神经周围及静脉注射地塞米松和右美托咪啶：对锁骨上神经阻滞辅助作用的网络Meta分析
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神经周围及静脉注射地塞米松和右美托咪啶：对锁骨上神经阻滞辅助作用的网络Meta分析
翻译：佟睿 编辑：冯玉蓉 审校：曹莹
背景：神经周围及静脉注射地塞米松和右美托咪啶均可作为局部麻醉，以增强周围神经阻滞特性。然而，地塞米松和右美托咪啶基于其给药途径的效果还没有被直接比较，且每种辅助药物延长感觉神经阻滞的相对程度仍不清楚。该网络meta分析试图比较神经周围与静脉注射地塞米松和右美托咪啶作为锁骨上神经阻滞辅助药物的效果并进行排序。
方法：我们搜索到研究应用长效局麻药对锁骨上神经阻滞辅助神经周围和静脉注射地塞米松或右美托咪啶的文献，观察指标包括感觉、运动和痛觉阻滞的起效时间和持续时间。对数据进行比较，并根据每个结果的相对有效性进行排序。我们的主要观察指标是感觉阻滞持续时间，临床认为差异2小时为显著差异。我们进行了频数分析，使用等级框架来评价证据等级。
结果：本研究共纳入100个试验(5728名患者)。对照组(单纯局麻药组)感觉神经阻滞时间为401 (366~435)min，运动神经阻滞时间为369(330~408)min，镇痛时间为435 (386~483)min。与对照组相比，静脉注射地塞米松组感觉神经阻滞时间最长[均差(95%CI) 477(160~795)min]，其次是神经周围注射地塞米松[411 (343~480) min]和右美托咪啶[284 (235~333)min]。神经周围注射地塞米松延长运动神经阻滞时间最长[均差(95%CI) 294 (236~352)min]，其次是静脉注射地塞米松[289 (129~448)min]和神经周围注射右美托咪啶[258 (212~304)min]。镇痛持续时间以神经周围注射地塞米松[均差(95%CI) 518 (448~589)min]最长，其次为静脉注射地塞米松[478 (277~679)min]和右美托咪啶[318 (266~371)min]。静脉注射右美托咪啶不会延长感觉神经、运动神经或镇痛阻滞时间。没有发现重大的网络不一致。静脉注射地塞米松、神经周围注射地塞米松和神经周围注射右美托咪啶延长锁骨上神经感觉阻滞时间的证据质量分别为“低”、“极低”和“低”。
结论：无论采用哪种途径，地塞米松作为辅助药物均比右美托咪啶更能延长感觉和镇痛阻滞的时间。神经周围注射地塞米松和静脉注射地塞米松阻滞效果的差异在临床上并不显著。静脉注射右美托咪啶不影响阻滞效果。
原始文献来源：H. Sehmbi, R. Brull, K. R. Cabellos, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular bracheal plexus block.[J]. Anaesthesia, 2020, doi:10.1111/anae.15288
Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular bracheal plexus block
Summary
Both perineural and intravenous dexamethasone and dexmedetomidine are used as local anaesthetic adjuncts to enhance peripheral nerve block characteristics. However, the effects of dexamethasone and dexmedetomidine based on their administration routes have not been directly compared, and the relative extent to which each adjunct prolongs sensory blockade remains unclear. This network meta-analysis sought to compare and rank the effects of perineural and intravenous dexamethasone and dexmedetomidine as supraclavicular block adjuncts. We sought randomised trials investigating the effects of adding perineural and intravenous dexamethasone or dexmedetomidine to long-acting local anaesthetics on supraclavicular block characteristics, including time to block onset and durations of sensory, motor and analgesic blockade. Data were compared and ranked according to relative effectiveness for each outcome. Our primary outcome was sensory block duration, with a 2-h difference considered clinically important. We performed a frequentist analysis, using the GRADE framework to appraise evidence. One-hundred trials (5728 patients) were included. Expressed as mean (95%CI), the control group (local anaesthetic alone) had a duration of sensory block of 401 (366–435) min, motor block duration of 369 (330–408) min and analgesic duration of 435 (386-483) min. Compared with control, sensory block was prolonged most by intravenous dexamethasone [mean difference (95%CI) 477 (160–795) min], followed by perineural dexamethasone [411 (343–480) min] and perineural dexmedetomidine [284 (235–333) min]. Motor block was prolonged most by perineural dexamethasone [mean difference (95%CI) 294 (236–352) min], followed by intravenous dexamethasone [289 (129–448)min] and perineural dexmedetomidine [258 (212–304)min]. Analgesic duration was prolonged most by perineural dexamethasone [mean difference (95%CI) 518 (448–589) min], followed by intravenous dexamethasone [478 (277–679) min] and perineural dexmedetomidine [318 (266–371) min]. Intravenous dexmedetomidine did not prolong sensory, motor or analgesic block durations. No major network inconsistencies were found. The quality of evidence for intravenous dexamethasone, perineural dexamethasone and perineural dexmedetomidine for prolongation of supraclavicular sensory block duration was’low’,’very low’ and ’low’, respectively. Regardless of route, dexamethasone as an adjunct prolonged the durations of sensory and analgesic blockade to a greater extent than dexmedetomidine. Differences in block characteristics between perineural and intravenous dexamethasone were not clinically important. Intravenous dexmedetomidine did not affect block characteristics.
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