预防成年患者全身麻醉后恶心呕吐的药物
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预防成年患者全身麻醉后恶心呕吐的药物
翻译：佟睿 编辑：冯玉蓉 审校：曹莹
背景：术后恶心和呕吐是麻醉的常见不良反应。尽管有数十种不同的止吐药可用于临床实践，但目前尚没有这些药物的疗效和安全性等级比较可为临床实践提供参考。
方法：我们通过网络meta分析进行了系统回顾，以比较单一止吐药及其组合（包括5-羟色胺3、多巴胺-2、神经激肽-1受体拮抗剂、皮质类固醇、抗组胺药和抗胆碱药）用于预防成年人在全身麻醉后恶心呕吐的有效性和安全性，并对其进行排名。我们系统地搜索了截至2017年11月的安慰剂对照和直接对照随机试验（于2020年4月更新）。我们使用“评估、建议、发展和评估等级（GRADE）”和“网络meta分析可信度（CINeMA）”的方法对术后24小时内呕吐、严重不良事件、任何不良反应和药物特异性副作用进行评估，以评估证据的可信度及效果。
结果：我们纳入了585项试验（97516名参与者，83％为女性），测试了44种单一药物和51种药物组合。仅27％的研究认为该研究的总体偏倚风险低。在282个试验中，与安慰剂相比，36种药物组合中的29种及28种单一药物中的10种将呕吐的风险降低了至少20％。在治疗排名中，药物组合通常比单一药物更有效。单独使用神经激肽-1受体拮抗剂与其他药物组合一样有效。在这10种有效的单一药物中，阿瑞匹坦的证据确凿性很高，风险比（95％CI）为0.26（0.18-0.38）；雷莫司琼为0.44（0.32-0.59）; 格拉司琼为0.45（0.38–0.54）；地塞米松为0.51（0.44-0.57）；昂丹司琼为0.55（0.51-0.60）。与安慰剂相比，格拉司琼和氨磺必利的不良反应可能很少或没有增加，而与安慰剂相比，茶苯海明和东莨菪碱可能增加任何不良事件的患者数量。
结论：迄今为止，尚无确切证据表明，与安慰剂相比，其他单一药物对严重或任何不良事件的发生率有影响。在药物特异性副作用中，单一药物的证据大多并无说服力。有明确证据表明，至少7种单一药物对术后呕吐有预防作用，因此未来对这些药物的研究可能不会改变预期的有益效果。然而，仍然缺乏足够的证据来证明安全方面的确有必要进行调查。
原始文献来源：S. Weibel, M. S. Schaefer, D. Raj, et al. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: an abridged Cochrane network meta-analysis.[J].Anaesthesia, 2020, Nov 10: doi:10.1111/anae.15295.
Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: an abridged Cochrane network meta-analysis
Summary
Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine3, dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies’ overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio(95%CI) 0.26 (0.18–0.38); ramosetron, 0.44 (0.32–0.59); granisetron, 0.45 (0.38–0.54); dexamethasone, 0.51(0.44–0.57); and ondansetron, 0.55 (0.51–0.60). It was moderate for fosaprepitant, 0.06 (0.02–0.21) and droperidol, 0.61 (0.54–0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.
贵州医科大学高鸿教授课题组
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