右美托咪定與全憑靜脈麻醉治療小兒甦醒期譫妄的比較:一項網路Meta分析

在選擇TIVA和七氟 烷 加右美托咪啶輔助 麻醉 時,應考慮患者的危險因素,如 甦醒期譫妄 和PONV, 再 進行臨床判斷。這些發現 受限于 證據品質不高(有條件建議)。

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右美托咪定與全憑靜脈麻醉治療小兒甦醒期譫妄的比較:一項網路Meta分析

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貴州醫科大學 麻醉與心臟電生理課題組  

翻譯:佟睿  編輯:張中偉  審校:曹瑩

背景

甦醒期譫妄  是兒科麻醉中常見的並發癥,發病率很高。全憑靜脈麻醉(TIVA)和術中右美托咪啶輔助七氟  烷  麻醉  與單純  七氟  烷  麻醉  相比  均可降低  甦醒期譫妄的  發生率,但尚無研究直接比較其相對療效。

目的

本研究的目的是比較TIVA和右美托咪啶對兒童  甦醒期譫妄  發生率的影響。

研究設計

本研究是對隨機對照試驗的系統綜述和網路  Meta  分析(NMA)。

資料來源

我們系統地搜索了包括Medline(Ovid)和Web of Science(Clarivate Analytics)  的  12個數據庫  中  自成立到2020年12月  的所有文獻  。

研究方法

納入標準為使用七氟  烷  、七氟  烷  加右美托咪啶或全憑靜脈注射  為  兒科患者進行全身麻醉的隨機對照試驗。數據由兩名評價者根據系統評價和  Meta  分析指南的首選報告項目提取,並使用NMA方法進行分析。計算所有  結局指標  [甦醒神志不清、術後噁心嘔吐(PONV)、甦醒時間和拔管時間]的風險比和95%可信區間(C  r  I)。該  試驗  已在Prospero註冊(CRD42018091237)。

結果

該系統綜述  納入  了66項符合條件的研究,其中包括5257例右美托咪啶聯合七氟  烷  、全憑靜脈注射和七氟  烷  單獨用藥組的粗中位數出現  譫  妄的發生率分別為12.8%、9.1%和40%。NMA顯示,與TIVA相比,七氟  烷  加右美托咪啶可降  甦醒期譫妄  的發生率,但無統計學差異(  風險  比0.88,95%C  r  I 0.61~1.20,證據品質低),但PONV發生率較高(  風險  比2.3,95%C  r  I 1.1~5.6,證據品質低),與TIVA組比較,差異無統計學意義(  風險  比0.88,95%C  r  I 0.61~1.20,證據品質低)。

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結論

在選擇TIVA和七氟  烷  加右美托咪啶輔助  麻醉  時,應考慮患者的危險因素,如  甦醒期譫妄  和PONV,  再  進行臨床判斷。這些發現  受限于  證據品質不高(有條件建議)。

原始文獻來源

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)

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