成人体外循环心脏手术中通气管理临床实践的全国性调查研究

Clinical practice of intraoperative ventilation management in cardiac surgery:A nationwide survey in China

目的调查我国心脏手术麻醉医师在成人体外循环(cardiopulmonary bypass,CPB)心脏手术中通气管理的临床实践,分析肺保护性通气(lung-protective ventilation,LPV)策略的临床应用与理论认识之间是否存在差距。方法采用横断面问卷调查的方法,在2021年9月—2022年2月向中国30家医院(心脏手术量>1000台/年)的心脏手术麻醉医师发送电子调查问卷。结果共回收问卷323份,有效问卷297份,有效率92.0%。在非CPB期间,联合使用小潮气量(tidal volume,V_(T))、呼气末正压(positive end expiratory pressure,PEEP)和肺复张手法(alveolar recruitment maneuver,ARM)的麻醉医师占84.8%(252/297);90.6%(269/297)的麻醉医师采用小V_(T)通气(6~8 mL/kg);92.3%(274/297)设置PEEP,其中PEEP水平<5 cm H_(2)O占57.9%(172/297);67.3%(200/297)常规实施ARM,其中86.2%(256/297)采用手控ARM。在CPB期间,89.9%(267/297)的麻醉医师不实施肺通气,29.6%(88/297)主动实施ARM。结论在中国成人CPB心脏手术通气管理中,大多数麻醉医师应用联合小V_(T)、PEEP和ARM的LPV策略,除小V_(T)的应用较一致外,其他通气参数的设置在麻醉医师之间存在差异。同时,LPV的临床实践与理论认识也存在差距。

Objective To investigate the current status of routine practice and perspective of anesthesiologists regarding ventilation strategies during cardiac surgery,and to analyze whether there is a gap between the clinical application and theoretical understanding of lung-protective ventilation(LPV)strategies.Methods We conducted a multi-institutional cross-sectional survey of anesthesiologists working at high-volume(>1000 cardiac procedures each year)Chinese hospitals.The electronic questionnaire was designed and distributed from September 2021 to February 2022.Results A total of 323 replies were collected and 297(92.0%)replies were valid.Among the respondents,84.8%(252/297)performed the combination of low tidal volume(V_(T)),positive end-expiratory pressure(PEEP)and alveolar recruitment maneuver(ARM)during non-CPB period.The vast majority of respondents(90.6%,269/297)ventilated patients with the V_(T) of 6-8 mL/kg.92.3%(274/297)of respondents applied PEEP,among those 57.9%(172/297)set a PEEP level<5 cm H_(2)O.Most of the respondents(67.3%,200/297)performed intraoperative ARM,and manual ARM was used by 86.2%(256/297)of anesthesiologists.During CPB,89.9%(267/297)of respondents withdrew mechanical ventilation,and 29.6%(88/297)performed ARM.Conclusion This national survey in China showed that the majority of anesthesiologists adopted LPV strategy with the combination of low V_(T),PEEP and ARM during cardiac surgery.Except V_(T),the intraoperative ventilator settings varied widely from one anesthesiologist to another.Meanwhile,there is a gap between the clinical practice and theoretical understanding of LPV.