不同自控鎮痛方式對胸腹部手術術后并發癥影響的Meta分析_《中國循證醫學雜志》

作者：

 王赫 , 孫喜家 , 馬虹

中國醫科大學附屬第一醫院麻醉科（沈陽 110001）;

關鍵詞：

硬膜外鎮痛靜脈鎮痛術后并發癥胸腹部手術系統評價 Meta分析隨機對照試驗

DOI：

10.7507/1672-2531.20100585

視頻：

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摘要 全文 圖表 視頻 參考文獻 施引文獻 補充材料

目的　評價硬膜外和靜脈不同自控鎮痛方法對胸、腹部手術術后并發癥的影響。
方法　計算機檢索PubMed、EBSCO、Springer、Ovid、CNKI等數據庫，并追溯納入文獻的參考文獻，收集發表于1985年至2009年行胸、腹部手術術后應用硬膜外和靜脈自控鎮痛的隨機對照試驗，按Cochrane系統評價員手冊5.0對納入文獻進行質量評價和資料提取，而后采用RevMan 4.2.10軟件進行統計分析。
結果　共納入13篇隨機對照試驗，包括3 055例患者。Meta分析結果顯示：① 對肺部并發癥和肺功能的影響：硬膜外鎮痛較靜脈鎮痛能顯著降低患者術后肺炎的發生率［RR=0.66，95%CI（0.53，0.83）］，提高患者術后第一秒用力呼氣量（FEV1）［WMD=0.17，95%CI（0.05，0.29）］和用力肺活量（FVC）［WMD=0.21，95%CI（0.1，0.32）］，但在降低患者術后呼吸衰竭［RR=0.77，95%CI（0.58，1.02）］和術后機械通氣延長方面［RR=0.75，95%CI（0.51，1.13）］與靜脈鎮痛無顯著差異；② 對心血管事件的影響：硬膜外鎮痛較靜脈鎮痛能顯著降低術后患者心肌梗死［RR=0.58，95%CI（0.35，0.95）］和心律失常［RR=0.64，95%CI（0.47，0.88）］的發生率，但對降低患者術后心力衰竭［RR=0.79，95%CI（0.47，1.34）］和低血壓［RR=1.21，95%CI（0.63，2.29）］的發生率無明顯差；③ 其他系統并發癥：兩者在降低患者術后腎功能不全［RR=0.78，95%CI（0.53，1.14）］、消化道出血［RR=0.78，95%CI（0.49，1.23）］、術后感染［RR=0.89，95%CI（0.70，1.12）］及惡心嘔吐方面［RR=1.03，95%CI（0.38，2.81）］無明顯差異。
結論　硬膜外鎮痛較靜脈鎮痛能顯著降低術后發生肺炎、心肌梗死及嚴重心律失常的發生率，改善術后患者肺功能。

引用本文： 王赫,孫喜家,馬虹. 不同自控鎮痛方式對胸腹部手術術后并發癥影響的Meta分析. 中國循證醫學雜志, 2010, 10(11): 1285-1292. doi: 10.7507/1672-2531.20100585 復制

1.	盛卓人, 王俊科. 實用臨床麻醉學. 北京: 科學出版社, 2009.
2.	Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA, 2003, 290(18): 2455-2463.
3.	Chen LM, Weinberg VK, Chen C, et al. Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery. Gynecol Oncol, 2009, 115(3): 357-361.
4.	Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Anesthesiology, 2006, 104(1): 142-151.
5.	Peyton PJ, Myles PS, Silbert BS, et al. Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg, 2003, 96(2): 548.
6.	Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg, 2001, 234(4): 560-569.
7.	Boisseau N, Rabary O, Padovani B, et al. Improvement of ‘dynamic analgesia’ does not decrease atelectasis after thoracotomy. Br J Anaesth, 2001, 87(4): 564-569.
8.	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.
9.	Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology, 2000, 92(2): 433-441.
10.	Boylan JF, Katz J, Kavanagh BP, et al. Epidural bupivacaine-morphine analgesia versus patient-controlled analgesia following abdominal aortic surgery: analgesic, respiratory, and myocardial effects. Anesthesiology, 1998, 89(3): 585-593.
11.	Garnett RL, MacIntyre A, Lindsay P, et al. Perioperative ischaemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia. Can J Anaesth, 1996, 43(8): 769-777.
12.	Baxter AD, Laganière S, Samson B, et al. A comparison of lumbar epidural and intravenous fentanyl infusions for post-thoracotomy analgesia. Can J Anaesth, 1994, 41(3): 184-191.
13.	Davies MJ, Silbert BS, Mooney PJ, et al. Combined epidural and general anaesthesia versus general anaesthesia for abdominal aortic surgery: a prospective randomised trial. Anaesth Intensive Care, 1993, 21(6): 790-794.
14.	Grant RP, Dolman Jf, Harper JA, et al. Patient-controlled Lumbar epidural fentanyl compares with patient-controller intravenous fentanyl for post-thoracotomy pain. Can J Anaesth, 1992, 39(3): 214-219.
15.	Tuman KJ, Mc Carthy RJ, March RJ, et al. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg, 1991, 73(6): 696-704.
16.	Ferguson SE, Malhotra T, Seshan VE, et al. A prosepective randomized trial comparing patient-controlled epidural analgesia to patient-controlled intravenous analgesia on postoperative pain control and recovery after major open gynecologic cancer surgery. Gynecol Oncol, 2009, 114(1): 111-116.
17.	Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesiaversus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev, 2005, CD004088.
18.	Paulsen EK, Porter MG, Helmer SD, et al. Thoracic epidural versus patient-controlled analgesia in elective bowel resections. Am J Surg, 2001, 182(6): 570–577.
19.	Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology, 1995, 82(6): 1474-1506.
20.	Beattie WS, Badner NH, Choi p, et al. Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis. AnesthAnalg, 2001, 93: 853–858.
21.	Ballantyne JC, Carr DB, et al. The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome: Cumulative Meta-Analyses of Randomized, Controlled Trials. AnesthAnalg, 1998, 86: 598-612.
22.	Ben-Eliyahu S. The promotion of tumor metastasis by surgery and stress: immunological basis and implications for psychoneuroimmunology. Brain Behav Immun, 2003, 17(Suppl 1): S27-36.
23.	Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. evidence from published data. Br J Anaesth, 2002, 89(3): 409-423.

1. 盛卓人, 王俊科. 實用臨床麻醉學. 北京: 科學出版社, 2009.
2. Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA, 2003, 290(18): 2455-2463.
3. Chen LM, Weinberg VK, Chen C, et al. Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery. Gynecol Oncol, 2009, 115(3): 357-361.
4. Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Anesthesiology, 2006, 104(1): 142-151.
5. Peyton PJ, Myles PS, Silbert BS, et al. Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg, 2003, 96(2): 548.
6. Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg, 2001, 234(4): 560-569.
7. Boisseau N, Rabary O, Padovani B, et al. Improvement of ‘dynamic analgesia’ does not decrease atelectasis after thoracotomy. Br J Anaesth, 2001, 87(4): 564-569.
8. 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.
9. Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology, 2000, 92(2): 433-441.
10. Boylan JF, Katz J, Kavanagh BP, et al. Epidural bupivacaine-morphine analgesia versus patient-controlled analgesia following abdominal aortic surgery: analgesic, respiratory, and myocardial effects. Anesthesiology, 1998, 89(3): 585-593.
11. Garnett RL, MacIntyre A, Lindsay P, et al. Perioperative ischaemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia. Can J Anaesth, 1996, 43(8): 769-777.
12. Baxter AD, Laganière S, Samson B, et al. A comparison of lumbar epidural and intravenous fentanyl infusions for post-thoracotomy analgesia. Can J Anaesth, 1994, 41(3): 184-191.
13. Davies MJ, Silbert BS, Mooney PJ, et al. Combined epidural and general anaesthesia versus general anaesthesia for abdominal aortic surgery: a prospective randomised trial. Anaesth Intensive Care, 1993, 21(6): 790-794.
14. Grant RP, Dolman Jf, Harper JA, et al. Patient-controlled Lumbar epidural fentanyl compares with patient-controller intravenous fentanyl for post-thoracotomy pain. Can J Anaesth, 1992, 39(3): 214-219.
15. Tuman KJ, Mc Carthy RJ, March RJ, et al. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg, 1991, 73(6): 696-704.
16. Ferguson SE, Malhotra T, Seshan VE, et al. A prosepective randomized trial comparing patient-controlled epidural analgesia to patient-controlled intravenous analgesia on postoperative pain control and recovery after major open gynecologic cancer surgery. Gynecol Oncol, 2009, 114(1): 111-116.
17. Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesiaversus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev, 2005, CD004088.
18. Paulsen EK, Porter MG, Helmer SD, et al. Thoracic epidural versus patient-controlled analgesia in elective bowel resections. Am J Surg, 2001, 182(6): 570–577.
19. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology, 1995, 82(6): 1474-1506.
20. Beattie WS, Badner NH, Choi p, et al. Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis. AnesthAnalg, 2001, 93: 853–858.
21. Ballantyne JC, Carr DB, et al. The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome: Cumulative Meta-Analyses of Randomized, Controlled Trials. AnesthAnalg, 1998, 86: 598-612.
22. Ben-Eliyahu S. The promotion of tumor metastasis by surgery and stress: immunological basis and implications for psychoneuroimmunology. Brain Behav Immun, 2003, 17(Suppl 1): S27-36.
23. Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. evidence from published data. Br J Anaesth, 2002, 89(3): 409-423.

《中國循證醫學雜志》

不同自控鎮痛方式對胸腹部手術術后并發癥影響的Meta分析

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《中國循證醫學雜志》

不同自控鎮痛方式對胸腹部手術術后并發癥影響的Meta分析

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