连续脉搏血氧饱和度和呼末二氧化碳分压波形监测术后呼吸抑制和不良事件：一篇系统评价和荟萃分析
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Continuous Pulse Oximetry and Capnography Monitoring for Postoperative Respiratory Depression and Adverse Events: A Systematic Review and Meta-analysis.
背景
无法识别的术后呼吸抑制（PORD）导致的死亡和缺氧性脑损伤是威胁患者安全的一个严重问题。美国患者安全基金会呼吁所有在术后期间接受阿片类药物治疗的患者进行持续的电子监测。这些建议主要基于目前有限证据的共识意见。本研究的目的是回顾连续脉搏血氧仪（CPOX）与常规护理的有效性以及连续二氧化碳监测有无脉搏血氧饱和度监测PORD并预防术后不良事件的有效性知识的现状。
方 法
我们对1946年至2017年5月期间发表的文献数据库进行了系统的搜索。我们选择了包括以下内容的研究：（1）成人外科患者（>18岁）; （2）术后期间使用阿片类药物; （3）用CPOX和/或二氧化碳图监测; （4）主要观察指标包括氧饱和度降低，呼吸减慢，高碳酸血症，救援队激活，重症监护病房（ICU）入住或死亡率;和（5）用英语发表的研究。采用Cochrane评价管理系统5.3进行Meta分析。
结 果
共有9项研究（4项CPOX检查和5项连续性二氧化碳监测）纳入本系统评价。在关于CPOX的文献中，1项随机对照试验显示ICU转移（6.7％vs 8.5％; P = 0.33）或死亡率（2.3％vs 2.2％）无差异。一项前瞻性的历史对照试验显示，当使用CPOX时，ICU转移（5.6-1.2天每1000患者天; P = 0.01）和救援队伍激活（3.4-1.2天每1000患者天; P =0 .02）显着降低。总体而言，CPOX组与标准监测组比较，ICU转移风险降低34％（P = 0.06），并且识别低血氧饱和（氧饱和度[SpO2] <90% > 1小时）的可能性是15倍更高（P <0.00001）。来自3项二氧化碳图研究的汇总数据显示，与脉搏血氧监测组相比，连续二氧化碳图组发现PORD事件（CO 2组vs SpO 2组：11.5％比2.8％; P <0.00001）增加了8.6％。与脉搏血氧饱和度测定组中比，CO2图形组识别PORD的几率几乎高出6倍（比值比：5.83,95％置信区间，3.54-9.63; P <0.00001）。没有研究检查连续二氧化碳图对减少救援队的激活，重症监护病房转移或死亡率的影响。
结 论
在外科病房使用CPOX可以显著改善氧饱和度降低与间歇性护理抽样检查的相关性。与标准监测相比，使用CPOX进行ICU转移的趋势较少。有关氧饱和度降低的检测是否导致救援队员激活和死亡率较低的证据尚无定论。二氧化碳图在低氧之前提供了PORD的早期预警，特别是当补充氧气时。需要高质量随机对照试验的进一步研究和改进的关于监测的教育。
原始文献摘要
Abstract
BACKGROUND: Death and anoxic brain injury from unrecognized postoperative respiratory depression (PORD) is a serious concern for patient safety. The American Patient Safety Foundation has called for continuous electronic monitoring for all patients receiving opioids in the postoperative period. These recommendations are based largely on consensus opinion with currently limited evidence. The objective of this study is to review the current state of knowledge on the effectiveness of continuous pulse oximetry (CPOX) versus routine nursing care and the effectiveness of continuous capnography monitoring with or without pulse oximetry for detecting PORD and preventing postoperative adverse events in the surgical ward.
METHODS: We performed a systematic search of the literature databases published between 1946 and May 2017. We selected the studies that included the following: (1) adult surgical patients (>18 years old); (2) prescribed opioids during the postoperative period; (3) monitored with CPOX and/or capnography; (4) primary outcome measures were oxygen desaturation, bradypnea, hypercarbia, rescue team activation, intensive care unit (ICU) admission, or mortality; and (5) studies published in the English language. Meta-analysis was performed using Cochrane Review Manager 5.3.
RESULTS: In total, 9 studies (4 examining CPOX and 5 examining continuous capnography) were included in this systematic review. In the literature on CPOX, 1 randomized controlled trial showed no difference in ICU transfers (6.7% vs 8.5%; P = .33) or mortality (2.3% vs 2.2%). A prospective historical controlled trial demonstrated a significant reduction in ICU transfers (5.6-1.2 per 1000 patient days; P = .01) and rescue team activation (3.4-1.2 per 1000 patient days; P = .02) when CPOX was used. Overall, comparing the CPOX group versus the standard monitoring group, there was 34% risk reduction in ICU transfer (P = .06) and odds of recognizing desaturation (oxygen saturation [SpO2] <90% >1 hour) was 15 times higher (P < .00001). Pooled data from 3 capnography studies showed that continuous capnography group identified 8.6% more PORD events versus pulse oximetry monitoring group (CO2 group versus SpO2 group: 11.5% vs 2.8%; P < .00001). The odds of recognizing PORD was almost 6 times higher in the capnography versus the pulse oximetry group (odds ratio: 5.83, 95% confidence interval, 3.54-9.63; P < .00001). No studies examined the impact of continuous capnography on reducing rescue team activation, ICU transfers, or mortality.
CONCLUSIONS: The use of CPOX on the surgical ward is associated with significant improvement in the detection of oxygen desaturation versus intermittent nursing spot-checks. There is a trend toward less ICU transfers with CPOX versus standard monitoring. The evidence on whether the detection of oxygen desaturation leads to less rescue team activation and mortality is inconclusive. Capnography provides an early warning of PORD before oxygen desaturation, especially when supplemental oxygen is administered. Improved education regarding monitoring and further research with high-quality randomized controlled trials is needed.
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