1.25；P=0.38）、急性呼吸衰竭（2.8% vs 3.7%；RR：0.74；95%CI：0.33-1.64；P=0.70）和心肌缺血（0.6%[2] vs 0%[0]；P=0.47）。

结 论

与常规FiO₂氧合策略相比，术中及术后高FiO₂氧合策略并未减少腹部手术患者术后SSIs发生。

原始文献摘要

Ferrando C, Aldecoa C, Unzueta C, et al. Effects of oxygen on post-surgical infections during an individualised perioperative open-lung ventilatory strategy: a randomised controlled trial. Br J Anaesth. 2020;124(1):110–120. doi:10.1016/j.bja.2019.10.009

Background: We aimed to examine whether using a high fraction of inspired oxygen (FIO2) in the context of an individualised intra- and postoperative open-lung ventilation approach could decrease surgical site infection (SSI) in patients scheduled for abdominal surgery.

Methods: We performed a multicentre, randomised controlled clinical trial in a network of 21 university hospitals from June 6, 2017 to July 19, 2018. Patients undergoing abdominal surgery were randomly assigned to receive a high (0.80) or conventional (0.3) FIO2 during the intraoperative period and during the fifirst 3 postoperative hours. All patients were mechanically ventilated with an open-lung strategy, which included recruitment manoeuvres and individualised positive end-expiratory pressure for the best respiratory-system compliance, and individualised continuous postoperative airway pressure for adequate peripheral oxyhaemoglobin saturation. The primary outcome was the prevalence of SSI within the fifirst 7 postoperative days. The secondary outcomes were composites of systemic complications, length of intensive care and hospital stay, and 6-month mortality.

Results: We enrolled 740 subjects: 371 in the high FIO₂ group and 369 in the low FIO₂ group. Data from 717 subjects were available for fifinal analysis. The rate of SSI during the fifirst postoperative week did not differ between high (8.9%) and low (9.4%) FIO₂ groups (relative risk [RR]: 0.94; 95% confifidence interval [CI]: 0.59-1.50; P¼0.90]). Secondary outcomes, such as

atelectasis (7.7% vs 9.8%; RR: 0.77; 95% CI: 0.48-1.25; P¼0.38) and myocardial ischaemia (0.6% [n¼2] vs 0% [n¼0]; P¼0.47) did not differ between groups.

Conclusions: An oxygenation strategy using high FIO₂ compared with conventional FIO₂ did not reduce postoperative SSIs in abdominal surgery. No differences in secondary outcomes or adverse events were found.

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翻译：王贵龙  编辑：冯玉蓉  审校：王贵龙