• Guido Mazzinari, Fernando G Zampieri, Lorenzo Ball, Niklas S Campos, Thomas Bluth, Sabrine Nt Hemmes, Carlos Ferrando, Julian Librero, Marina Soro, Paolo Pelosi, Gama de AbreuMarceloMDepartment of Intensive Care and Resuscitation, Institute of Anesthesiology, Cleveland Clinic, 13951 Terrace Rd, Cleveland, OH 44112, USA.Department of Cardiothoracic Anesthesia, Institute of Anesthesiology, Cleveland Clinic, 13951 Te, Marcus J Schultz, Ary Serpa Neto, for REPEAT, PROVHILO, iPROVE, PROBESE Investigators, and PROVE Network investigators.
• Department of Anesthesiology and Pain Medicine, Hospital Universitario y Politécnico la Fe Avenida Fernando Abril Martorell 106, 46026, Valencia, Spain.
• Anesthesiology. 2024 Jul 22.

BackgroundThe influence of high positive end-expiratory pressure (PEEP) with recruitment maneuvers on the occurrence of postoperative pulmonary complications after surgery is still not definitively established. Bayesian analysis can help to gain further insights from the available data and provide a probabilistic framework that is easier to interpret. Our objective was to estimate the posterior probability that the use of high PEEP with recruitment maneuvers is associated with reduced postoperative pulmonary complications in patients with intermediate-to-high risk under neutral, pessimistic, and optimistic expectations regarding the treatment effect.MethodsMultilevel Bayesian logistic regression analysis on individual patient data from three randomized clinical trials carried out on surgical patients at Intermediate-to-High Risk for postoperative pulmonary complications. The main outcome was the occurrence of postoperative pulmonary complications in the early postoperative period. We studied the effect of high PEEP with recruitment maneuvers versus Low PEEP Ventilation. Priors were chosen to reflect neutral, pessimistic, and optimistic expectations of the treatment effect.ResultsUsing a neutral, pessimistic, or optimistic prior, the posterior mean odds ratio (OR) for High PEEP with recruitment maneuvers compared to Low PEEP was 0.85 (95% Credible Interval [CrI] 0.71 to 1.02), 0.87 (0.72 to 1.04), and 0.86 (0.71 to 1.02), respectively. Regardless of prior beliefs, the posterior probability of experiencing a beneficial effect exceeded 90%. Subgroup analysis indicated a more pronounced effect in patients who underwent laparoscopy (OR: 0.67 [0.50 to 0.87]) and those at high risk for PPCs (OR: 0.80 [0.53 to 1.13]). Sensitivity analysis, considering severe postoperative pulmonary complications only or applying a different heterogeneity prior, yielded consistent results.ConclusionHigh PEEP with recruitment maneuvers demonstrated a moderate reduction in the probability of PPC occurrence, with a high posterior probability of benefit observed consistently across various prior beliefs, particularly among patients who underwent laparoscopy.Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.

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