硬膜外镇痛对减少心脏手术术后并发症的有效性及安全性系统评价_《中国循证医学杂志》

作者：

魏国 , 宣燕 , 郑宏 ,  王江

新疆医科大学第一附属医院麻醉科（乌鲁木齐 830054）;

关键词：

心脏手术硬膜外镇痛全身麻醉系统评价 Meta分析随机对照试验

DOI：

10.7507/1672-2531.20130211

视频：

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摘要 全文 图表 视频 参考文献 施引文献 补充材料

目的　系统评价心脏手术中实施硬膜外镇痛对减少心脏手术术后并发症的有效性和安全性。
方法　计算机检索PubMed、SCI、EMbase、The Cochrane Library、CNKI和CBM等数据库，全面收集硬膜外镇痛减少心脏手术术后并发症的随机对照试验（RCT），检索时限均为建库至2012年10月，并追溯纳入研究的参考文献。由两位研究者按照纳入与排除标准独立筛选文献、提取资料和评价质量后，采用RevMan 5.0软件进行Meta分析。
结果　共纳入14个RCT，1 942例患者。Meta分析结果显示：联合硬膜外镇痛组在减少心肌缺血及梗死发生率［RR=0.63，95%CI（0.41，0.96），P=0.03］、呼吸系统并发症发生率［RR=0.55，95%CI（0.40，0.75），P=0.000 1］、室上性心律失常发生率［RR=0.64，95%CI（0.47，0.88），P=0.005］和机械通气时间［MD= –2.15，95%CI（–3.72，–0.58），P=0.00 7］方面均优于单独使用全身麻醉组，且差异均有统计学意义。
结论　基于当前证据，术后硬膜外镇痛可降低心脏手术患者术后心肌缺血及梗死、呼吸系统并发症、室上性心律失常发生率并减少机械通气时间。但目前缺乏评估硬膜外镇痛不良事件（主要为硬膜外血肿）发生率的数据。受纳入研究数量与质量限制，临床上在选择是否使用硬膜外镇痛之前，应该对患者各方面情况进行综合考虑。

引用本文： 魏国,宣燕,郑宏,王江. 硬膜外镇痛对减少心脏手术术后并发症的有效性及安全性系统评价. 中国循证医学杂志, 2013, 13(10): 1229-1235. doi: 10.7507/1672-2531.20130211 复制

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, 程红. 胸部硬膜外阻滞在心脏开胸手术术后镇痛的临床研究. 四川医学杂志, 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, 程红. 胸部硬膜外阻滞在心脏开胸手术术后镇痛的临床研究. 四川医学杂志, 2010, 31(3): 344-346.

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《中国循证医学杂志》

硬膜外镇痛对减少心脏手术术后并发症的有效性及安全性系统评价

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《中国循证医学杂志》

硬膜外镇痛对减少心脏手术术后并发症的有效性及安全性系统评价

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