血管内降温相较体表降温对心脏骤停患者预后影响的Meta分析

Efficacy of intravascular cooling versus surface cooling on the prognosis of patients with cardiac arrest: a meta-analysis

目的系统评价血管内降温与体表降温诱导亚低温治疗对复苏后心脏骤停(CA)患者预后的影响及安全性。方法计算机检索PubMed、EMbase,The Cochrane Librarys CNKI和WanFang Data数据库,搜集血管内降温与体表降温比较对CA患者预后影响的队列研究或随机对照试验(RCT),检索时限均为建库至2019年7月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Stata 13.0软件进行Meta分析。结果共纳入9个队列研究和3个RCT,包含2104例患者。Meta分析结果显示:与体表降温相比,血管内降温可改善患者的神经功能预后[OR=1.45,95%CI(1.18,1.78),P<0.001],降低亚低温诱导时间[SMD=-1.35,95%CI(-2.34,-0.36),P=0.008],但两种方法对患者死亡率影响的差异无统计学意义[OR=0.84,95%CI(0.70,1.00),P=0.053]。在亚低温相关并发症方面,血管内降温组患者的过度降温发生率[OR=0.27,95%CI(0.18,0.41),P<0.001]、心律失常发生率[OR=0.60,95%CI(0.40,0.89),P=0.012]明显低于体表降温组,但凝血障碍发生率高于体表降温组[OR=1.61,95%CI(1.05,2.49),P=0.03]。两组在肺炎发生率方面的差异无统计学意义[OR=1.20,95%CI(0.94,1.53),P=0.147]。结论当前证据表明,相较于体表降温,血管内降温可有效保护CA患者的神经功能、降低亚低温诱导时间、过度降温和心律失常发生率,但对患者凝血功能可能存在负面影响。受纳入研究数量和质量限制,上述结论尚需开展更多高质量研究予以验证。

Objectives To systematically review the efficacy and safety of intravascular cooling versus surface cooling for induced mild hypothermia on the prognosis of patients with cardiac arrest(CA)after resuscitation.Methods PubMed,EMbase,The Cochrane Library,CNKI and WanFang Data databases were electronically searched to collect cohort studies and randomized controlled trials(RCTs)on the efficacy and safety of intravascular cooling versus surface cooling for CA patients after resuscitation from inception to July 2019.Two reviewers independently screened literature,extracted data and assessed risk of bias of included studies.Meta-analysis was then performed by using Stata 13.0 software.Results A total of 9 cohort studies and 3 RCTs involving 2104 patients were included.The results of metaanalysis showed that:the rate of good neurological function was significantly higher(OR=1.45,95%CI 1.18 to 1.7&P<0.001)and the induction time was significantly shorter(SMD=-1.35,95%CI-2.34 to-0.36,P=0.008)in the intravascular cooling group,but there was no statistical difference in mortality between two groups(OR=0.84,95%CI 0.70 to 1.00,P=0.053).In terms of complications related to mild hypothermia,the rate of excessive hypothermia(OR=0.27,95%CI 0.18 to 0.41,P<0.001)and arrhythmia(OR=0.60,95%CI 0.40 to 0.89,P=0.012)was significantly lower in the patients treated with intravascular cooling.However,the incidence of coagulopathy was higher(OR=1.61,95%CI 1.05 to 2.49,P=0.03).There was no statistical difference in the incidence of pneumonia between two groups(OR=1.20,95%CI 0.94 to 1.53,P=0.147).Conclusions Current evidence shows that intravascular cooling has significant neurological protection for patients with CA compared with surface cooling since it can decrease the induction time and the rate of excessive hypothermia and arrhythmia.However,it may have a negative effect on the coagulation function.Due to the limited quality and quantity of the included studies,more high-quality studies are required to verify the conclusions.