静脉单剂量氯胺酮对剖宫产单次腰麻后镇痛有效性的分析
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摘要
目的系统评价氯胺酮用于剖宫产术后临床镇痛的效果及安全性,为临床实践提供证据。方法计算机检索Cochrane图书馆、PubMed、Springer、EBSCO、CNKI和CBM等数据库,查找关于单次腰麻下行剖宫产手术的产妇予静脉单剂量氯胺酮注射、术后镇痛效果对比的随机对照试验,检索时限为1990年1月1日至2018年3月17日。按Cochrane系统评价方法对纳入的文献进行质量评价及数据提取,采用RevMan 5.3进行统计学分析。结果共纳入13篇随机对照试验,包括1 435例患者。Meta分析结果显示:与对照组相比,静脉单剂量注射氯胺酮可显著降低产妇术后2 h[均数差=-1.26,95%可信区间(-1.88,-0.63),P<0.000 1]和12 h[均数差=-2.22,95%可信区间(-3.74,-0.70),P=0.004]的视觉疼痛模拟评分;但1 h[均数差=-3.21,95%可信区间(-9.27,2.84),P=0.30]和3 h[均数差=-1.41,95%可信区间(-3.52,0.69),P=0.19]视觉疼痛模拟评分较对照组差异无统计学意义。单剂量静注氯胺酮能显著减少术后第一天[均数差=-86.48,95%可信区间(-128.52,-44.43),P <0.000 1]及第二天[均数差=-12.23,95%可信区间(-22.80,-1.67),P=0.02]静脉非甾体类抗炎镇痛药双氯芬酸的累计使用量。氯胺酮组术后首次要求使用镇痛药物时间明显延长[均数差=59.68,95%可信区间(43.98,75.38),P<0.000 01]。氯胺酮组术后瘙痒[均数差=0.55,95%可信区间(0.32,0.95),P=0.03]及寒战[均数差=0.07,95%可信区间(0.01,0.71),P=0.02]发生率较对照组明显下降,但产妇术后幻觉发生率明显增高[均数差=2.65,95%可信区间(1.23,5.69),P=0.01]。在术后恶心[均数差=0.70,95%可信区间(0.49,1.01),P=0.06]、呕吐[均数差=-0.77,95%可信区间(0.54,1.11),P=0.17]、头痛[均数差=1.29,95%可信区间(0.27,6.14),P=0.75]等不良反应方面两组间未见明显差异。结论静脉单次注射氯胺酮可显著增强腰麻下行剖宫产手术患者术后镇痛满意度,明显减少非甾体类抗炎镇痛药的不良反应,并且不增加产妇及胎儿的不良反应。
Objective To systematically evaluate the efficacy and safety of Ketamine on postoperative pain and side effects after spinal anaesthesia for caesarean section. Methods A systematic literature search was conducted in the Cochrane Library,PubMed,Springer,EBSCO,CNKI and CBM databases from January 1 st,1990 to March 17 th,2018 to identify randomized controlled trials(RCTs)on intravenous Ketamine during spinal anaesthesia for caesarean section.All included RCTs were assessed and the data were extracted according to the standard of Cochrane systematic review.The homogenous studies were pooled using RevMan 5.3 software. Results 13 RCTs,in total of 1 435 patients,were included herein. The results indicated that compare to the control group,intravenous infusion of Ketamine significantly reduced the visual analog scale(VAS)scores after 2~(nd)[MD=-1.26,95%CI(-1.88,-0.63),P<0.000 1]and 12~(th)[MD=-2.22,95%CI(-3.74,-0.70),P=0.004]hours since the spinal anaesthesia for ceasrean section. But the VAS scores after 1 st[MD=-3.21,95%CI(-9.27,2.84),P=0.30]and 3~(rd)[MD=-1.41,95%CI(-3.52,0.69),P=0.19]hours showed no significant difference to control groups. Bolus injected Ketamine considerably decreased the cumulative dose of non-steroid anti-inflammatory drug Diclofenac in the first[MD=-86.48,95%CI(-128.52,-44.43),P < 0.000 1]and second 24 h[MD=-12.23,95%CI(-22.80,-1.67),P=0.02]postoperatively. Meanwhile,the first requirement of analgesic[MD=59.68,95%CI(43.98,75.38),P<0.000 01] was dramatically prolonged in the Ketamine-treated groups. Ketamine attenuated the morbidity of pruritus[MD=0.55,95%CI(0.32,0.95),P=0.03],shivering[MD=0.07,95%CI(0.01,0.71),P=0.02]and illusion[MD=2.65,95%CI(1.23,5.69),P=0.01],respectively. Nevertheless,the incidents of postoperative nausea[MD=0.70,95%CI(0.49,1.01),P=0.06],vomit[MD=0.77,95%CI(0.54,1.11),P=0.17]and headache[MD=1.29,95% CI(0.27,6.14),P=0.75] were similar to control groups. Conclusion The intravenous Ketamine during spinal anaesthesia for caesarean section can dramatically decrease the postoperative pain and side effects,which can extremely enhance the satisfactory of maternal patients.
Objective To systematically evaluate the efficacy and safety of Ketamine on postoperative pain and side effects after spinal anaesthesia for caesarean section. Methods A systematic literature search was conducted in the Cochrane Library,PubMed,Springer,EBSCO,CNKI and CBM databases from January 1 st,1990 to March 17 th,2018 to identify randomized controlled trials(RCTs)on intravenous Ketamine during spinal anaesthesia for caesarean section.All included RCTs were assessed and the data were extracted according to the standard of Cochrane systematic review.The homogenous studies were pooled using RevMan 5.3 software. Results 13 RCTs,in total of 1 435 patients,were included herein. The results indicated that compare to the control group,intravenous infusion of Ketamine significantly reduced the visual analog scale(VAS)scores after 2~(nd)[MD=-1.26,95%CI(-1.88,-0.63),P<0.000 1]and 12~(th)[MD=-2.22,95%CI(-3.74,-0.70),P=0.004]hours since the spinal anaesthesia for ceasrean section. But the VAS scores after 1 st[MD=-3.21,95%CI(-9.27,2.84),P=0.30]and 3~(rd)[MD=-1.41,95%CI(-3.52,0.69),P=0.19]hours showed no significant difference to control groups. Bolus injected Ketamine considerably decreased the cumulative dose of non-steroid anti-inflammatory drug Diclofenac in the first[MD=-86.48,95%CI(-128.52,-44.43),P < 0.000 1]and second 24 h[MD=-12.23,95%CI(-22.80,-1.67),P=0.02]postoperatively. Meanwhile,the first requirement of analgesic[MD=59.68,95%CI(43.98,75.38),P<0.000 01] was dramatically prolonged in the Ketamine-treated groups. Ketamine attenuated the morbidity of pruritus[MD=0.55,95%CI(0.32,0.95),P=0.03],shivering[MD=0.07,95%CI(0.01,0.71),P=0.02]and illusion[MD=2.65,95%CI(1.23,5.69),P=0.01],respectively. Nevertheless,the incidents of postoperative nausea[MD=0.70,95%CI(0.49,1.01),P=0.06],vomit[MD=0.77,95%CI(0.54,1.11),P=0.17]and headache[MD=1.29,95% CI(0.27,6.14),P=0.75] were similar to control groups. Conclusion The intravenous Ketamine during spinal anaesthesia for caesarean section can dramatically decrease the postoperative pain and side effects,which can extremely enhance the satisfactory of maternal patients.
引文
[1]BLUSTEIN J,LIU J.Time to consider the risks of caesarean delivery for long term child health[J].BMJ,2015,350:h2410.
[2]SEN S,OZMERT G,AYDIN O N,et al.The persisting analgesic effect of low-dose intravenous Ketamine after spinal anaesthesia for caesarean section[J].Eur J Anaesthesiol,2005,22(7):518-523.
[3]JAAFARPOUR M,VASIGH A,KHAJAVIKHAN J,et al.Effect of Ketofol on pain and complication after Caesarean delivery under spinal anaesthesia:A randomized double-blind clinical trial[J].J Clin Diagn Res,2017,11(3):uc04-uc07.
[4]MENKITI I D,DESALU I,KUSHIMO O T.Low-dose intravenous Ketamine improves postoperative analgesia after caesarean delivery with spinal Bupivacaine in African parturients[J].Int J Obstet Anesth,2012,21(3):217-221.
[5]BEHDAD S,HAJIESMAEILI M R,ABBASI H R,et al.Analgesic effects of intravenous Ketamine during spinal anesthesia in pregnant women undergone caesarean section:Arandomized clinical trial[J].Anesth Pain Med,2013,3(2):230-233.
[6]RAHMANIAN M,LEYSI M,HEMMATI A A,et al.The effect of low-dose intravenous Ketamine on postoperative pain following cesarean section with spinal anesthesia:Arandomized clinical trial[J].Oman Med J,2015,30(1):11-16.
[7]BAUCHAT J R,HIGGINS N,WOJCIECHOWSKI K G,et al.Low-dose Ketamine with multimodal postcesarean delivery analgesia:A randomized controlled trial[J].Int J Obstet Anesth,2011,20(1):3-9.
[8]KOSE E A,HONCA M,DAL D,et al.Prophylactic Ketamine to prevent shivering in parturients undergoing cesarean delivery during spinal anesthesia[J].J Clin Anesth,2013,25(4):275-280.
[9]陈岱莉,齐晓非,庄仁坤,等.小剂量氯胺酮和曲马多预防剖宫产术蛛网膜下腔麻醉后寒战效果分析[J].中国医药,2015,10(6):869-871.
[10]周世勇,肖红霞,徐建华,等.氯胺酮和曲马多在剖宫产术中预防寒战的临床观察[J].河南职工医学院学报,2010,22(1):10-12.
[11]章庆,刘宗英,王晓斌.术中静注小剂量氯胺酮对预防剖宫产术后抑郁的疗效观察[J].川北医学院学报,2016,31(4):502-505.
[12]XU Y,LI Y,HUANG X,et al.Single bolus low-dose of Ketamine does not prevent postpartum depression:Arandomized,double-blind,placebo-controlled,prospective clinical trial[J].Arch Gynecol Obstet,2017,295(5):1167-1174.
[13]刘幸清,胡旭东,张文礼,等.预注小剂量氯胺酮对剖宫产术产妇爱丁堡产后抑郁量表评分值的影响[J].广东医学,2013,34(12):1917-1919.
[14]吕丽岭.氯胺酮小剂量预注对剖宫产术产妇产后抑郁评分的影响[J].医学综述,2015,21(24):4570-4572.
[15]LIM G,FARRELL L M,FACCO F L,et al.Labor analgesia as a predictor for reduced postpartum depression scores:Aretrospective observational study[J].Anesth Analg,2018,126(5):1598-1605.
[16]ROGERS R,WISE R G,PAINTER D J,et al.An investigation to dissociate the analgesic and anesthetic properties of Ketamine using functional magnetic resonance imaging[J].Anesthesiology,2004,100(2):292-301.
[17]姚传玉.小剂量氯胺酮在局麻剖宫产手术中的应用80例分析[J].中国误诊学杂志,2011,11(4):928.
[18]周鸿丽,王茂华,王晓斌.小剂量氯胺酮辅用于剖宫产椎管内麻醉临床疗效的meta分析[J].西南医科大学学报,2017,40(6):551-557.
[19]刘国凯,黄宇光,罗爱伦.小剂量氯胺酮用于术后镇痛的研究及其临床价值[J].中华麻醉学杂志,2003,23(3):238-240.
[20]RABBEN T,SKJELBRED P,OYE I.Prolonged analgesic effect of Ketamine,an N-methyl-D-aspartate receptor inhibitor,in patients with chronic pain[J].J Pharmacol Exp Ther,1999,289(2):1060-1066.
[21]HONARMAND A,SAFAVI M R.Comparison of prophylactic use of Midazolam,Ketamine,and Ketamine plus Midazolam for prevention of shivering during regional anaesthesia:Arandomized double-blind placebo controlled trial[J].Br JAnaesth,2008,101(4):557-562.
[2]SEN S,OZMERT G,AYDIN O N,et al.The persisting analgesic effect of low-dose intravenous Ketamine after spinal anaesthesia for caesarean section[J].Eur J Anaesthesiol,2005,22(7):518-523.
[3]JAAFARPOUR M,VASIGH A,KHAJAVIKHAN J,et al.Effect of Ketofol on pain and complication after Caesarean delivery under spinal anaesthesia:A randomized double-blind clinical trial[J].J Clin Diagn Res,2017,11(3):uc04-uc07.
[4]MENKITI I D,DESALU I,KUSHIMO O T.Low-dose intravenous Ketamine improves postoperative analgesia after caesarean delivery with spinal Bupivacaine in African parturients[J].Int J Obstet Anesth,2012,21(3):217-221.
[5]BEHDAD S,HAJIESMAEILI M R,ABBASI H R,et al.Analgesic effects of intravenous Ketamine during spinal anesthesia in pregnant women undergone caesarean section:Arandomized clinical trial[J].Anesth Pain Med,2013,3(2):230-233.
[6]RAHMANIAN M,LEYSI M,HEMMATI A A,et al.The effect of low-dose intravenous Ketamine on postoperative pain following cesarean section with spinal anesthesia:Arandomized clinical trial[J].Oman Med J,2015,30(1):11-16.
[7]BAUCHAT J R,HIGGINS N,WOJCIECHOWSKI K G,et al.Low-dose Ketamine with multimodal postcesarean delivery analgesia:A randomized controlled trial[J].Int J Obstet Anesth,2011,20(1):3-9.
[8]KOSE E A,HONCA M,DAL D,et al.Prophylactic Ketamine to prevent shivering in parturients undergoing cesarean delivery during spinal anesthesia[J].J Clin Anesth,2013,25(4):275-280.
[9]陈岱莉,齐晓非,庄仁坤,等.小剂量氯胺酮和曲马多预防剖宫产术蛛网膜下腔麻醉后寒战效果分析[J].中国医药,2015,10(6):869-871.
[10]周世勇,肖红霞,徐建华,等.氯胺酮和曲马多在剖宫产术中预防寒战的临床观察[J].河南职工医学院学报,2010,22(1):10-12.
[11]章庆,刘宗英,王晓斌.术中静注小剂量氯胺酮对预防剖宫产术后抑郁的疗效观察[J].川北医学院学报,2016,31(4):502-505.
[12]XU Y,LI Y,HUANG X,et al.Single bolus low-dose of Ketamine does not prevent postpartum depression:Arandomized,double-blind,placebo-controlled,prospective clinical trial[J].Arch Gynecol Obstet,2017,295(5):1167-1174.
[13]刘幸清,胡旭东,张文礼,等.预注小剂量氯胺酮对剖宫产术产妇爱丁堡产后抑郁量表评分值的影响[J].广东医学,2013,34(12):1917-1919.
[14]吕丽岭.氯胺酮小剂量预注对剖宫产术产妇产后抑郁评分的影响[J].医学综述,2015,21(24):4570-4572.
[15]LIM G,FARRELL L M,FACCO F L,et al.Labor analgesia as a predictor for reduced postpartum depression scores:Aretrospective observational study[J].Anesth Analg,2018,126(5):1598-1605.
[16]ROGERS R,WISE R G,PAINTER D J,et al.An investigation to dissociate the analgesic and anesthetic properties of Ketamine using functional magnetic resonance imaging[J].Anesthesiology,2004,100(2):292-301.
[17]姚传玉.小剂量氯胺酮在局麻剖宫产手术中的应用80例分析[J].中国误诊学杂志,2011,11(4):928.
[18]周鸿丽,王茂华,王晓斌.小剂量氯胺酮辅用于剖宫产椎管内麻醉临床疗效的meta分析[J].西南医科大学学报,2017,40(6):551-557.
[19]刘国凯,黄宇光,罗爱伦.小剂量氯胺酮用于术后镇痛的研究及其临床价值[J].中华麻醉学杂志,2003,23(3):238-240.
[20]RABBEN T,SKJELBRED P,OYE I.Prolonged analgesic effect of Ketamine,an N-methyl-D-aspartate receptor inhibitor,in patients with chronic pain[J].J Pharmacol Exp Ther,1999,289(2):1060-1066.
[21]HONARMAND A,SAFAVI M R.Comparison of prophylactic use of Midazolam,Ketamine,and Ketamine plus Midazolam for prevention of shivering during regional anaesthesia:Arandomized double-blind placebo controlled trial[J].Br JAnaesth,2008,101(4):557-562.