心血管干预在肝切除术中减少失血的应用：系统性评价和meta分析

心血管干预在肝切除术中减少失血的应用：系统性评价和meta分析

贵州医科大学     麻醉与心脏电生理课题组

翻译 :  宋雨婷    编辑 :  严旭    审校 :  曹莹

背景：围术期失血和异体输血通常会影响患者的预后。这项meta分析旨在确定几种心血管干预措施对肝切除术患者的益处和风险。

方法：该系统性综述和meta分析，在Cochrane Library、Medline、Embase和Web of Science检索了截至2023年2月2日的随机对照试验（RCTs）。本研究纳入了在肝切除术期间减少失血或输血需求的心血管干预的随机对照试验。主要观察结果是围术期失血量、需要异体输血的患者数量和术后并发症的总发生率。次要观察结果是手术时间、围术期死亡率、术后肝肾功能和住院时间。

结果：此次研究纳入17项随机对照试验。10项试验中行肝切除术的841例患者被纳入低中心静脉压（CVP）组与对照组的比较分析。森林图显示手术出血量较少[（均差（MD）：-409.75 mL，95%置信区间（CI）-616.56至-202.94，P < 0.001]，输血率较低[风险比（RR）：0.47，95%CI 0.34至0.65，P <0.001]， 手术时间较短（MD：-13.42分钟，95%CI -22.59至-4.26，P = 0.004），术后并发症较少（RR： 低CVP组为0.76，95%CI 0.58至0.99，P = 0.04）。五项和两项试验分别比较了以下干预措施：“急性等容性血液稀释（ANH）与对照组”和“自体血回输与对照组”。ANH和自体血回输不能减少失血量，但大大减少了异体输血的患者数量。在上述比较中，死亡率和术后住院时间无显著差异。

结论：降低CVP似乎对接受肝切除术的成年患者有效且安全。在某些情况下，ANH和自体血回输应作为患者血液管理的一部分。

原始文献来源 ：  

Ye, H., Wu, H., Li, B. et al. Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis. BMC Anesthesiol 23, 89 (2023).

英文原文

The Minimum Effective Concentration (MEC95) of different volumes of ropivacaine for ultrasound-guided caudal epidural block: a dose-finding study

Abstract

Background  Caudal epidural block (CEB) may be beneficial in anorectal surgery because its use may extend postoperative analgesia. This dose-finding study aimed to estimate the minimum effective anesthetic concentrations for 95% patients(MEC95) of 20 ml or 25 ml of ropivacaine in with CEB.

Patients and methods  In this double-blind, prospective study, the concentration of ropivacaine administered in 20 ml and 25 ml for ultrasound-guided CEB were determined using the sample up-and-down sequential allocation study design of binary response variables. The first participant was given 0.5% ropivacaine. Depending on whether a block was successful or unsuccessful, the concentration of local anesthesia was decreased or increased by 0.025% in the next patient. Every five minutes for 30 min, the sensory blockade using a pin-prick sensation at S3 dermatome compared to at T6 dermatome were evaluated every 5 min within 30 min. An effective CEB was defined as a a reduction of sensation at S3 dermatome and the existence of flaccid anal sphincter. Anesthesia was considered successful if the surgeon could perform the surgery without additional anesthesia. We determined the MEC50 using the Dixon and Massey up-and-down method and estimated the MEC95 using probit regression.

Results  The concentration of ropivacaine administered in 20 ml for CEB ranged from 0.2% to 0.5%. Probit regression with a bias-corrected Morris 95% CI derived by bootstrapping showed an MEC50 and MEC 50 of ropivacaine for anorectal surgical anesthesia were 0.27% (95% CI, 0.24 to 0.31) and 0.36%(95% CI, 0.32 to 0.61). The concentration of ropivacaine administered in 25 ml for CEB ranged from 0.175 to 0.5. Probit regression with a bias-corrected Morris 95% CI derived by bootstrapping showed an MEC50 and MEC95 for CEB were 0.24% (95% CI, 0.19 to 0.27) and 0.32% (95% CI, 0.28 to 0.54).

Conclusion  With ultrasound-guided CEB, the MEC95 of 0.36% ropivacaine at 20 ml and 0.32% ropivacaine at 25 ml provide adequate surgical anesthesia/analgesia 95% of patients undergoing anorectoal 

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