硬膜外镇痛对减少心脏手术术后并发症的有效性及安全性系统评价

Effectiveness and Safety of Thoracic Epidural Analgesia for Postoperative Complications after Cardiac Surgery: A Systematic Review

目的系统评价心脏手术中实施硬膜外镇痛对减少心脏手术术后并发症的有效性和安全性。方法计算机检索PubMed、SCI、EMbase、he Cochrane Library、CNKI和CBM等数据库,全面收集硬膜外镇痛减少心脏手术术后并发症的随机对照试验(RCT),检索时限均为建库至2012年10月,并追溯纳入研究的参考文献。由两位研究者按照纳入与排除标准独立筛选文献、提取资料和评价质量后,采用RevMan 5.0软件进行Meta分析。结果共纳入14个RCT,1 942例患者。Meta分析结果显示:联合硬膜外镇痛组在减少心肌缺血及梗死发生率[RR=0.63,95%CI(0.41,0.96),P=0.03]、呼吸系统并发症发生率[RR=0.55,95%CI(0.40,0.75),P=0.000 1]、室上性心律失常发生率[RR=0.64,95%CI(0.47,0.88),P=0.005]和机械通气时间[MD=–2.15,95%CI(–3.72,–0.58),P=0.00 7]方面均优于单独使用全身麻醉组,且差异均有统计学意义。结论基于当前证据,术后硬膜外镇痛可降低心脏手术患者术后心肌缺血及梗死、呼吸系统并发症、室上性心律失常发生率并减少机械通气时间。但目前缺乏评估硬膜外镇痛不良事件(主要为硬膜外血肿)发生率的数据。受纳入研究数量与质量限制,临床上在选择是否使用硬膜外镇痛之前,应该对患者各方面情况进行综合考虑。

Objective To systematically review the effectiveness and safety of thoracic epidural analesis （TEA） for postoperative complications after cardiac surgery. Methods Such databases as PubMed, Science Citation Index, EMbase, The Cochrane Library, CNKI and CBM were electronically searched from inception to October 2012 for collecting the randomized controlled trials on the effectiveness and safety of thoracic epidural analgesisa for postoperative complications after cardiac surgery. Two reviewers independently screened literature according to inclusion and exclusion criteria, extracted data, and assessed the methodological quality of the included studies. Then, meta-analysis was performed using RevMan 5.1 software. Results Totally 14 studies were eligible, involving 1 942 patients. The results of meta-analysis showed that, TEA combined with general anesthesia （GA） was superior to GA alone in reducing the incidences of myocardial ischemia/infarction （RR=0.63, 95%CI 0.41 to 0.96, P=0.03）, respiratory complications （RR=0.55, 95%CI 0.40 to 0.75, P=0.000 1）, supraventricular arrhythmias （RR=0.64, 95%CI 0.47 to 0.88, P=0.005）, and duration of mechanical ventilation （MD= –2.15, 95%CI –3.72 to –0.58, P=0.007）, with significant differences. Conclusions Current evidence shows that, TEA after surgery is effective in reducing the incidences of myocardial ischemia/infarction, respiratory complications, supraventricular arrhythmias, and duration of mechanical ventilation. There is the lack of data on the adverse events of TEA （mainly referring to epidural hematoma）. Due to limited quality and quantity of the included studies, patients’ conditions should be fully considered before applying TEA in clinical practice.