血管加压素与去甲肾上腺素治疗感染性休克疗效比较的Meta分析

Effectiveness of Vasopressin versus Norepinephrine in Patients with Septic Shock: a Meta-analysis

背景去甲肾上腺素是临床治疗感染性休克的一线升压药物,但部分患者对去甲肾上腺素不敏感,可采用血管加压素治疗。血管加压素与去甲肾上腺素治疗感染性休克的临床效果有无差异目前尚无定论。目的采用Meta分析法,比较血管加压素与去甲肾上腺素治疗感染性休克的临床效果及安全性。方法计算机检索Medline、Embase、ScienceDirect、HighWire、Cochrane Library及万方数据知识服务平台、中国知网中血管加压素与去甲肾上腺素治疗感染性休克临床效果的随机对照研究,检索时间为2000年1月至2020年10月。干预组患者给予血管加压素(特利加压素及其他血管加压素)升压治疗,对照组患者给予去甲肾上腺素升压治疗。采用RevMan 5.3软件进行Meta分析,绘制漏斗图以分析纳入文献是否存在发表偏倚。结果最终共纳入10篇文献,共包含2041例患者,其中干预组1032例、对照组1009例。Meta分析结果显示,血管加压素与去甲肾上腺素治疗的感染性休克患者28 d死亡率〔风险比(RR)=1.02,95%CI(0.93,1.13)〕、ICU住院天数〔标准化均数差(SMD)=0.05,95%CI(-0.06,0.15)〕、严重心律失常发生率〔RR=1.19,95%CI(0.85,1.67)〕、急性冠脉综合征(ACS)发生率〔RR=1.14,95%CI(0.60,2.15)〕比较,差异无统计学意义(P>0.05)。亚组分析结果显示,特利加压素与去甲肾上腺素治疗的感染性休克患者28 d死亡率比较,差异无统计学意义〔RR=1.02,95%CI(0.88,1.19),P=0.78〕;其他血管加压素与去甲肾上腺素治疗的感染性休克患者28 d死亡率比较,差异无统计学意义〔RR=1.03,95%CI(0.91,1.18),P=0.63〕。敏感性分析结果显示,本Meta分析结果稳定。针对主要评价指标为28 d死亡率的文献绘制漏斗图,显示数据点大体对称分布,且所有数据点分布于漏斗图内部,但考虑本Meta分析纳入的文献数量偏少,故不能完全排除发表偏倚。结论血管加压素与去甲肾上腺素治疗感染性休克患者的临床效果及安全性相当,因此对于儿茶酚胺类血管活性药物不敏感的患者,可酌情采用血管加压素治疗。

Background Norepinephrine is the first-line vasopressor drugs for septic shock. However, some patients are insensitive to norepinephrine and can be treated with vasopressin. Whether there is any difference between vasopressin and norepinephrine in the treatment of septic shock is still incomplete. Objective To evaluate the clinical efficacy and safety of vasopressin and norepinephrine in the treatment of septic shock by meta-analysis. Methods Databases of Medline, Embase,ScienceDirect, HighWire, Cochrane Library and Wanfang Data and CNKI were searched for randomized controlled trials about the clinical effect and safety of vasopressin and norepinephrine in the treatment of septic shock from January 2000 to October 2020.Patients in intervention group were given vasopressin(terlipressin and other vasopressins), while patients in control group were given norepinephrine. Meta-analysis was carried out by RevMan 5.3 software, and funnel diagram was drawn to analyze whether there was publication bias of the included literature. Results A total of 10 literatures were included, involving 2 041 cases of patients, there were 1 032 cases in intervention group and 1 009 cases in control group. Meta-analysis results showed that, there was no significant difference of 28 d mortality rate [RR=1.02, 95%CI(0.93, 1.13) ], length of ICU stay [SMD=0.05, 95%CI(-0.06,0.15) ], incidence of severe arrhythmia [RR=1.19, 95%CI(0.85, 1.67) ], incidence of acute coronary syndrome(ACS) [RR=1.14,95%CI(0.60, 2.15) ] between the patients with septic shock treated by vasopressin and norepinephrine(P > 0.05). Subgroup analysis showed that, there was no significant difference of 28 d mortality rate between the patients with septic shock treated by terlipressin and norepinephrine [RR=1.02, 95%CI(0.88, 1.19), P=0.78];there was no significant difference of 28 d mortality rate between the patients with septic shock treated by the other kinds of vasopressin and norepinephrine [RR=1.03, 95%CI(0.91, 1.18),P=0.63]. Sensitivity analysis showed that, the results of meta-analysis were stable. The funnel chart was drawn for the literatures whose main evaluation index was 28 d mortality rate, showed the data points were distributed symmetrically and all the data points were distributed in the funnel chart. However, considering the small number of literatures included in this meta-analysis, the publication bias cannot be completely ruled out. Conclusion Compared with norepinephrine, vasopressin has similar efficacy and safety in the treatment of septic shock, so patients who are insensitive to catecholamine vasoactive drugs can be treated with vasopressin.