小儿下腹部和泌尿外科手术中骶管阻滞辅助药物的比较：一项网络Meta分析

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小儿下腹部和泌尿外科手术中骶管阻滞辅助药物的比较：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：潘志军  编辑：潘志军  审校：曹莹

研究目的：骶管阻滞有助于缓解小儿下腹部手术后的疼痛；然而，它发挥镇痛作用的持续时间是有限的。在局部麻醉剂（LA）中加入某些辅助剂，用于实施骶管阻滞，可以延长术后镇痛。因此，我们的目的是比较小儿下腹部和泌尿外科手术中骶管阻滞辅助剂的疗效和副作用。

试验设计：一项网络Meta分析 (NMA)。   

受试人群：最终分析了6800名儿科患者，包括112项随机对照试验（RCT）。

干预措施：不同的辅助剂，即可乐定、地塞米松、右美托咪定、芬太尼、氯胺酮、硫酸镁、咪唑安定、吗啡、新斯的明和曲马多。

测定方法：主要结果是镇痛持续时间。次要结果包括需要额外的镇痛、镇痛剂消耗量和术后并发症。分别使用NMA和优选概率排名曲线得分下的面积来评估效果和排名。

主要结果：新斯的明、右美托咪定和地塞米松被发现是延长骶管阻滞镇痛持续时间的三种最有效辅助剂，它们分别延长了8.9小时（95%可信区间[CI]，7.1-10.7）、7.3小时（95%CI，6.0-8.6）和5.9小时（95%置信区间，4.0-7.7）。添加新斯的明与术后恶心和呕吐的发生率增加有关，而右美托咪定和地塞米松没有发生术后并发症。

结论：这项NMA提供了证据，并提示右美托咪定和地塞米松可能是最有益的局麻药辅助剂，对于儿童的骶管阻滞。然而，考虑到骶管辅助使用右美托咪定和地塞米松仍不是这两个药物的适应症，故仍需进一步进行高质量的RCT，特别是确定是否会发生迟发性神经并发症。

原始文献来源：

Chang Xiong，Chengpeng Han, Huayan Lv,et al.Comparison of adjuvant pharmaceuticals for caudal block in pediatric lower abdominal and urological surgeries: A network meta-analysis [J]. (J Clin Anesth 2022 10;81).

  英文原文

Comparison of adjuvant pharmaceuticals for caudal block in pediatric lower abdominal and urological surgeries: A network meta-analysis

Abstract

Study objective: Caudal block helps relieve pain after sub-umbilical surgery in pediatric patients; however, the duration for which it exerts its analgesic effect is limited. The addition of certain adjuvant agents to local anesthetics (LAs) that are used to administer caudal block can prolong postoperative analgesia. Therefore, we aimed to compare the efficiencies and side effects of caudal adjuvants in the settings of pediatric lower abdominal and urological surgeries.

Design: A network meta-analysis (NMA).

Patients: One hundred and twelve randomized controlled trials (RCTs) involving 6800 pediatric patients were included in the final analysis.

Interventions: Different adjuvant agents, namely clonidine, dexamethasone, dexmedetomidine, fentanyl, ketamine, magnesium, midazolam, morphine, neostigmine, and tramadol.

Measurements: The primary outcome was the duration of analgesia. The secondary outcomes included the requirement for additional analgesia, analgesic consumption, and postoperative complications. The effects and rankings were evaluated using NMA and the surface under the cumulative ranking curve scores, respectively.

Results: Neostigmine, dexmedetomidine, and dexamethasone were found to be the three most effective adjuvants that prolong the duration of analgesia for caudal block, and these adjuvants extended this duration by 8.9 h (95% confidence interval [CI], 7.1–10.7), 7.3 h (95% CI, 6.0–8.6), and 5.9 h (95% CI, 4.0–7.7), respectively. Caudal neostigmine was associated with an increase in the incidence of postoperative nausea and vomiting, whereas dexmedetomidine and dexamethasone showed no postoperative complications.

Conclusions: This NMA provided evidence and suggested that dexmedetomidine and dexamethasone may be the most beneficial adjuvant pharmaceutics adding to LAs for caudal block in children. However, given the off-label status of caudal dexmedetomidine and dexamethasone, further high-quality RCTs are still warranted, especially to determine whether delayed neurological complications will occur.

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