机械通气模式不影响脊柱手术中的失血或输血要求:回顾性研究
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Ventilator Mode Does Not Influence Blood Loss or Transfusion Requirements During Major Spine Surgery: A Retrospective Study
背景与目的
成人脊柱畸形手术失血是多种因素影响的结局。麻醉相关的机械通通气方式可导致术中失血。本研究旨在探讨通气模式及呼吸参数对俯卧位脊柱手术患者术中失血量及输血需求的影响。
方 法
这项单中心回顾性研究纳入了2015年5月至2016年6月期间接受择期俯卧位脊柱手术的18岁以上患者的电子病历。通气模式和呼吸参数与术中估计失血量（EBL）的关系，其包括浓缩红细胞（PRBCs）、新鲜冰冻血浆（FFP）、冷沉淀和血小板输注，采用多元线性回归模型对年龄、性别、ASA分级、体重指数（BMI）、术前凝血参数和实验室数值、手术水平、支架结构、截骨术、经孔腰椎间融合术、椎板切除术、再手术、脊柱手术侵入指数和手术时间进行分析。在二次分析中，比较了压力控制通气（PCV）和容积控制通气（VCV）倾向评分匹配队列的术中估计失血量（EBL）、输血量和术后引流量的关系。
结 果
回顾了946份记录，并将822份记录纳入分析。调整复杂因素后，未观察到通气模式和术中EBL（估计值 -2；95%置信区间[CI]，-248至245；P=0.99）或血制品输注之间差异具有统计意义（PRBC：估计值 -9；95%CI，-154至135；P=0.90；FFP：估计值 -3；95%CI，-59至54；P=0.93；冷沉淀：估计值 -14；95%CI，-70至43；P=0.63；血小板：-7；95%CI，-39至24；P=0.64)。在倾向性评分匹配后，PCV组和VCV组在EBL（平均差525ml；95%CI，-15至1065；P=0.056）和输血方面（PRBC：平均差 208mL；95%CI，-23至439；P=0.077；FFP:平均差34mL；95%CI，-17至84；P=。19；冷冻沉淀:平均差55mL；95%CI，-24至133；P=。17）或血小板：平均差26mL；95%CI，-12-64；P=。18）都无显著性差异。
结 论
在俯卧位脊柱手术中，机械通气模式和气道压力与术中失血或需要异体输血无关。
原始文献摘要
Lauren K. Dunn, Davis G. Taylor, Ching-Jen Chen, Priyanka Singla, MBBS.et al.Ventilator Mode Does Not Influence Blood Loss or Transfusion Requirements During Major Spine Surgery:
A Retrospective Study.Anesth Analg 2020;130:100–10.
BACKGROUND: Blood loss during adult spinal deformity surgery is multifactorial. Anestheticrelated factors, such as mode of mechanical ventilation, may contribute to intraoperative blood loss. The aim of this study was to determine the influence of ventilator mode and ventilator
parameters on intraoperative blood loss and transfusion requirements in patients undergoing prone position spine surgery.
METHODS: This single-center retrospective study examined electronic medical records of patients ≥18 years of age who underwent elective prone position spine surgery between May 2015 and June 2016. Associations between ventilator mode and ventilator parameters with
intraoperative estimated blood loss (EBL), packed red blood cells (PRBCs), fresh-frozen plasma (FFP), cryoprecipitate and platelet transfusions, and subfascial drain output were examined using
multiple linear regression models controlling for age, sex, American Society of Anesthesiologist (ASA) physical status score, body mass index (BMI), preoperative blood coagulation parameters and laboratory values, operative levels, cage constructs, osteotomies, transforaminal lumbar
interbody fusions, laminectomies, reoperation, spine surgery invasiveness index, and operative time. In a secondary analysis, EBL, blood product transfusions, and postoperative drain output were compared between pressure-controlled ventilation (PCV) and volume-controlled ventilation
(VCV) propensity score–matched cohorts.
RESULTS: Nine hundred forty-six records were reviewed, and 822 were included in the analysis. After adjusting for confounding, no statistically significant associations were observed between mode of ventilation and intraoperative EBL (estimate, −2; 95% confidence interval [CI], −248 to 245; P =0 .99) or blood product transfusions (PRBC: estimate, −9; 95% CI, −154 to 135; P =0 .90; FFP: estimate, −3; 95% CI, −59 to 54; P =0 .93; cryoprecipitate: estimate, −14; 95% CI, −70 to 43; P =0 .63; platelets: −7; 95% CI, −39 to 24; P =0 .64). After propensity score matching (n = 27 per group), no significant differences were observed in EBL (mean difference, 525 mL; 95% CI,
−15 to 1065; P =0 .056) or blood transfusions (PRBC: mean difference, 208 mL; 95% CI, −23 to 439; P=0 .077; FFP (mean difference, 34 mL; 95% CI, −17 to 84; P =0.19); cryoprecipitate (mean difference, 55 mL; 95% CI, −24 to 133; P =0 .17); or platelets (mean difference, 26 mL; 95% CI, −12 to 64; P = 0.18) between PCV and VCV groups.
CONCLUSIONS: In prone position spine surgery, neither mode of mechanical ventilation nor airway pressure is associated with intraoperative blood loss or need for allogeneic transfusion. Use of modern ventilation strategies using lung protective techniques may mitigate differences in blood loss previously observed between PCV and VCV modes.
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贵州医科大学高鸿教授课题组
翻译：任文鑫 编辑：冯玉蓉 审校：王贵龙