【罂粟摘要】鞘内注射吗啡用于下肢关节置换术术后镇痛的有效性和安全性：一项系统回顾和应用Meta回归与试验序贯方法的Meta分析
鞘内注射吗啡用于下肢关节置换术术后镇痛的有效性和安全性：一项系统回顾和应用Meta回归与试验序贯方法的Meta分析
贵州医科大学 高鸿教授课题组
翻译：吴学艳 修改/编辑：佟睿 审校：曹莹
鞘内注射吗啡在临床的广泛应用因其潜在副作用而受到影响；我们采用系统回顾、Meta分析和试验序贯分析，主要目的是确定鞘内注射吗啡的有效性和安全性；次要目的是确定最大疗效的安全性相关剂量，试验还评估了鞘内注射吗啡对呼吸抑制的影响。我们系统地检索文献，比较鞘内注射吗啡组和对照组在下行髋关节或膝关节置换术患者的疗效。试验主要疗效指标为评估术后8-12小时的静息疼痛评分(0-10分)；试验主要安全指标是观察术后24小时内恶心、呕吐的发生率。本研究共纳入29项试验，共1814名患者。鞘内注射吗啡组8-12h静息疼痛评分明显降低，平均差值(95%CI)为-1.7(-2.0至-1.3)，p<0.0001(19次试验，1420例患者，高质量证据)，亚组间无显著差异(p=0.35)。鞘内注射吗啡增加患者术后恶心呕吐发生率，其风险比(95%CI)为1.4 (1.3–1.6)，p<0.0001(24项试验，1603名患者，高质量证据)。按剂量亚组分析显示，100µg剂量组间术后24小时内恶心呕吐发生率相似，但随着剂量增加，发生恶心呕吐的危险性越高(亚组差异p值=0.02)。鞘内注射吗啡患者出现呼吸抑制可能性小，风险比(95%CI)为0.9(0.5-1.7)，p=0.78，(16项试验，1173名患者，高质量证据)。总之，有充分证据表明，鞘内注射吗啡可为下肢关节置换术后提供有效镇痛，不增加呼吸抑制风险，但可增加术后恶心呕吐的发生率。100µg吗啡是鞘内注射镇痛的“上限”剂量，也是术后恶心呕吐发生率增加的阈值剂量。
Gonvers E, El-Boghdadly K, Grape S,et al. Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis[J].Anaesthesia. 2021 Aug 27. DOI: 10.1111/anae.15569.
Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis
Summary
Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side-effects. We undertook a systematic review, meta-analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0-10) at 8-12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty-nine trials including 1814 patients were identified. Rest pain score at 8-12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of -1.7 (-2.0 to -1.3), p < 0.0001 (19 trials; 1420 patients; high-quality evidence), without sub-group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3-1.6), p < 0.0001 (24 trials; 1603 patients; high-quality evidence). However, a sub-group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub-group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5-1.7), p = 0.78 (16 trials; 1173 patients; high-quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a 'ceiling' dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting.
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