胸段硬膜外阻滯對冠脈搭橋術預后影響的系統評價_《中國循證醫學雜志》

作者：

方波 , 陳杰 , 李曉倩 ,  馬虹

中國醫科大學附屬第一醫院麻醉科（沈陽?110001）;

關鍵詞：

胸段硬膜外阻滯冠脈搭橋 Meta分析系統評價

DOI：

10.7507/1672-2531.20100522

視頻：

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目的 ?系統評價胸段硬膜外阻滯對冠脈搭橋術預后的影響。
方法 ?電子檢索PubMed、EBSCO、Springer、Ovid、CNKI等數據庫，納入1990～2009年間關于冠脈搭橋手術行胸段硬膜外阻滯聯合全麻和傳統的單純全麻預后比較的RCT，按Cochrane系統評價方法對納入文獻進行質量評價和資料提取，采用RevMan軟件進行Meta分析。
結果 ?共納入16篇RCT，包括1 316例患者。Meta分析結果顯示：胸段硬膜外阻滯聯合全麻與傳統單純全麻相比，術后拔氣管插管時間縮短［MD= –332.43，95%CI（–640.19，–24.68），P=0.03］，術后第一天靜息疼痛VAS［MD= –1.23，95%CI（–2.19，–0.27），P=0.01］、術后第一天運動疼痛VAS［MD= –2.52，95%CI（–4.65，–0.39），P=0.02］和術后第二天運動疼痛VAS［MD= –1.5，95%CI（–2.56，–0.43），P=0.006］降低，術后心肌缺血發生率降低［RR=0.53，95%CI（0.29，0.97），P=0.04］；而在術后心梗、房顫發生率、死亡率和肺功能方面兩組間差異無統計學意義。
結論 ?冠脈搭橋手術行胸段硬膜外阻滯聯合全麻較傳統的單純全麻能明顯縮短術后拔氣管插管時間，明顯降低術后疼痛VAS，降低術后心肌缺血發生率。對于術后心梗、房顫發生率，死亡率和肺功能的影響尚需開展更多深入研究來證實。

引用本文： 方波,陳杰,李曉倩,馬虹. 胸段硬膜外阻滯對冠脈搭橋術預后影響的系統評價. 中國循證醫學雜志, 2010, 10(8): 932-938. doi: 10.7507/1672-2531.20100522 復制

1.	Gramling-Babb PM, Zile MR, Reeves ST. Preliminary report on high thoracic epidural analgesia: Relationship between its therapeutic effects and myocardial blood flow as assessed by stress thallium distribution. J Cardiovasc Vasc Anesth, 2000, 14(6): 657-661.
2.	Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg, 1997, 84(6): 1211-1221.
3.	Grass JA. The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North Am, 2000, 18(2): 407–428, viii.
4.	Scott NB, Turfrey DJ, Ray DA, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg, 2001, 93(3): 528-535.
5.	Berendes E, Schmidt C, Van Aken H, et al. Reversible Cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting. Arch Surgm, 2003, 138(12): 1283-1290.
6.	Fillinger MP, Yeager MP, Dodds TM, et al. Epidural anesthesia and analgesia: Effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth, 2002, 16(1):15-20.
7.	Jideus L, Joachimsson PO, Stridsberg M, et al. Thoracic epidural anesthesia does not influence the occurrence of postoperative sustained atrial fibrillation. Ann Tho- rac Surg, 2001, 72(1): 65-71.
8.	Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2): 275-282.
9.	Kirno K, Friberg P, Grzegorczyk A, et al. Thoracic epidural anesthesia during coronary artery bypass surgery: effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg, 1994, 79(6): 1075-1081.
10.	Liem TH, Hasenbos MA, Booij LH, et al. Coronary artery bypass grafting using two different anesthetic techniques: II. Postoperative outcome. J Cardiothorac Vasc Anesth, 1992, 6(2): 156-161.
11.	Barrington MJ, Kluger R, Watson, R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4): 921-928.
12.	Nygård E, Sørensen LH, Hviid LB. Effects of amiodarone and thoracic epidural analgesia on atrial fibrillation after coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2004, 18(6 ): 709-714.
13.	Tenenbein PK, Debrouwere R, Maguire D, et al. Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery. Can J Anesth, 2008, 55(6): 344-350.
14.	Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1): 93-100.
15.	Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural analgesiaas an adjunct to general anesthesia for cardiac surgery: Effects on pulmonary mechanics. Acta Anaesthesiol Scand, 2000, 44(9): 1071-1076.
16.	Fawcett WJ, Edwards RE, Quinn AC, et al. Thoracic epidural analgesia started after cardiopulmonary bypass. Anaesth, 1997, 52(4): 294-299.
17.	Loick HM, Schmidt C, Van Aken H, et al. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg, 1999, 88(4): 701–709.
18.	Rodriguez MAP, Gonzalo LS, Villaralvarez F, et al. Thoracic epidural anesthesia decrease C-reactive protein levels in patients undergoing elective coronary artery bypass raft surgery with cardiopulmonary bypass. Minerva Anesthesiol, 2008, 74(11): 619-626.
19.	Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth, 1999, 13(3): 258-264.
20.	Moore CM, Cross MH, Desborough JP, et al. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth, 1995, 75(4): 387-393.
21.	Buggy DJ, Smith G. Epidural anaesthesia and analgesia:better outcome after major surgery? Growing evidence suggests so. BMJ, 1999, 319(7209): 531-532.
22.	Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology, 1990, 73(5): 840-847.
23.	Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstableangina pectoris. Anesth Analg, 1989, 69(5): 558-562.
24.	Meissner A, Rolf N, Van Aken H. Thoracic epidural anesthesia and the patient with heart disease: Benefits, risks, and controversies. Anesth Analg, 1997, 85(3): 517-528.
25.	Hogue CW, Hyder ML. Atrial ?brillation after cardiac operation: Risks, mechanisms, and treatment. Ann Thorac Surg, 2000, 69(1): 300-306.

1. Gramling-Babb PM, Zile MR, Reeves ST. Preliminary report on high thoracic epidural analgesia: Relationship between its therapeutic effects and myocardial blood flow as assessed by stress thallium distribution. J Cardiovasc Vasc Anesth, 2000, 14(6): 657-661.
2. Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg, 1997, 84(6): 1211-1221.
3. Grass JA. The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North Am, 2000, 18(2): 407–428, viii.
4. Scott NB, Turfrey DJ, Ray DA, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg, 2001, 93(3): 528-535.
5. Berendes E, Schmidt C, Van Aken H, et al. Reversible Cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting. Arch Surgm, 2003, 138(12): 1283-1290.
6. Fillinger MP, Yeager MP, Dodds TM, et al. Epidural anesthesia and analgesia: Effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth, 2002, 16(1):15-20.
7. Jideus L, Joachimsson PO, Stridsberg M, et al. Thoracic epidural anesthesia does not influence the occurrence of postoperative sustained atrial fibrillation. Ann Tho- rac Surg, 2001, 72(1): 65-71.
8. Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2): 275-282.
9. Kirno K, Friberg P, Grzegorczyk A, et al. Thoracic epidural anesthesia during coronary artery bypass surgery: effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg, 1994, 79(6): 1075-1081.
10. Liem TH, Hasenbos MA, Booij LH, et al. Coronary artery bypass grafting using two different anesthetic techniques: II. Postoperative outcome. J Cardiothorac Vasc Anesth, 1992, 6(2): 156-161.
11. Barrington MJ, Kluger R, Watson, R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4): 921-928.
12. Nygård E, Sørensen LH, Hviid LB. Effects of amiodarone and thoracic epidural analgesia on atrial fibrillation after coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2004, 18(6 ): 709-714.
13. Tenenbein PK, Debrouwere R, Maguire D, et al. Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery. Can J Anesth, 2008, 55(6): 344-350.
14. Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1): 93-100.
15. Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural analgesiaas an adjunct to general anesthesia for cardiac surgery: Effects on pulmonary mechanics. Acta Anaesthesiol Scand, 2000, 44(9): 1071-1076.
16. Fawcett WJ, Edwards RE, Quinn AC, et al. Thoracic epidural analgesia started after cardiopulmonary bypass. Anaesth, 1997, 52(4): 294-299.
17. Loick HM, Schmidt C, Van Aken H, et al. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg, 1999, 88(4): 701–709.
18. Rodriguez MAP, Gonzalo LS, Villaralvarez F, et al. Thoracic epidural anesthesia decrease C-reactive protein levels in patients undergoing elective coronary artery bypass raft surgery with cardiopulmonary bypass. Minerva Anesthesiol, 2008, 74(11): 619-626.
19. Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth, 1999, 13(3): 258-264.
20. Moore CM, Cross MH, Desborough JP, et al. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth, 1995, 75(4): 387-393.
21. Buggy DJ, Smith G. Epidural anaesthesia and analgesia:better outcome after major surgery? Growing evidence suggests so. BMJ, 1999, 319(7209): 531-532.
22. Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology, 1990, 73(5): 840-847.
23. Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstableangina pectoris. Anesth Analg, 1989, 69(5): 558-562.
24. Meissner A, Rolf N, Van Aken H. Thoracic epidural anesthesia and the patient with heart disease: Benefits, risks, and controversies. Anesth Analg, 1997, 85(3): 517-528.
25. Hogue CW, Hyder ML. Atrial ?brillation after cardiac operation: Risks, mechanisms, and treatment. Ann Thorac Surg, 2000, 69(1): 300-306.

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胸段硬膜外阻滯對冠脈搭橋術預后影響的系統評價

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《中國循證醫學雜志》

胸段硬膜外阻滯對冠脈搭橋術預后影響的系統評價

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