心脏手术后右美托咪定镇静效果的Meta分析

Effectiveness and Safety of Dexmedetomidine for Postoperative Sedation in Cardiac Patients: A Meta-Analysis

目的系统评价心脏手术后右美托咪定镇静的疗效和安全性。方法计算机检索PubMed、EBSCO、Springer、Ovid、Cochrane Library、CNKI、VIP和Wanfang Data,同时手工检索相关专业杂志并追溯纳入文献的参考文献,检索时限均为建库至2012年5月。由两名评价者按照纳入与排除标准选择试验、提取资料和评价质量后,采用RevMan 5.1软件进行Meta分析。结果纳入8个随机对照试验(RCT),共1 157例患者。7个RCT的Jadad评分>3分,仅1个为2分。Meta分析结果显示:与对照组比较,右美托咪定更能提高末梢血氧饱和度[RR=0.90,95%CI(0.31,0.49),P=0.003],降低平均心率[RR=–5.86,95%CI(–7.31,–4.40),P<0.000 01]、室性心动过速[RR=0.27,95%CI(0.08,0.88),P=0.03]、躁动[RR=0.28,95%CI(0.16,0.48),P<0.000 01]、高血糖[RR=0.57,95%CI(0.38,0.85),P=0.006]的发生率,还能减少需要肾上腺素[RR=0.53,95%CI(0.29,0.96),P=0.04]及β-受体阻滞剂支持的患者数[RR=0.60,95%CI(0.38,0.94),P=0.03]。但右美托咪定并不能缩短心脏术后患者ICU住院时间[RR=–1.24,95%CI(–4.35,1.87),P=0.43]和机械通气时间[RR=–2.28,95%C(I–5.13,0.57),P=0.12],也不能提高平均动脉压[RR=–2.78,95%CI(–6.89,1.34),P=0.19],且对术后恶心呕吐和房颤的控制效果不佳。此外,两组患者在心肌梗死、急性心衰、急性肾衰及病死率方面,差异无统计学意义。结论右美托咪定用于心脏手术术后镇静时可明显稳定血流动力学指标,降低室性心动过速、躁动及术后高血糖的发生率并减少血管活性药物的应用,但对患者预后无明显影响。由于纳入研究的数量和质量有限,本研究结论尚需高质量、大样本的RCT证实。

Objective To evaluate the effectiveness and safety of dexmedetomidine for postoperative sedation in cardiac patients. Methods Such databases as PubMed, EBSCO, Springer, Ovid, The Cochrane Library, CBM, CNKI, VIP and WanFang Data were searched electronically from the date of their establishment to May 2012, and other relevant journals and references of the included literature were also searched manually. Two reviewers independently screened the studies in accordance with the inclusion and exclusion criteria, extracted data and assessed methodology quality. Then the meta-analysis was performed using RevMan 5.1software. Results A total of 8 randomized controlled trials （RCTs） in- volving 1 157 patients were included. The Jadad scores of 7 RCTs were more than 3, and only 1 RCT scored 2. The results of meta-analysis showed that compared with the control group, dexmedetomidine significantly raised peripheral oxygen saturation （RR=0.90, 95%CI 0.31 to 0.49, P=0.003）, decreased the incidence of average heart rate （RR=-5.86, 95%CI -7.31 to -4.40, P〈0.000 01）, ventricular tachycardia （RR=0.27, 95%CI 0.08 to 0.88, P=0.03）, delirium （RR=0.28, 95%CI 0.16 to 0.48, P〈0.000 01） and postoperative hyperglycemia （RR=0.57, 95%CI 0.38 to 0.85, P=0.006）, and reduced the number of patients who needed vasoactive agents such as epinephrine （RR=0.53, 95%CI 0.29 to 0.96, P=0.04） and [3-blocker （RR=0.60, 95%CI 0.38 to 0.94, P=0.03）. However, it failed to shorten the time of both ICU stay （RR=-l.24, 95%CI -4.35 to 1.87, P=0.43） and mechanical ventilation （RR=-2.28, 95%CI -5.13 to 0.57, P=0.12）, increase mean artery pressure （RR=-2.78, 95%CI -6.89 to 1.34, P=0.19）, and well control postoperative nausea, vomiting and atrial-fibrillation. There were no sig- nificant differences between the two groups in myocardial infarction, acute cardiac failure, acute kidney failure, and mortality rate. Conclusion For postoperative sedation in cardiac patients, dexmedetomidine can effectively stabilize hemo- dynamic indexes, and reduce tachycardia, delirium, postoperative hyperglycemia and vasoactive agents. However, it has no marked influence on the prognosis. For the quantity and quality limitation of included studies, this conclusion needs to be proved by performing more high quality and large sample RCTs.