右美托咪定与全凭静脉麻醉治疗小儿苏醒期谵妄的比较：一项网络Meta分析

本文由“罂粟花”授权转载

右美托咪定与全凭静脉麻醉治疗小儿苏醒期谵妄的比较：一项网络Meta分析

贵州医科大学 麻醉与心脏电生理课题组  

翻译：佟睿  编辑：张中伟  审校：曹莹

背景

苏醒期谵妄  是儿科麻醉中常见的并发症，发病率很高。全凭静脉麻醉(TIVA)和术中右美托咪啶辅助七氟  烷  麻醉  与单纯  七氟  烷  麻醉  相比  均可降低  苏醒期谵妄的  发生率，但尚无研究直接比较其相对疗效。

目的

本研究的目的是比较TIVA和右美托咪啶对儿童  苏醒期谵妄  发生率的影响。

研究设计

本研究是对随机对照试验的系统综述和网络  Meta  分析(NMA)。

资料来源

我们系统地搜索了包括Medline(Ovid)和Web of Science(Clarivate Analytics)  的  12个数据库  中  自成立到2020年12月  的所有文献  。

研究方法

纳入标准为使用七氟  烷  、七氟  烷  加右美托咪啶或全凭静脉注射  为  儿科患者进行全身麻醉的随机对照试验。数据由两名评价者根据系统评价和  Meta  分析指南的首选报告项目提取，并使用NMA方法进行分析。计算所有  结局指标  [苏醒神志不清、术后恶心呕吐(PONV)、苏醒时间和拔管时间]的风险比和95%可信区间(C  r  I)。该  试验  已在Prospero注册(CRD42018091237)。

结果

该系统综述  纳入  了66项符合条件的研究，其中包括5257例右美托咪啶联合七氟  烷  、全凭静脉注射和七氟  烷  单独用药组的粗中位数出现  谵  妄的发生率分别为12.8%、9.1%和40%。NMA显示，与TIVA相比，七氟  烷  加右美托咪啶可降  苏醒期谵妄  的发生率，但无统计学差异(  风险  比0.88，95%C  r  I 0.61~1.20，证据质量低)，但PONV发生率较高(  风险  比2.3，95%C  r  I 1.1~5.6，证据质量低)，与TIVA组比较，差异无统计学意义(  风险  比0.88，95%C  r  I 0.61~1.20，证据质量低)。

结论

在选择TIVA和七氟  烷  加右美托咪啶辅助  麻醉  时，应考虑患者的危险因素，如  苏醒期谵妄  和PONV，  再  进行临床判断。这些发现  受限于  证据质量不高(有条件建议)。

原始文献来源

Maria-Alexandra Petre, David N. Levin, Marina Englesakis  ,  et al. Dexmedetomidine vs. total intravenous anaesthesia in     paediatric emergence delirium  :  A network meta-analysis.[J].Eur J Anaesthesiol     2021;38:1111–1123  .

Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis

Abstract

BACKGROUND   Emergence delirium is a common complication in paediatric anaesthesia associated with significant morbidity. Total intravenous anaesthesia (TIVA) and intraoperative dexmedetomidine as an adjuvant to sevoflurane anaesthesia can both reduce the incidence of emergence delirium compared with sevoflurane alone, but no studies have directly compared their relative efficacy. OBJECTIVE   The study objective was to compare the effects of TIVA and dexmedetomidine on the incidence of paediatric emergence delirium. STUDY DESIGN   The current study is a systematic review and network meta-analysis (NMA) of randomised controlled trials. DATA SOURCES   We conducted a systematic search of 12 databases including Medline (Ovid) and Web of Science (Clarivate Analytics) from their respective inception to December 2020. ELIGIBILITY   Inclusion criteria were randomised controlled trials of paediatric patients undergoing general anaesthesia using sevoflurane, sevoflurane with dexmedetomidine or TIVA. Data were extracted by two reviewers according to Preferred Reporting Items for Systematic Reviews and Metaanalyses guidelines and analysed using NMA methodology. Risk ratios and 95% credible intervals (CrI) were calculated for all outcomes [emergence delirium, postoperative nausea and vomiting (PONV), and time to emergence and extubation]. The protocol was registered with PROSPERO (CRD42018091237). RESULTS   The systematic review returned 66 eligible studies comprising 5257 patients with crude median emergence delirium incidences of 12.8, 9.1 and 40% in the dexmedetomidine with sevoflurane, TIVA and sevoflurane alone groups, respectively. NMA indicated that compared with TIVA, sevoflurane with adjuvant dexmedetomidine decreased the incidence of emergence delirium without statistical difference (risk ratio 0.88, 95% CrI 0.61 to1.20, low quality of evidence), but resulted in a higher incidence of PONV (risk ratio: 2.3, 95% CrI 1.1 to 5.6, low quality of evidence). CONCLUSION   Clinical judgement, considering the patient’s risk factors for the development of clinically significant outcomes such as emergence delirium and PONV, should be used when choosing between TIVA and sevoflurane with adjuvant dexmedetomidine. These findings are limited by the low quality of evidence (conditional recommendation)