下肢部位神经肌肉电刺激对ICU机械通气患者影响的Meta分析

Meta-analysis of effects of neuromuscular electrical stimulation of lower limbs on patients with mechanical ventilation in intensive care unit

目的采用Meta分析方法评价下肢部位神经肌肉电刺激(NMES)对重症监护病房(ICU)机械通气患者的有效性。方法应用计算机检索Cochrane图书馆数据库、美国国立医学图书馆PubMed数据库、科学网(Web of Science)、荷兰医学文摘Embase数据库、中国生物医学文献服务系统(SinoMed)、中国知网(CNKI)、维普中文科技期刊数据库(VIP)和万方数据中,从建库至2021年5月公开发表的有关ICU机械通气患者下肢部位进行NMES效果的随机对照试验(RCT)。对照组实施常规康复措施;观察组在常规康复措施基础上进行下肢部位NMES。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RevMan 5.3软件进行Meta分析;绘制漏斗图分析文献发表偏倚。结果最终纳入8篇RCT,文献质量评价结果显示,1项研究为A级,7项研究为B级,提示纳入文献质量相对较高。Meta分析结果显示,与对照组比较,下肢部位NMES能够有效缩短ICU患者机械通气时间〔标准化均数差(SMD)=-0.51,95%可信区间(95%CI)为-0.72~-0.31,P<0.00001〕,提高最大吸气压〔MIP;均数差(MD)=14.19,95%CI为9.30~19.09,P<0.00001〕,改善患者运动功能状态〔ICU运动功能状态评分(FSS-ICU);MD=10.44,95%CI为3.12~17.77,P=0.005〕,差异均具有统计学意义;然而,在提高MRC肌力评估量表评分(MRC评分;MD=2.13,95%CI为-1.38~5.63,P=0.23)、降低ICU病死率〔相对危险度(RR)=0.80,95%CI为0.51~1.24,P=0.31〕、缩短ICU住院时间(MD=-0.54,95%CI为-3.67~2.59,P=0.74)等方面均未见明显优势,合并效应无统计学意义。基于患者机械通气时间相关文献绘制漏斗图显示,纳入文献分布基本对称,未检测到发表偏倚。结论下肢部位NMES能有效缩短ICU机械通气患者的机械通气时间,提高MIP及运动功能状态,但对MRC评分、ICU病死率及ICU住院时间无明显影响。未来仍需开展高质量、大样本、多中心的RCT对研究结果加以论证。

Objective To evaluate the effect of lower limb neuromuscular electrical stimulation(NMES)on mechanical ventilation patients in intensive care unit(ICU).Methods Databases including the Cochrane Library,PubMed,Web of Science,Embase,SinoMed,CNKI,VIP and Wanfang database were searched from inception to May 2021.Randomized controlled trails(RCT)about the influence of NMES of lower limbs in patients with mechanical ventilation in ICU were collected.Routine rehabilitation measures were implemented in the control group,while the combination of routine rehabilitation and NMES on the lower limbs was implemented in the observation group.The literature screening,data extracting,and bias risk assessment of included studies were conducted independently by two reviewers.RevMan 5.3 software was used to perform Meta-analysis.Funnel plot was used to test publication bias.Results A total of 8 RCT were eventually enrolled.The literature quality evaluation results showed that 1 study was grade A and 7 studies were grade B,suggesting that the quality of the included literature was relatively high.The Meta-analysis results showed that NMES in the lower extremities could effectively shorten the duration of mechanical ventilation in ICU patients[standardized mean difference(SMD)=-0.51,95%confidence interval(95%CI)was-0.72 to-0.31,P<0.00001],increase the maximum inspiratory pressure[MIP;mean difference(MD)=14.19,95%CI was 9.30 to 19.09,P<0.00001],and improve the functional status of critically ill patients[functional status score for ICU(FSS-ICU);MD=10.44,95%CI was 3.12 to 17.77,P=0.005]with statistically significances.However,there were no significant advantages in increasing the Medical Research Council(MRC)score(MD=2.13,95%CI was-1.38 to 5.63,P=0.23),reducing ICU mortality[relative risk(RR)=0.80,95%CI was 0.51 to 1.24,P=0.31],shortening length of ICU stay(MD=-0.54,95%CI was-3.67 to 2.59,P=0.74),and the combined effect was not statistically significant.Funnel plot based on the duration of mechanical ventilation showed that the distribution of included articles was basically symmetrical,and no publication bias was detected.Conclusions NMES of the lower limbs can not only shorten the ventilation duration effectively,but also improve the MIP and functional status of mechanically ventilated patients in ICU.However,it has no significant effect on the MRC score,ICU mortality and length of ICU stay of patients with mechanical ventilation.In the future,high-quality,large sample size and multi-center RCT are needed to verify the effects of NMES.