证据综合 | 减少动脉穿刺相关疼痛的干预措施：系统评价和荟萃分析

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Abstract

Background

Arterial puncture-related pain remains unaddressed across several clinical settings. Analgesic techniques are not routinely employed before arterial puncture despite the recommendation that local anesthesia be used, except in emergencies. A comprehensive review of interventions aimed at reducing arterial puncture-related pain and their potential effectiveness is lacking, and the benefit of some interventions is uncertain.

Objective

To describe interventions aimed at reducing arterial puncture-related pain and provide an estimate of their effectiveness.

Design

Systematic review and meta-analysis (PROSPERO no. CRD42020212299).

Data source(s)

PubMed, CINAHL EBSCO, EMBASE, the Cochrane Database of Systematic Reviews, and Scopus were searched from their inception to 7 October 2020. No temporal or language limits were applied.

Methods

Published, quantitative studies on interventions aimed at reducing arterial puncture-related pain among adults were included. Screening, quality appraisal, and data extraction were undertaken independently by two reviewers. Random effects meta-analyses were performed to assess the association between interventions aimed at reducing arterial puncture-related pain and patients’ perceived pain using difference in means (MD) with 95% confidence intervals (CIs). A funnel plot and Egger test were used to assess publication bias.

Results

The titles and abstracts of the 2446 identified articles were screened, and 43 and 31 studies were finally included in the systematic review and meta-analysis, respectively. Interventions to reduce arterial puncture-related pain included: topical anesthetics (n=16), cryotherapy (n=9), local anesthetic infiltration (n=5), narrower needle gauge (n=5), ultrasound-guided procedure (n=3), topical anesthetics combined with local anesthetic infiltration (n=1), iontophoresis using anesthetics (n=1), engineered blood gas syringe (n=1), jet injector (n=1), and local massage (n=1). Topical anesthetics [MD -0.58, 95% CI -1.00, -0.15], cryotherapy [MD -1.13, 95% CI -1.72, -0.53], and local anesthetic infiltration [MD -1.13, 95% CI -1.72, -0.53] reduced arterial puncture-related pain. No benefit was found for narrower needle gauge [MD -0.07, 95% CI -0.86, 0.71] or ultrasound-guided procedure [MD -1.74, 95% CI -3.51, 0.03]. No publication bias was detected.

Conclusions

Local anesthetic infiltration provided the greatest pain reduction and should be considered standard practice. Cryotherapy may be a safe, convenient alternative to local anesthetic infiltration. Topical anesthetics had limited benefit, and their lengthy time of onset makes them unsuitable for critical or emergency situations, though they may represent an option when comorbid conditions make cooling impossible. Caution must be used when interpreting these results, given the high risk of bias in the methods of included studies and the heterogeneity across the studies.

摘要翻译（仅供参考）

背景介绍

在一些临床环境中，与动脉穿刺有关的疼痛仍然没有得到解决。尽管建议使用局部麻醉，但在动脉穿刺前并没有常规使用镇痛技术，除非是在紧急情况下。目前还缺乏对旨在减少动脉穿刺相关疼痛的干预措施及其潜在有效性的全面审查，而且一些干预措施的益处也不确定。

目的

描述旨在减少动脉穿刺相关疼痛的干预措施，并提供对其有效性的估计。

设计

系统回顾和荟萃分析（PROSPERO编号：CRD42020212299）。

数据来源

对PubMed、CINAHL EBSCO、EMBASE、Cochrane系统回顾数据库和Scopus进行了检索，检索时间从开始到2020年10月7日。没有使用时间或语言限制。

研究方法

纳入已发表的、旨在减少成人动脉穿刺相关疼痛的干预措施的定量研究。筛选、质量评估和数据提取由两位评审员独立完成。进行随机效应荟萃分析以评估旨在减少动脉穿刺相关疼痛的干预措施与患者感知到的疼痛之间的关系，使用均值差异（MD）和95%置信区间（CIs）。漏斗图和Egger测试被用来评估出版偏倚。

结果

对2446篇文章的标题和摘要进行了筛选，最终分别有43项和31项研究被纳入系统回顾和荟萃分析。减少动脉穿刺相关疼痛的干预措施包括。局部麻醉剂（n=16），冷冻疗法（n=9），局部麻醉剂浸润（n=5），更窄的针距（n=5），超声引导下的手术（n=3），局部麻醉剂结合局部麻醉剂浸润（n=1），使用麻醉剂的离子电渗（n=1），工程血气注射器（n=1），喷射注射器（n=1），以及局部按摩（n=1）。局部麻醉剂[MD -0.58, 95% CI -1.00, -0.15]、冷冻疗法[MD -1.13, 95% CI -1.72, -0.53]和局部麻醉剂浸润[MD -1.13, 95% CI -1.72, -0.53]减少了动脉穿刺相关疼痛。较窄的针距[MD -0.07, 95% CI -0.86, 0.71]或超声引导下的手术[MD -1.74, 95% CI -3.51, 0.03]没有发现好处。没有发现出版偏倚。

结论

局部麻醉剂浸润提供了最大的疼痛缓解，应被视为标准做法。冷冻疗法可能是一种安全、方便的局部麻醉剂浸润的替代方法。局部麻醉剂的益处有限，其漫长的起效时间使其不适合在危急或紧急情况下使用，尽管当合并症导致无法冷却时，它们可能是一种选择。鉴于所纳入的研究方法存在较高的偏倚风险，且各研究之间存在异质性，因此在解释这些结果时必须谨慎行事。