神经刺激器定位对周围神经阻滞效果和安全性的影响

Efficacy and Safety of Nerve-stimulator-guide Needle Placement in Peripheral Nerve Block:A Systematic Review

目的系统评价神经刺激器引导下的神经阻滞效果和安全性。方法采用Cochrane系统评价方法,计算机检索Cochrane Library(2008年第1期)、OVID(1950～2008.04)、VIP(1989～2008.04)、CNKI(1979～2008.04)、CBM(1978～2008.04)等数据库。由3名评价者共同评价纳入研究质量,并采用RevMan4.2.9进行Meta分析。结果共纳入20个RCT,包括1287例患者。仅2个研究描述了具体的随机方法、分配隐藏和盲法,其余研究均未完整描述。按定位方法和测量指标进行亚组分析,Meta分析结果显示:①阻滞绝对成功率:神经刺激器定位法成功率高于异感定位法[OR=4.36,95%CI(1.97,9.67),P=0.0003]和解剖定位法[OR=30.3,95%CI(1.73,532.74),P=0.02],但低于超声定位法[OR=0.27,95%CI(0.06,1.21),P=0.09]。②阻滞起效时间:神经刺激器法与异感法相似[WMD=–1.78,95%CI(–4.50,0.95),P=0.20],比动脉搏动法快[WMD=–6.00,95%CI(–11.71,–0.29),P=0.04],但慢于超声定位法[WMD=8.38,95%CI(0.72,16.04),P=0.04]。③阻滞相关并发症总发生率:神经刺激器定位法与异感定位法[OR=0.98,95%CI(0.33,2.93),P=0.97]、解剖定位法[OR=0.06,95%CI(0.00,1.21),P=0.07]和动脉搏动法[OR=0.65,95%CI(0.10,4.11),P=0.65]相似,但高于超声定位法[OR=4.87,95%C(I1.68,14.15),P=0.004]。④阻滞实施时间:神经刺激器法与异感法相似[WMD=–0.62,95%C(I–3.09,1.86),P=0.63],比动脉搏动法短[WMD=–4.00,95%CI(–5.58,–2.42),P<0.00001],但长于超声定位法[WMD=1.90,95%C(I0.47,3.33),P=0.009]。⑤患者接受率:神经刺激器法比异感法具有更高的接受率[OR=2.32,95%C(I1.02,5.30),P=0.05],但与动脉搏动法相似[OR=8.14,95%CI(0.88,75.48),P=0.06]。结论现有研究显示,神经刺激器定位法进行神经阻滞是一种定位准确、阻滞效果好,安全性高,患者易接受的定位方法。但鉴于本系统评价纳入研究存在选择性偏倚和测量性偏倚的中度可能性,以上结论仅供参考。并期待有更多高质量的随机、盲法测定的试验提供质量更可靠的证据。

Objective To assess the efficacy and safety of nerve-stimulator-guide needle placement in the peripheral nerve blockade. Methods The Cochrane Library, MEDLINE, OVID, VIP, CNKI and CBM were searched. The quality of the included studies was evaluated by three reviewers, and meta-analysis was performed. Results Twenty studies involving 1 287 participants related to needle placement in the peripheral nerve blockade were included. There were only 2 studies that described a detailed randomization method and allocation concealment and blinding, and the others were inadequate. Meta-analysis based on the included studies showed that： （1） Absolute success ratio： nerve-stimulatorguide was higher than eliciting paraesthesia （OR= 4.05, 95%CI 2.57 to 6.36, P〈0.00001） and anatomy localization （OR=30.3, 95%CI 1.73 to 532.74, P=0.02）, but lower than ultrasound-guide-localization （OR=0.27, 95%CI 0.10 to 0.74, P=0.01）. （2） Onset time of the block： nerve-stimulator-guide was similar to eliciting paraesthesia （WMD= -1.70, 95%CI -4.50 to 0.95, P=0.08）, faster than arteriopalmus localization （WMD= 8.38, 95%CI 0.72 to 16.04, P〈0.000 01）, but slower than ultrasound-guide-localization （WMD= 8.38, 95%CI 0.72 to 16.04, P=0.04）. （3） Ratio of complication associated to block： nerve-stimulator-guide was similar to eliciting paraesthesia （OR= 1.01, 95%CI 0.55 to 1.86, P=0.97）, anatomy localization （WMD= 0.06, 95%CI 0.00 to 1.21, P=0.07） and arteriopalmus localization （WMD= 8.82, 95%CI 0.10 to 4.11, P=0.65）, but higher than ultrasound-guide-localization （OR= 5.03, 95%CI 1.74 to 14.49, P=0.003）. （4） Time toblock： nerve-stimulator-guide was similar to eliciting paraesthesia （WMD=0.02, 95%CI -0.46 to 0.51, P=0.92）, shorter than arteriopalmus localization （WMD=-4.00, 95%CI -5.58 to -2.42, P〈0.000 01） and longer than ultrasound-guidelocalization （WMD= 1.90, 95%CI 0.47 to 3.33, P=0.009）. （5） Patient-accepted ratio： nerve-stimulator-guide was higher than eliciting paraesthesia （OR=2.32, 95%CI 1.02 to 5.30, P=0.05）, and similar to arteriopalmus localization （OR=8.14, 95%CI 0.88 to 75.48, P=0.06）. Conclusion Nerve-stimulator-guide location is a precise, effective and safe localization method. Due to moderate risk of selection bias and detection bias of included studies, the evidence is not strong. Our results suggest that well-designed double-blind randomized controlled and larger-scale trials on the use of nerve stimulator in the peripheral nerve block are needed.