预负荷和共负荷补液对剖宫产术中蛛网膜下腔麻醉相关低血压发生率影响的Meta分析

Effect of preload versus coload on reducing the incidence of spinal anesthesia-induced hypotension during cesarean section: a Meta-analysis

目的系统评价在择期剖宫产术中,不同补液策略对蛛网膜下腔麻醉(腰麻)引起产妇低血压的发生率及新生儿结局的影响。方法计算机检索PubMed、Embase、The Cochrane Library、中国知网、万方数据库、维普数据库和中国生物医学文献数据库,搜集关于在腰麻之前补液(预负荷)和在腰麻同时补液(共负荷)对产妇低血压发生率及新生儿结局影响的随机对照试验,检索时间均为从建库至2018年1月。由2位评价员独立筛选文献、提取资料、评价纳入研究的偏倚风险,采用RevMan 5.3软件进行Meta分析。结果共纳入11个随机对照试验,包括894例产妇,其中预负荷组448例,共负荷组446例。结果显示,与预先补液相比,在行腰麻同时补液可明显降低剖宫产中腰麻导致的低血压发生率,差异有统计学意义[风险比(risk ratio,RR)=1.27,95%置信区间(confidence interval,CI)(1.13,1.43),P<0.000 1]。亚组分析显示,在行腰麻同时补充晶体液可明显降低剖宫产中腰麻导致低血压的发生率[RR=1.48,95%CI(1.26,1.73),P<0.00001],而补充胶体液两组差异无统计学意义[RR=1.00,95%CI(0.85,1.17),P=0.96]。预负荷组和共负荷组在产妇血压最低值、恶心、呕吐发生率、缩血管药物使用量及新生儿结局等指标方面,差异均无统计学意义(P>0.05)。结论与预先补充(预负荷)晶体液比较,在腰麻同时补充(共负荷)晶体液可明显降低择期剖宫产产妇低血压发生率;而在补充胶体液时,共负荷与预负荷比较则无此优势。两组产妇低血压严重程度、恶心、呕吐发生率、缩血管药物使用以及新生儿结局均无明显差异。受纳入研究数量和质量的限制,上述结论尚待更多高质量研究予以验证。

Objective To evaluate the effect of different rehydration strategies on the incidence of spinal anesthesia-induced hypotension and neonatal outcomes during elective cesarean section. Methods We searched PubMed, Embase, the Cochran Library, China National Knowledge Internet, VIP database, Wanfang database, and China Biology Medicine database from inception to January 2018, to collect randomized controlled trials（RCTs） about the incidence of spinal anesthesia-induced hypotension during elective cesarean section and neonatal outcomes of preloading or coloading. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias in the study. Meta-analysis was conducted using RevMan 5.3 software. Results A total of 11 RCTs were included, including894 parturients, of whom 448 cases in the preload group and 446 cases in the coload group. Comparing with the preload group, the incidence of spinal anesthesia-induced hypotension during cesarean section in the coload group significantly decreased [risk ratio（RR）=1.27, 95% confidence interval（CI）（1.13, 1.43）, P〈0.000 1]. Subgroup analysis showed that in the crystalloid fluid group, the difference in the incidence of hypotension between the preload group and the coload group was statistically significant [RR=1.48, 95%CI（1.26, 1.73）, P〈0.000 01]; while in the colloidal fluid group, the difference in the the incidence of hypotension between the preload group and the coload group was not significant [RR=1.00, 95%CI（0.85, 1.17）, P=0.96]. The lowest systolic blood pressure, the incidence of nausea and vomiting, and neonatal outcomes had no significant difference between the two groups. Conclusions Comparing with preloading crystalloid fluid, rapid infusion of crystalloid fluid at the same time implementation of spinal anesthesia could significantly reduce the incidence of hypotension during cesarean section while there was no superiority in infusion of colloid fluid. There was no significant effect on the severity of hypotension, nausea and vomiting, and neonatal outcomes. Due to the limitation of the quantity and quality of the included studies, the above conclusions need to be verified by more high-quality studies.