Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy.
OBJECTIVE
In this study, we examined whether (1) positive end-expiratory pressure (PEEP) has a protective effect on the risk of major postoperative respiratory complications in a cohort of patients undergoing major abdominal surgeries and craniotomies, and (2) the effect of PEEP is differed by surgery type.


BACKGROUND
Protective mechanical ventilation with lower tidal volumes and PEEP reduces compounded postoperative complications after abdominal surgery. However, data regarding the use of intraoperative PEEP is conflicting.


METHODS
In this observational study, we included 5915 major abdominal surgery patients and 5063 craniotomy patients. Analysis was performed using multivariable logistic regression. The primary outcome was a composite of major postoperative respiratory complications (respiratory failure, reintubation, pulmonary edema, and pneumonia) within 3 days of surgery.


RESULTS
Within the entire study population (major abdominal surgeries and craniotomies), we found an association between application of PEEP ≥5 cmH2O and a decreased risk of postoperative respiratory complications compared with PEEP <5 cmH2O. Application of PEEP >5 cmH2O was associated with a significant lower odds of respiratory complications in patients undergoing major abdominal surgery (odds ratio 0.53, 95% confidence interval 0.39 - 0.72), effects that translated to deceased hospital length of stay [median hospital length of stay : 6 days (4-9 days), incidence rate ratios for each additional day: 0.91 (0.84 - 0.98)], whereas PEEP >5 cmH2O was not significantly associated with reduced odds of respiratory complications or hospital length of stay in patients undergoing craniotomy.


CONCLUSIONS
The protective effects of PEEP are procedure specific with meaningful effects observed in patients undergoing major abdominal surgery. Our data suggest that default mechanical ventilator settings should include PEEP of 5-10 cmH2O during major abdominal surgery.
Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Myrthe A C
MAC
de Jong
Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Karim S
KS
Ladha
Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Marcos F
MF
Vidal Melo
Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.|Department of Anesthesiology, University of Copenhagen, Herlev Hospital, Copenhagen, Denmark.
Anne Kathrine
AK
Staehr-Rye
Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Edward A
EA
Bittner
Inserm Research Center for Epidemiology and Biostatistics (U897) -Team Neuroepidemiology, Bordeaux, France.|University of Bordeaux, College of Health Sciences, Bordeaux, France.|Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Tobias
T
Kurth
Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.|Essen-Duisburg University, Essen, Germany.
Matthias
M
Eikermann
D000005:Abdomen / Q000601:surgery*; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003399:Craniotomy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration; D011183:Postoperative Complications / Q000517:prevention & control*; D012120:Respiration Disorders / Q000517:prevention & control*; D013990:Tidal Volume