麻醉药物对心脏手术患者术后肺损伤(APLICS)的预防作用
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Anesthetics to Prevent Lung Injury in Cardiac Surgery (APLICS): a protocol for a randomized controlled trial
背景与目的
体外循环心脏手术患者术后肺部并发症的风险增加，并且其会导致过高的发病率和死亡率。体外循环期间肺缺血再灌注损伤可能是导致围手术期肺损伤的主要原因之一。因此，能够最大地减少缺血再灌注肺损伤对于减轻这一潜在可预防疾病过程的意义重大。
方 法
APLICS是成人心脏外科患者的前瞻性随机对照试验(RCT)。参与者将随机接受术中七氟醚或异丙酚麻醉维持。两组患者都按照尽可能减少呼吸机引起的肺损伤和高氧的影响的方案进行通气。在麻醉诱导后且再灌注2~4h后，再进行支气管肺泡灌洗(BAL)和采血。主要的结果是各组间在转流后肺部炎症程度上的差异，这是由支气管肺泡灌洗后的肿瘤坏死因子α的浓度所决定。次要结果将包括额外的相关支气管肺泡灌洗和全身炎症标志物的差异，以及术后肺部并发症的发生率。
结 论
七氟醚在内的挥发性麻醉剂已在临床和人体试验中得到证明，其可以有效地抑制包括缺血再灌注损伤在内的多种环境下的肺部炎症。
原始文献摘要
Brian O’Gara, Balachundhar Subramaniam, Shahzad Shaefi, Ariel Mueller, Valerie Banner-Goodspeed and Daniel Talmor，Anesthetics to Prevent Lung Injury in Cardiac Surgery (APLICS): a protocol for a randomized controlled trial. (2019) 20:312
Background: Patients undergoing cardiac surgery with cardiopulmonary bypass are at an increased risk of developing postoperative pulmonary complications, potentially leading to excess morbidity and mortality. It is likely that pulmonary ischemia-reperfusion (IR) injury during cardiopulmonary bypass is a major contributor to perioperative lung injury. Therefore, interventions that can minimize IR injury would be valuable in reducing the excess burden of this potentially preventable disease process. Volatile anesthetics including sevoflurane have been shown in both preclinical and human trials to effectively limit pulmonary inflammation in a number of settings including ischemia-reperfusion injury. However, this finding has not yet been demonstrated in the cardiac surgery population. The Anesthetics to Prevent Lung Injury in Cardiac Surgery (APLICS) trial is a randomized controlled trial (RCT) investigating whether sevoflurane anesthetic maintenance can modulate pulmonary inflammation occurring during cardiac surgery with cardiopulmonary bypass and whether this potential effect can translate to a reduction in postoperative pulmonary complications.
Methods: APLICS is a prospective RCT of adult cardiac surgical patients. Participants will be randomized to receive intraoperative anesthetic maintenance with either sevoflurane or propofol. Patients in both groups will be ventilated according to protocols intended to minimize the influences of ventilator-induced lung injury and hyperoxia. Bronchoalveolar lavage (BAL) and blood sampling will take place after anesthetic induction and 2–4 h after pulmonary reperfusion. The primary outcome is a difference between groups in the degree of post-bypass lung inflammation, defined by BAL concentrations of TNFα. Secondary outcomes will include differences in additional relevant BAL and systemic inflammatory markers and the incidence of postoperative pulmonary complications.
Conclussion: APLICS investigates whether anesthetic choice can influence lung inflammation and pulmonary outcomes following cardiac surgery with cardiopulmonary bypass. A positive result from this trial would add to the growing body of evidence describing the lung protective properties of the volatile anesthetics and potentially reduce unnecessary morbidity for cardiac surgery patients.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：任文鑫 编辑：何幼芹 审校：王贵龙