罹患肺动脉高压的心脏手术患者采用雾化血管扩张药物治疗的系统评价和Meta分析
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Aerosolized Vasodilators for the Treatment of Pulmonary Hypertension in Cardiac Surgical Patients: A Systematic Review and Meta-analysis.
背景与目的
心脏手术中肺动脉高压的程度是实时选用治疗方式的重要预测因子。本次系统评价和Meta分析中，我们对比了心脏手术中使用吸入雾化血管扩张药物和静脉血管扩张药物以及安慰剂治疗肺动脉高压的疗效，检索了自2015年10月始MEDLINE，CENTRAL，EMBASE，Science网以及临床研究中心数据库的文献，并以死亡率为主要结局指标，以住院时间和ICU滞留时间以及期间血流动力学的情况作为次要结局指标。
方 法
初步检索获得2897篇文献，最终10篇文献符合纳入条件（含434名患者）。
结 果
与静脉扩血管药物比较，吸入雾化血管活性药物能显著降低肺血管的阻力（-41.36 dyne.s/cm5，P=0.03）和增加平均动脉压力（8.24 mmHg，P=0.02）以及右心室射血分数（7.29%，P＜0.0001）.虽然使用雾化吸入血管活性药物和安慰剂之间血流动力学情况的差异无统计学差异，但使用使用雾化吸入血管活性药物能增加ICU的滞留时间（0.66天，P=0.01）。此外，三组其它方面的差异均无统计学差异。
结 论
与静脉扩血管药物比较，罹患肺动脉高压的心脏手术患者使用吸入雾化血管活性药物能增加右心室的射血分数。但本研究结果表明，与安慰剂对比，使用吸入雾化血管活性药物并没有改善罹患肺动脉高压的心脏手术患者的死亡率。因此，需要进一步深入相关的研究并着重于关注其临床主要结局的转归（死亡率）。
原始文献摘要
Elmi-Sarabi M, Deschamps A, Delisle S, et al. Aerosolized Vasodilators for the Treatment of Pulmonary Hypertension in Cardiac Surgical Patients: A Systematic Review and Meta-analysis.[J]. Anesthesia and analgesia, 2017,125(2):393-402. DOI:10.1213/ANE.0000000000002138
Abstract：
BACKGROUND: In cardiac surgery, pulmonary hypertension is an important prognostic factor for which several treatments have been suggested over time. In this systematic review and meta-analysis, we compared the efficacy of inhaled aerosolized vasodilators to intravenously administered agents and to placebo in the treatment of pulmonary hypertension during cardiac surgery. We searched MEDLINE, CENTRAL, EMBASE, Web of Science, and clinicaltrials.gov databases from inception to October 2015. The incidence of mortality was assessed as the primary outcome. Secondary outcomes included length of stay in hospital and in the intensive care unit, and evaluation of the hemodynamic profile.
METHODS: Of the 2897 citations identified, 10 studies were included comprising a total of 434 patients.
RESULTS: Inhaled aerosolized agents were associated with a significant decrease in pulmonary vascular resistance (-41.36 dyne.s/cm, P= .03) and a significant increase in mean arterial pressure (8.24 mm Hg, P= .02) and right ventricular ejection fraction (7.29%, P< .0001) when compared to intravenously administered agents. No significant hemodynamically meaningful differences were observed between inhaled agents and placebo; however, an increase in length of stay in the intensive care unit was shown with the use of inhaled aerosolized agents (0.66 days, P= .01). No other differences were observed for either comparison.
CONCLUSIONS: The administration of inhaled aerosolized vasodilators for the treatment of pulmonary hypertension during cardiac surgery is associated with improved right ventricular performance when compared to intravenously administered agents. This review does not support any benefit compared to placebo on major outcomes. Further investigation is warranted in this area of research and should focus on clinically significant outcomes.
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