瑞芬太尼与其它不同药物预防依托咪酯诱发肌阵挛的疗效和安全性比较：随机对照试验

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Comparison of the efficacy and safety of remifentanil versus different pharmacological approaches on prevention of etomidate-induced myoclonus: a meta-analysis of randomized controlled trials

背景与目的

使用依托咪酯麻醉诱导常发生肌阵挛而导致临床麻醉过程风险增加。本研究旨在比较瑞芬太尼与其它不同药物处理对减少依托咪酯诱导产生的肌阵挛疗效差异。

方  法

我们搜索了PubMed、Embase、Cochrane图书馆和中国知网（CNKI）从建立到2018年10月的相关文献。将所有瑞芬太尼与其它药物在减少依托咪酯诱导的肌阵挛方面的随机对照试验纳入此次研究。

结 果  

最终，13项试验及1392名患者符合纳入标准。1） 瑞芬太尼预处理能降低依托咪酯所致肌阵挛的发生率；瑞芬太尼和咪达唑仑的使用没有什么不同(肌阵挛发生率：瑞芬太尼组为5.56%，生理盐水组为71.65%，P<0.0001;瑞芬太尼组为3.80%VS芬太尼组为13.33%;瑞芬太尼组46.00%VS咪达唑仑组55.45％)。2） 与安慰剂组相比，瑞芬太尼预处理可降低轻、中、重度肌阵挛的发生率；与咪达唑仑组相比，瑞芬太尼治疗的患者重症肌阵挛的发生率较低；与芬太尼组相比，瑞芬太尼预处理可显著降低中、重度肌阵挛的发生率。3） 与芬太尼相比，瑞芬太尼预处理可预防气管插管后血流动力学的过度波动。

结 论

瑞芬太尼预处理可作为降低依托咪酯麻醉诱导诱发肌阵挛发生率和严重程度的一种治疗选择。

原始文献摘要

Bingchen Lang,Lingli Zhang,Fengshan Li,et al.Comparison of the efficacy and safety of remifentanil versus different pharmacological approaches on prevention of etomidate-induced myoclonus: a meta-analysis of randomized controlled trials.Drug Design, Development and Therapy 2019,13:1593–1607

Objective: Myoclonus was considered as one conundrum in etomidate induction, which led to multiple risks during clinical anesthesia. The present study was conducted to compare the efficacy of pretreatment with remifentanil to different pharmacological approaches on reducing etomidate-induced myoclonus.

Methods: We searched PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure from the inception to October 2018. Randomized controlled trials comparing remifentanil versus other pharmacological approaches in reducing etomidateinduced myoclonus were eligible to be analyzed.

Results: Overall, 13 trials with 1,392 patients met with the inclusion criteria. 1) Pretreatment with remifentanil could reduce the incidence of etomidate-induced myoclonus compared to placebo and fentanyl; few differences were found between the use of remifentanil and the use of midazolam: (incidence of myoclonus: 5.56% with remifentanil vs 71.65% with saline, RR=0.08, with 95% CI [0.05, 0.12], P<0.0001; 3.80% with remifentanil vs 13.33% with fentanyl, RR with 95% 0.31 [0.11, 0.86], P=0.02; 46.00% with remifentanil vs 55.45% with midazolam, RR=0.82, with 95% CI [0.64, 1.06], P=0.13). 2) Compared with placebo, pretreatment with remifentanil could reduce the incidence of mild, moderate, and severe myoclonus; compared with midazolam, patients receiving remifentanil experienced lower occurrence of severe myoclonus; compared with fentanyl, pretreatment with remifentanil associated with significant low occurrence of moderate and severe myoclonus. 3) The outcomes also indicated that pretreatment with remifentanil could prevent excessive hemodynamic changes after endotracheal intubation compared to fentanyl.

Conclusions: Pretreatment with remifentanil could be considered as one operative option to reduce both incidence and severity of etomidate-induced myoclonus. Compared with fentanyl, it also provides efficacy in preventing excessive hemodynamic changes after endotracheal intubation. However, the best treatment and the proper prophylactic dosage calls for more high quality evidence with large sample size.

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