氢吗啡酮与吗啡用于剖宫产术后镇痛的有效性和安全性的系统评价

Hydromorphone versus morphine in the treatment of postoperative analgesia after cesarean section: a systematic review

目的系统评价氢吗啡酮与吗啡用于剖宫产术后镇痛治疗的有效性和安全性。方法计算机检索The Cochrane Central Register of Controlled Trials(CENTRAL)、PubMed、EMbase、CNKI、WanFang Data、VIP和SinoMed等数据库,搜集比较氢吗啡酮与吗啡应用于剖宫产术后镇痛的随机对照试验(RCT),检索时限均为建库至2017年12月。由2名评价员独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用RevMan 5.3软件进行meta分析。结果共纳入7个RCT,共586例剖宫产术后产妇。meta分析结果显示:氢吗啡酮组术后硬膜外镇痛泵给药6 h [MD=–0.23,95%CI(–0.38,–0.08),P=0.003]、12 h [MD=–0.56,95%CI(–1.10,–0.02),P=0.04]、24 h [MD=–0.37,95%CI(–0.65,–0.09),P=0.01]和48 h [MD=–0.41,95%CI(–0.74,–0.08),P=0.01]的疼痛视觉模拟评分(VAS)均低于与吗啡组。但两组在各时点Ramsay镇静评分的差异均无统计学意义。不良反应方面,氢吗啡酮组的瘙痒发生率[RR=0.27,95%CI(0.09,0.81),P=0.02]和呕吐发生率[RR=0.15,95%CI(0.03,0.65),P=0.01]均低于吗啡组,其差异均有统计学意义。结论现有证据表明,氢吗啡酮与吗啡相比,在剖宫产术后镇痛方面可能疗效更佳,且能够有效减少产妇的皮肤瘙痒及呕吐的不良反应。受纳入研究质量和数量的限制,上述结论尚待开展更多高质量研究予以验证。

Objectives To systematically review the efficacy and safety of hydromorphone and morphine in postcesarean section analgesia. Methods The Cochrane Central Register of Controlled Trials(CENTRAL), PubMed,EMbase, CNKI, WanFang Data, VIP and SinoMed databases were electronically searched to identify randomized controlled trials(RCTs) of hydromorphone vs. morphine in the treatment of postoperative analgesia after cesarean section from the inception of the database to December 2017. Two reviewers independently screened literatures, extracted data and assessed risk of bias of the included trials. The meta-analysis was conducted with RevMan 5.3 software. Results Seven trials with 586 post-cesarean section patients were included. The results of the meta-analysis showed that, compared with the morphine group, the hydromorphone group had lower 6 h(MD=–0.23, 95%CI –0.38 to –0.08, P=0.003), 12 h(MD=–0.56, 95%CI –1.10 to –0.02, P=0.04), 24 h(MD=–0.37, 95%CI –0.65 to –0.09, P=0.01) and 48 h(MD=–0.41,95%CI –0.74 to –0.08, P=0.01) postoperative VAS scores the with epidural anesthesia pump(PECA). There was no statistically significant difference of the postoperative Ramsay scores between the two groups. In terms of side effects,the incidence of skin pruritus(RR=0.27, 95%CI 0.09 to 0.81. P=0.02) and vomit(RR=0.15, 95%CI 0.03 to 0.65, P=0.01) of the hydromorphone group were lower than those of the morphine group. Conclusions The current evidence demonstrate that, compared with morphine, hydromorphone has better postoperative analgesia performance and less risk of exhibiting skin pruritus and vomit after cesarean section. Considering of the overall quality of evidence and the relatively small pooled sample size, more well-conducted randomized controlled trials are required to verify the above conclusion.