【罂粟摘要】右美托咪定与全凭静脉麻醉治疗小儿苏醒期谵妄的比较：一项网络Meta分析
右美托咪定与全凭静脉麻醉治疗小儿苏醒期谵妄的比较：一项网络Meta分析
贵州医科大学 麻醉与心脏电生理课题组
翻译：佟睿 编辑：张中伟 审校：曹莹
背景
苏醒期谵妄是儿科麻醉中常见的并发症，发病率很高。全凭静脉麻醉(TIVA)和术中右美托咪啶辅助七氟烷麻醉与单纯七氟烷麻醉相比均可降低苏醒期谵妄的发生率，但尚无研究直接比较其相对疗效。
目的
本研究的目的是比较TIVA和右美托咪啶对儿童苏醒期谵妄发生率的影响。
研究设计
本研究是对随机对照试验的系统综述和网络Meta分析(NMA)。
资料来源
我们系统地搜索了包括Medline(Ovid)和Web of Science(Clarivate Analytics)的12个数据库中自成立到2020年12月的所有文献。
研究方法
纳入标准为使用七氟烷、七氟烷加右美托咪啶或全凭静脉注射为儿科患者进行全身麻醉的随机对照试验。数据由两名评价者根据系统评价和Meta分析指南的首选报告项目提取，并使用NMA方法进行分析。计算所有结局指标[苏醒神志不清、术后恶心呕吐(PONV)、苏醒时间和拔管时间]的风险比和95%可信区间(CrI)。该试验已在Prospero注册(CRD42018091237)。
结果
该系统综述纳入了66项符合条件的研究，其中包括5257例右美托咪啶联合七氟烷、全凭静脉注射和七氟烷单独用药组的粗中位数出现谵妄的发生率分别为12.8%、9.1%和40%。NMA显示，与TIVA相比，七氟烷加右美托咪啶可降苏醒期谵妄的发生率，但无统计学差异(风险比0.88，95%CrI 0.61~1.20，证据质量低)，但PONV发生率较高(风险比2.3，95%CrI 1.1~5.6，证据质量低)，与TIVA组比较，差异无统计学意义(风险比0.88，95%CrI 0.61~1.20，证据质量低)。
结论
在选择TIVA和七氟烷加右美托咪啶辅助麻醉时，应考虑患者的危险因素，如苏醒期谵妄和PONV，再进行临床判断。这些发现受限于证据质量不高(有条件建议)。
原始文献来源
Maria-Alexandra Petre, David N. Levin, Marina Englesakis, et al. Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis.[J].Eur J Anaesthesiol 2021;38:1111–1123.
Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis
Abstract
BACKGROUND Emergence delirium is a common complication in paediatric anaesthesia associated with significant morbidity. Total intravenous anaesthesia (TIVA) and intraoperative dexmedetomidine as an adjuvant to sevoflurane anaesthesia can both reduce the incidence of emergence delirium compared with sevoflurane alone, but no studies have directly compared their relative efficacy.
OBJECTIVE The study objective was to compare the effects of TIVA and dexmedetomidine on the incidence of paediatric emergence delirium.
STUDY DESIGN The current study is a systematic review and network meta-analysis (NMA) of randomised controlled trials.
DATA SOURCES We conducted a systematic search of 12 databases including Medline (Ovid) and Web of Science (Clarivate Analytics) from their respective inception to December 2020.
ELIGIBILITY Inclusion criteria were randomised controlled trials of paediatric patients undergoing general anaesthesia using sevoflurane, sevoflurane with dexmedetomidine or TIVA. Data were extracted by two reviewers according to Preferred Reporting Items for Systematic Reviews and Metaanalyses guidelines and analysed using NMA methodology. Risk ratios and 95% credible intervals (CrI) were calculated for all outcomes [emergence delirium, postoperative nausea and vomiting (PONV), and time to emergence and extubation]. The protocol was registered with PROSPERO (CRD42018091237).
RESULTS The systematic review returned 66 eligible studies comprising 5257 patients with crude median emergence delirium incidences of 12.8, 9.1 and 40% in the dexmedetomidine with sevoflurane, TIVA and sevoflurane alone groups, respectively. NMA indicated that compared with TIVA, sevoflurane with adjuvant dexmedetomidine decreased the incidence of emergence delirium without statistical difference (risk ratio 0.88, 95% CrI 0.61 to1.20, low quality of evidence), but resulted in a higher incidence of PONV (risk ratio: 2.3, 95% CrI 1.1 to 5.6, low quality of evidence).
CONCLUSION Clinical judgement, considering the patient’s risk factors for the development of clinically significant outcomes such as emergence delirium and PONV, should be used when choosing between TIVA and sevoflurane with adjuvant dexmedetomidine. These findings are limited by the low quality of evidence (conditional recommendation).
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