预防性单用麻黄碱或联合去氧肾上腺素对蛛网膜下腔阻滞剖宫产术中产妇和新生儿影响的Meta分析

The effects of prophylactic infusing ephedrine combined with phenylephrine versus ephedrine alone in maternal and neonate undergoing spinal anesthesia for cesarean section:A Meta-analysis of randomized trials

目的采用Meta分析的方法评价预防性单用麻黄碱或联合去氧肾上腺素对蛛网膜下腔阻滞剖宫产术中产妇血流动力学和新生儿血气分析的影响。方法检索Cochrane Library、PubMed、Embase、万方数据、中国知网、中国生物医学文献服务系统,收集蛛网膜下腔阻滞剖宫产术中预防性单用麻黄碱或联合去氧肾上腺素对产妇和新生儿影响的临床随机对照试验(randomized controlled trial, RCT)。采用Jadad评分量表评价所纳入文献的质量,采用RevMan 5.3软件进行Meta分析。对连续变量以均数差(mean differences, MD)及其95%CI分析统计量;对二分类变量以比值比(odd ratio, OR)及95%CI分析统计量。对不能进行Meta分析的资料进行描述性分析。结果纳入9篇文献,其中5篇英文文献、6篇中文文献;共590例产妇,其中麻黄碱组(E组)294例,麻黄碱联合去氧肾上腺素组(EP组)296例。分析结果显示,麻黄碱联合去氧肾上腺素和单用麻黄碱相比,产妇术中低血压[OR=0.49,95%CI(0.3, 0.8),P<0.01]、高血压[OR=0.52,95%CI(0.30, 0.92),P=0.02]、恶心呕吐[OR=0.32,95%CI(0.19,0.53),P<0.01]的发生率降低,新生儿酸中毒的发生率较低[OR=0.22,95%CI(0.10, 0.49),P<0.01];使用麻黄碱联合去氧肾上腺素后新生儿脐动脉血pH值[MD=0.1,95%CI(0.07,0.13),P<0.01]、碱剩余(base excess, BE)值[MD=2.24,95%CI(0.78, 3.69),P<0.01]、氧分压(oxygen partial pressure, PO2)[MD=1.53,95%CI(0.08,2.98),P<0.01]高于单用麻黄碱,乳酸[MD=-1.39,95%CI(-1.73,-1.05),P<0.01]、二氧化碳分压(partial pressure of cardon dioxide, PCO2)[MD=-8,95%CI(-13.2,-2.8),P<0.01]低于单用麻黄碱;新生儿1 min和5 min Apgar评分,两组间差异无统计学意义。结论麻黄碱联合去氧肾上腺素可预防蛛网膜下腔阻滞剖宫产产妇低血压,其对维持术中血流动力学的稳定优于单用麻黄碱,且可降低产妇恶心呕吐发生率,并降低新生儿发生酸中毒的风险。

Objective Used a Meta-analysis to evaluate the effects of prophylactic infusing ephedrine alone or combined with phenylephrine on maternal hemodynamics and neonatal blood gas analysis undergoing spinal anesthesia for cesarean section. Methods Randomized controlled trial(RCT) about the effects of prophylactic infusing ephedrine alone or combined with phenylephrine on maternal and neonate undergoing spinal anesthesia for cesarean section were retrieved from Cochrane Library, PubMed, Embase, Wangfang Database, CNKI and SinoMed from the date of their establishment to September, 2017. The documents were screened and the relevant data were extracted according to the inclusion criteria. The methodological quality of the included RCT was evaluated by Jadad scale. Using RevMan 5.3 software for Meta-analysis. Continuous variables were dealt with mean differences(MD) and 95% confidence intercal(CI), and the dichotomous variables were dealt with odd ratio(OR) and 95%CI. Descriptive analysis of the RCTs which is not available for Meta-analysis. Results We identified 9 RCTs including 590 patients, including 5 RCTs in English and 4 RCTs in Chinese. Among them, 294 patients were in the ephedrine group(E group) while 296 patients were in the ephedrine combined with phenylephrine group(EP group). The results of Meta-analysis showed that the incidence of maternal hypotension [OR=0.49, 95%CI(0.3, 0.8), P<0.01], hypertension [OR=0.52, 95%CI(0.30, 0.92), P=0.02], nausea and vomiting [OR=0.32, 95%CI (0.19, 0.53), P<0.01] and the incidence of neonatal acidosis [OR=0.22, 95%CI(0.10, 0.49), P<0.01] were significantly lower in the ephedrine combined phenylephrine group than these parameters in the ephedrine alone groups. The neonatal umbilical artery pH [MD=0.1, 95%CI(0.07, 0.13), P<0.01], base excess(BE)[MD=2.24, 95%CI(0.78, 3.69), P<0.01], oxygen partial pressure(PO2)[MD=1.53, 95CI (0.08, 2.98), P<0.01] value in the ephedrine combined with phenylephrine group was significantly higher than those parameter in the ephedrine alone group. Moreover, the umbilical artery lactic acid [MD=-1.39, 95%CI (-1.73,-1.05), P<0.01], partial pressure of cardon dioxide(PCO2)[MD=-8, 95%CI(-13.2,-2.8), P<0.01] value were lower than those in the ephedrine alone group. The neonatal 1 min and 5 min Apgar score were not significant difference between the two groups. Conclusions Ephedrine combined with phenylephrine can prevent maternal hypotension undergoing spinal anesthesia for cesarean section and to maintain intraoperative hemodynamic stability. It also can reduce the incidence of maternal nausea and vomiting and neonatal acidosis.