21 de agosto de 2015

Artigo recomendado: Protective versus Conventional Ventilation for Surgery

A Systematic Review and Individual Patient Data Meta-analysis

Ary Serpa Neto, Sabrine N. T. Hemmes, Carmen S. V. Barbas, Martin Beiderlinden, Michelle Biehl, Jan M. Binnekade, Jaume Canet, Ana Fernandez-Bustamante, Emmanuel Futier, Ognjen Gajic, Göran Hedenstierna, Markus W. Hollmann, Samir Jaber, Alf Kozian, Marc Licker, Wen-Qian Lin, Andrew D. Maslow, Stavros G. Memtsoudis, Dinis Reis Miranda, Pierre Moine,Thomas Ng, Domenico Paparella, M.D., Christian Putensen, Marco Ranieri, Federica Scavonetto, Thomas Schilling, Werner Schmid, Gabriele Selmo, Paolo Severgnini, Juraj Sprung, Sugantha Sundar, Daniel Talmor, Tanja Treschan, Carmen Unzueta, Toby N. Weingarten, Esther K. Wolthuis, Hermann Wrigge, Marcelo Gama de Abreu, Paolo Pelosi, Marcus J. Schultz

Anesthesiology 2015; 123:66-78

Background: Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data meta-analysis is to evaluate the individual associations between VT size and positive end–expiratory pressure (PEEP) level and occurrence of PPC.

Methods: Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression.

Results: Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose–response relationship was found between the appearance of PPC and VT size (R2 = 0.39) but not between the appearance of PPC and PEEP level (R2 = 0.08).

Conclusions: These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.

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