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. 2020 Jan;130(1):165-175.
doi: 10.1213/ANE.0000000000004191.

Association of Intraoperative Ventilator Management With Postoperative Oxygenation, Pulmonary Complications, and Mortality

Nicholas J Douville  1 , Elizabeth S Jewell, Neal Duggal, Ross Blank, Sachin Kheterpal, Milo C Engoren, Michael R Mathis
Affiliations

Association of Intraoperative Ventilator Management With Postoperative Oxygenation, Pulmonary Complications, and Mortality

Nicholas J Douville et al. Anesth Analg. 2020 Jan.

Abstract

Background: "Lung-protective ventilation" describes a ventilation strategy involving low tidal volumes (VTs) and/or low driving pressure/plateau pressure and has been associated with improved outcomes after mechanical ventilation. We evaluated the association between intraoperative ventilation parameters (including positive end-expiratory pressure [PEEP], driving pressure, and VT) and 3 postoperative outcomes: (1) PaO2/fractional inspired oxygen tension (FIO2), (2) postoperative pulmonary complications, and (3) 30-day mortality.

Methods: We retrospectively analyzed adult patients who underwent major noncardiac surgery and remained intubated postoperatively from 2006 to 2015 at a single US center. Using multivariable regressions, we studied associations between intraoperative ventilator settings and lowest postoperative PaO2/FIO2 while intubated, pulmonary complications identified from discharge diagnoses, and in-hospital 30-day mortality.

Results: Among a cohort of 2096 cases, the median PEEP was 5 cm H2O (interquartile range = 4-6), median delivered VT was 520 mL (interquartile range = 460-580), and median driving pressure was 15 cm H2O (13-19). After multivariable adjustment, intraoperative median PEEP (linear regression estimate [B] = -6.04; 95% CI, -8.22 to -3.87; P < .001), median FIO2 (B = -0.30; 95% CI, -0.50 to -0.10; P = .003), and hours with driving pressure >16 cm H2O (B = -5.40; 95% CI, -7.2 to -4.2; P < .001) were associated with decreased postoperative PaO2/FIO2. Higher postoperative PaO2/FIO2 ratios were associated with a decreased risk of pulmonary complications (adjusted odds ratio for each 100 mm Hg = 0.495; 95% CI, 0.331-0.740; P = .001, model C-statistic of 0.852) and mortality (adjusted odds ratio = 0.495; 95% CI, 0.366-0.606; P < .001, model C-statistic of 0.820). Intraoperative time with VT >500 mL was also associated with an increased likelihood of developing a postoperative pulmonary complication (adjusted odds ratio = 1.06/hour; 95% CI, 1.00-1.20; P = .042).

Conclusions: In patients requiring postoperative intubation after noncardiac surgery, increased median FIO2, increased median PEEP, and increased time duration with elevated driving pressure predict lower postoperative PaO2/FIO2. Intraoperative duration of VT >500 mL was independently associated with increased postoperative pulmonary complications. Lower postoperative PaO2/FIO2 ratios were independently associated with pulmonary complications and mortality. Our findings suggest that postoperative PaO2/FIO2 may be a potential target for future prospective trials investigating the impact of specific ventilation strategies for reducing ventilator-induced pulmonary injury.

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Conflict of interest statement

Conflict of Interest: No personal conflicts of interest among study authors.

Figures

Figure 1.
Figure 1.
Derivation of Study Cohort
Figure 2.
Figure 2.
Distribution of Ventilation Parameters (A) Histogram of Median Tidal Volumes, (B) Duration of Time with Tidal Volume > 500 mL, (C) Median Tidal Volume as a Function of PBW, (D) Duration of Time with Tidal Volume > 8 mL/kg, (E) Median Driving Pressures, (F) Duration with Driving Pressure > 16 cmH2O, and (G) Median FiO2, (H) Duration with SpO2 < 90%, (I) Median PEEP.
Figure 3.
Figure 3.
Distribution of Primary Outcome - Minimum Postoperative PaO2/FiO2
See this image and copyright information in PMC

References

    1. Kilpatrick B, Slinger P. Lung protective strategies in anaesthesia. British journal of anaesthesia. 2010;105:i108–i116. - PMC - PubMed
    1. Sloane PJ, Gee MH, Gottlieb JE, Albertine KH, Peters SP, Burns JR, Machiedo G, Fish JE. A multicenter registry of patients with acute respiratory distress syndrome: physiology and outcome. Am. Rev. Respir. Dis. 1992;146(2):419–26. - PubMed
    1. Zilberberg MD, Epstein SK. Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome. Am. J. Respir. Crit. Care Med. 1998;157(4):1159–64. - PubMed
    1. Amato MBP, Barbas CSV, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, Kairalla RA, Deheinzelin D, Munoz C, Olveira R, Takagaki TY, Carvalho CRR. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N. Engl. J. Med. 1998;338(6):347–54. - PubMed
    1. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N. Engl. J. Med. 2000;342:1301–8. - PubMed

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