肝素或生理盐水延长外周静脉短导管留置时间的系统评价和Meta分析

Effect of heparin or normal saline on prolonging the duration of peripheral intravenous catheters: A systematic review and meta-analysis

背景 新生儿或儿童选择生理盐水还是肝素溶液封管,在2021年《静脉输液护理实践指南》未做出明确推荐,在《儿童静脉输液治疗临床实践循证指南》则明确推荐用肝素溶液封管。目的 儿科使用含肝素溶液和0.9%的生理盐水溶液作为外周静脉短导管(PIVC)封管液的效果比较。研究设计基于RCT的系统评价/Meta分析。方法 住院留置PIVC的患儿,干预组和对照组分别采用含肝素溶液和0.9%的生理盐水进行PIVC封管,在英文数据库(Ovid-Medline, Web of Science, Embase, Cochrane Library)和中国生物医学文献服务系统中进行检索。鉴于在2005和2013年已经发表了2篇系统评价/Meta分析,本文检索时间为2014年4月1日至2021年11月23日。RCT文献采用ROB 2.0行文献风险偏倚评价。主要结局指标PIVC留置时间和相关并发症。结果 共21篇RCT文献纳入本文研究。基于21篇文献的汇总,I^(2)=91%,随机效应模型,PIVC留置时间延长8.62 h(95%CI:2.98~14.26),差异有统计学意义;新生儿人群中4篇文献异质性大,去除后再行Meta分析,8篇新生儿人群的文献汇总(I^(2)=56%,随机效应模型),PIVC留置时间延长6.04 h(95%CI:4.17~7.91),差异有统计学意义;5篇新生儿+儿童人群文献汇总(I^(2)=20%,随机效应模型),PIVC留置时间延长6.22 h(95%CI:2.72~9.73),差异有统计学意义;3篇儿童人群文献汇总(I^(2)=27%,固定效应模型),PIVC留置时间延长6.94 h(95%CI:-1.27~15.15)差异无统计学意义。基于18篇文献的汇总(I^(2)=19.5%,固定效应模型)。肝素较生理盐水冲封管,并发症的发生率降低17%(RR=0.83,95%CI:0.71~0.97),差异有统计学意义;9篇新生儿文献的汇总(I^(2)=0%,固定效应模型),并发症的发生率降低25%(RR=0.75,95%CI:0.62~0.91),差异有统计学意义;4篇儿童人群和5篇新生儿+儿童人群文献汇总并发症的发生率降低差异无统计学意义。结论 综合封管延长留置时间和降低并发症考虑,新生儿人群肝素较生理盐水封管获益明确,儿童人群PIVC留置时间延长作用不明确。

Background Infusion Therapy Standards of Practice published in 2021 did not provide a clear recommendation on how to choose between normal saline and heparin saline as the locking solution for neonates and children, however, Clinical Practice Guideline on Infusion Therapy in Children recommended using heparin solution. Objective To compare the effects of heparin saline(HS) and 0.9% normal saline(NS) solution as the locking solution of a peripheral intravenous catheter(PIVC) on different pediatric populations. Design Systematic review and meta-analysis of RCTs. Methods Hospitalized pediatric patients who need PIVC were divided into the intervention group using HS and the control group using NS. Literature was searched in English databases of Ovid MEDLINE, PubMed, Cochrane Library, and Chinese database of SinoMed from April 1, 2014 to November 23, 2021 for there have been two articles of systematic review and meta-analysis on this topic published in 2005 and 2013. RoB 2 was used to evaluate the risk of bias in the included studies. Main outcome measures PIVC duration and the related complications. Results A total of 21 RCTs were included in the analysis. The duration of PIVC in HS group was 8.62 h longer than that in NS group(95%Cl: 2.98-14.26, I^(2)=91%, random effects model), and the difference was statistically significant. After removal of four literature about neonates because of greater heterogeneity, the meta-analysis of other eight literature showed that PIVC duration in neonates of HS group was increased by 6.04 h(95%Cl: 4.17-7.91, I^(2)=56%, random effects model), and the difference was statistically significant. The pooled results of five studies for both neonates and children showed that the PIVC duration of HS group was prolonged by 6.22 h(95%Cl: 2.72-9.73, I^(2)=20%, random effects model), and the difference was statistically significant. For the population of children, the pooled results of three studies indicated that the PIVC duration was prolonged by 6.94 h(95%Cl:-1.27-15.15, I^(2)=27%, fixed effects model) in HS group, and there was no statistically significant difference. According to the pooled results of 18 studies, the incidence of complications decreased by 17%(RR=0.83, 95%Cl: 0.71-0.97, I^(2)=19.5%, fixed effects model) in HS group compared with that of NS group, and the difference was statistically significant. The incidence of complications in neonates decreased by 25% in HS group(RR =0.75, 95%Cl: 0.62-0.91, I^(2)=0%, fixed effects model) according to the pooled analysis of 9 studies, and the difference was statistically significant. There was no significant difference in reducing the incidence of complications between the two groups for children(4 studies) and the population of both newborns and children(5 studies). Conclusion Locking PIVC by heparin saline is desirable for the neonatal population in terms of duration and complication incidence. Whether it is beneficial to the whole pediatric population still needs to be further explored.