硬膜外鎮痛對減少心臟手術術后并發癥的有效性及安全性系統評價_《中國循證醫學雜志》

作者：

魏國 , 宣燕 , 鄭宏 ,  王江

新疆醫科大學第一附屬醫院麻醉科（烏魯木齊 830054）;

關鍵詞：

心臟手術硬膜外鎮痛全身麻醉系統評價 Meta分析隨機對照試驗

DOI：

10.7507/1672-2531.20130211

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目的　系統評價心臟手術中實施硬膜外鎮痛對減少心臟手術術后并發癥的有效性和安全性。
方法　計算機檢索PubMed、SCI、EMbase、The Cochrane Library、CNKI和CBM等數據庫，全面收集硬膜外鎮痛減少心臟手術術后并發癥的隨機對照試驗（RCT），檢索時限均為建庫至2012年10月，并追溯納入研究的參考文獻。由兩位研究者按照納入與排除標準獨立篩選文獻、提取資料和評價質量后，采用RevMan 5.0軟件進行Meta分析。
結果　共納入14個RCT，1 942例患者。Meta分析結果顯示：聯合硬膜外鎮痛組在減少心肌缺血及梗死發生率［RR=0.63，95%CI（0.41，0.96），P=0.03］、呼吸系統并發癥發生率［RR=0.55，95%CI（0.40，0.75），P=0.000 1］、室上性心律失常發生率［RR=0.64，95%CI（0.47，0.88），P=0.005］和機械通氣時間［MD= –2.15，95%CI（–3.72，–0.58），P=0.00 7］方面均優于單獨使用全身麻醉組，且差異均有統計學意義。
結論　基于當前證據，術后硬膜外鎮痛可降低心臟手術患者術后心肌缺血及梗死、呼吸系統并發癥、室上性心律失常發生率并減少機械通氣時間。但目前缺乏評估硬膜外鎮痛不良事件（主要為硬膜外血腫）發生率的數據。受納入研究數量與質量限制，臨床上在選擇是否使用硬膜外鎮痛之前，應該對患者各方面情況進行綜合考慮。

引用本文： 魏國,宣燕,鄭宏,王江. 硬膜外鎮痛對減少心臟手術術后并發癥的有效性及安全性系統評價. 中國循證醫學雜志, 2013, 13(10): 1229-1235. doi: 10.7507/1672-2531.20130211 復制

1.	Mangano DT. Assessment of the patient with cardiac disease: An anesthesiologist’s paradigm. Anesthesiology, 1999, 92(5): 1521-1526.
2.	Coriat P, Beaussier M. Fast-tracking after coronary artery bypass graft surgery. Anesth Analg, 2001, 92(5): 1081-1083.
3.	Sabaté S, Mases A, Guilera N, et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth, 2011, 107(6): 879-890.
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.	Djaiani G. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: Effects on ventilationperfusion relationships. J Cardiothorac Vasc Anesth, 2000, 14(3): 359-360.
6.	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.
7.	Nygård E, Kofoed KF, Freiberg J, et al. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation, 2005, 111(17): 2165-2170.
8.	Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3): 919-920.
9.	Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. Anesth Analg, 1998, 86(3): 598-612.
10.	Stenseth R, Bjella L, Berg EM, et al. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg, 1996, 10(10): 859-865.
11.	Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: Estimating the risk of a rare adverse event that has not (yet) occurred. Chest, 2000, 117(2): 551-555.
12.	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.
13.	Kiliçkan L, Gonca S, Dalçik C, et al. General anesthesia with thoracic epidural anesthesia in the cardiopulmonary bypass surgery reduces apoptosis by upregulating antiapoptotic protein Bcl-2. J Cardiovasc Surg (Torino), 2006, 47(3): 315-322.
14.	Kerstein J, Soodan A, Qamar M, et al. Giving IV and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery: The GAP study. Chest, 2004, 126(3): 716-724.
15.	Burgess DC, Kilborn MJ, Keech AC. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: A meta-analysis. Eur Heart J, 2006, 27(23): 2846-2857.
16.	Cheng DC. Fast-track cardiac surgery:Economic implications in postoperative care. J Cardiothorac Vasc Anesth, 1998, 12(1): 72-79.
17.	Cheng DC, Karski J, Peniston C, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: A prospective, randomized, controlled trial. Anesthsiology, 1996, 85(6): 1300-1310.
18.	Silbert BS, Santamaria JD, O’Brien JL, et al. Early extubation following coronary artery bypass surgery: A prospective randomized controlled trial. The Fast Track Cardiac Care Team. Chest, 1998, 113(6): 1481-1488.
19.	Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: A meta-analysis. Anesthesiology, 2004, 101(1): 153-161.
20.	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.
21.	Bach F, Grundmann U, Bauer M, et al. Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia. Acta Anaesthesiol Scand, 2002, 46(10): 1227-1235.
22.	de Vries AJ, Mariani MA, van der Maaten JM, et al. To ventilate or not after minimally invasive direct coronary artery bypass surgery: The role of epidural anesthesia. J Cardiothorac Vasc Anesth, 2002, 16(1): 21-26.
23.	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: A randomized trial. Arch Surg, 2003, 138(12): 1283-1290.
24.	Kendall JB, Russell GN, Scawn ND, et al. A prospective, randomised, single-blind pilot study to determine the effect of anaesthetic technique on troponin T release after off-pump coronary artery surgery. Anaesthesia, 2004, 59(6): 545-549.
25.	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.
26.	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. Anesthesilogy, 2006, 104(1): 142-151.
27.	Bakhtiary F, Therapidis P, Dzemali O, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting: A prospective randomized study. J Thorac Cardiovasc Surg, 2007, 134(2), 460-464.
28.	Caputo M, Alwair H, Rogers CA, et al. Myocardial, inflammatory, and stress responses in off-pump coronary artery bypass graft surgery with thoracic epidural anesthesia. Ann Thorac Surg, 2009, 87(4): 1119-1126.
29.	Svircevic V, Nierich AP, Moons KG, et al. Thoracic epidural anesthesia for cardiac surgery: A randomized trial. Aneshesilogy, 2011, 114(2): 262-270.
30.	周新, 程紅. 胸部硬膜外阻滯在心臟開胸手術術后鎮痛的臨床研究. 四川醫學雜志, 2010, 31(3): 344-346.

1. Mangano DT. Assessment of the patient with cardiac disease: An anesthesiologist’s paradigm. Anesthesiology, 1999, 92(5): 1521-1526.
2. Coriat P, Beaussier M. Fast-tracking after coronary artery bypass graft surgery. Anesth Analg, 2001, 92(5): 1081-1083.
3. Sabaté S, Mases A, Guilera N, et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth, 2011, 107(6): 879-890.
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. Djaiani G. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: Effects on ventilationperfusion relationships. J Cardiothorac Vasc Anesth, 2000, 14(3): 359-360.
6. 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.
7. Nygård E, Kofoed KF, Freiberg J, et al. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation, 2005, 111(17): 2165-2170.
8. Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3): 919-920.
9. Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. Anesth Analg, 1998, 86(3): 598-612.
10. Stenseth R, Bjella L, Berg EM, et al. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg, 1996, 10(10): 859-865.
11. Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: Estimating the risk of a rare adverse event that has not (yet) occurred. Chest, 2000, 117(2): 551-555.
12. 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.
13. Kiliçkan L, Gonca S, Dalçik C, et al. General anesthesia with thoracic epidural anesthesia in the cardiopulmonary bypass surgery reduces apoptosis by upregulating antiapoptotic protein Bcl-2. J Cardiovasc Surg (Torino), 2006, 47(3): 315-322.
14. Kerstein J, Soodan A, Qamar M, et al. Giving IV and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery: The GAP study. Chest, 2004, 126(3): 716-724.
15. Burgess DC, Kilborn MJ, Keech AC. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: A meta-analysis. Eur Heart J, 2006, 27(23): 2846-2857.
16. Cheng DC. Fast-track cardiac surgery:Economic implications in postoperative care. J Cardiothorac Vasc Anesth, 1998, 12(1): 72-79.
17. Cheng DC, Karski J, Peniston C, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: A prospective, randomized, controlled trial. Anesthsiology, 1996, 85(6): 1300-1310.
18. Silbert BS, Santamaria JD, O’Brien JL, et al. Early extubation following coronary artery bypass surgery: A prospective randomized controlled trial. The Fast Track Cardiac Care Team. Chest, 1998, 113(6): 1481-1488.
19. Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: A meta-analysis. Anesthesiology, 2004, 101(1): 153-161.
20. 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.
21. Bach F, Grundmann U, Bauer M, et al. Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia. Acta Anaesthesiol Scand, 2002, 46(10): 1227-1235.
22. de Vries AJ, Mariani MA, van der Maaten JM, et al. To ventilate or not after minimally invasive direct coronary artery bypass surgery: The role of epidural anesthesia. J Cardiothorac Vasc Anesth, 2002, 16(1): 21-26.
23. 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: A randomized trial. Arch Surg, 2003, 138(12): 1283-1290.
24. Kendall JB, Russell GN, Scawn ND, et al. A prospective, randomised, single-blind pilot study to determine the effect of anaesthetic technique on troponin T release after off-pump coronary artery surgery. Anaesthesia, 2004, 59(6): 545-549.
25. 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.
26. 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. Anesthesilogy, 2006, 104(1): 142-151.
27. Bakhtiary F, Therapidis P, Dzemali O, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting: A prospective randomized study. J Thorac Cardiovasc Surg, 2007, 134(2), 460-464.
28. Caputo M, Alwair H, Rogers CA, et al. Myocardial, inflammatory, and stress responses in off-pump coronary artery bypass graft surgery with thoracic epidural anesthesia. Ann Thorac Surg, 2009, 87(4): 1119-1126.
29. Svircevic V, Nierich AP, Moons KG, et al. Thoracic epidural anesthesia for cardiac surgery: A randomized trial. Aneshesilogy, 2011, 114(2): 262-270.
30. 周新, 程紅. 胸部硬膜外阻滯在心臟開胸手術術后鎮痛的臨床研究. 四川醫學雜志, 2010, 31(3): 344-346.

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《中國循證醫學雜志》

硬膜外鎮痛對減少心臟手術術后并發癥的有效性及安全性系統評價

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