靶控输注与恒速输注丙泊酚复合瑞芬太尼全凭静脉麻醉效果和安全性对比的系统评价
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摘要
目的系统评价对比靶控输注与恒速输注丙泊酚复合瑞芬太尼全凭静脉麻醉的效果和安全性。方法计算机检索Cochrane图书馆、Cochrane协作网麻醉专业协作组数据库、MEDLINE、EMBASE、PubMed、中国知网、维普和万方数据库中关于靶控输注与恒速输注丙泊酚复合瑞芬太尼全凭静脉麻醉的临床随机对照研究,检索时限截止至2018年5月。由2位评价者独立选择文献、提取资料和评估方法学质量后,采用RevMan 5.3软件进行统计学处理。结果纳入16项研究,合计1 131例患者。Meta分析结果显示:与传统恒速输注丙泊酚复合瑞芬太尼组相比,靶控输注组诱导期平均动脉压波动更平稳(均数差=6.81,95%可信区间1.54～12.07,P=0.01);靶控组苏醒时间(均数差=-2.32,95%可信区间-4.17～-0.48,P=0.01)、自主呼吸恢复时间(均数差=-1.44,95%可信区间-2.86～-0.02,P=0.05)和拔管时间(均数差=-2.41,95%可信区间-4.62～-0.19,P=0.03)均明显缩短;同时,靶控组可明显减少丙泊酚用量(均数差=-48.83,95%可信区间-87.80～-9.86,P=0.01)以及瑞芬太尼用量(均数差=-116.62,95%可信区间-218.95～-14.29,P=0.03),降低呼吸抑制的发生率(相对危险度=0.35,95%可信区间0.14～0.84,P=0.02),差异均具有统计学意义;但两组间术中知晓、低血压、心动过缓、术后恶心呕吐、躁动的发生率差异无统计学意义。结论与恒速输注相比较,靶控输注丙泊酚复合瑞芬太尼可维持诱导期血流动力学稳定,明显缩短麻醉恢复时间,减少麻醉药物用量及费用,降低呼吸抑制发生率。
Objecive To systematically evaluate the efficacy and safety of target controlled infusion(TCI)compared to manually controlled infusion(MCI) with Propofol and Remifentanil for total intravenous anesthesia. Methods Databases including the Cochrane library,the database of the Cochrane anesthesia group,MEDLINE,EMBASE,PubMed,CNKI,VIP and Wanfang data were electronically searched from inception to May 2018 to collect the randomized controlled trials(RCTs)related to the efficacy and safety of TCI compared to MCI with Propofol and Remifentanil for total intravenous anesthesia. Two reviewers independently secreened literature,extracted data,and assessed the risk of bias of included studies. Then statistical analysis was performed using RevMan 5.3 software. Results A total of sixteen RCTs were included,involving 1 131 patients. The results of meta-analyses showed that:Compared with the MCI group,the mean arterial pressure changes during induction period(MD=6.81,95%CI 1.54～12.07,P=0.01)was more stable in the TCI group;The emergence time(MD=-2.32,95% CI-4.17～-0.48,P=0.01),spontaneous breathing recovery time(MD=-1.44,95% CI-2.86～-0.02,P=0.05)and extubation time(MD=-2.41,95% CI-4.62～-0.19,P=0.03)were significant shorter in the TCI group. The TCI group significantly reduced Propofol dosage(MD=-48.83,95%CI-87.80～-9.86,P=0.01)and Remifentanil dosage(MD=-116.62,95% CI-218.95～-14.29,P=0.03),at last,the TCI group decreased the occurrence rate of respiratory depression(RR=0.35,95% CI 0.14～0.84,P=0.02),but there was no statistically significant difference in the intraoperative awareness,hypotension,bradycardia,restlessnes,nausea and vomiting between the two groups. Conclusion Compared with the MCI group,the TCI group can maintain hemodynamic stability during induction,significantly shorten the recovery time of anesthesia,reduce the dosage of anesthetic drugs,and reduce the incidence of respiratory depression.
Objecive To systematically evaluate the efficacy and safety of target controlled infusion(TCI)compared to manually controlled infusion(MCI) with Propofol and Remifentanil for total intravenous anesthesia. Methods Databases including the Cochrane library,the database of the Cochrane anesthesia group,MEDLINE,EMBASE,PubMed,CNKI,VIP and Wanfang data were electronically searched from inception to May 2018 to collect the randomized controlled trials(RCTs)related to the efficacy and safety of TCI compared to MCI with Propofol and Remifentanil for total intravenous anesthesia. Two reviewers independently secreened literature,extracted data,and assessed the risk of bias of included studies. Then statistical analysis was performed using RevMan 5.3 software. Results A total of sixteen RCTs were included,involving 1 131 patients. The results of meta-analyses showed that:Compared with the MCI group,the mean arterial pressure changes during induction period(MD=6.81,95%CI 1.54～12.07,P=0.01)was more stable in the TCI group;The emergence time(MD=-2.32,95% CI-4.17～-0.48,P=0.01),spontaneous breathing recovery time(MD=-1.44,95% CI-2.86～-0.02,P=0.05)and extubation time(MD=-2.41,95% CI-4.62～-0.19,P=0.03)were significant shorter in the TCI group. The TCI group significantly reduced Propofol dosage(MD=-48.83,95%CI-87.80～-9.86,P=0.01)and Remifentanil dosage(MD=-116.62,95% CI-218.95～-14.29,P=0.03),at last,the TCI group decreased the occurrence rate of respiratory depression(RR=0.35,95% CI 0.14～0.84,P=0.02),but there was no statistically significant difference in the intraoperative awareness,hypotension,bradycardia,restlessnes,nausea and vomiting between the two groups. Conclusion Compared with the MCI group,the TCI group can maintain hemodynamic stability during induction,significantly shorten the recovery time of anesthesia,reduce the dosage of anesthetic drugs,and reduce the incidence of respiratory depression.
引文
[1]中华医学会麻醉学分会全凭静脉麻醉专家共识工作小组.全凭静脉麻醉专家共识[J].中华麻醉学杂志,2016,36(6):641-649.
[2]张兴安,秦再生,屠伟峰.静脉麻醉理论与实践[M].广州:广东科技出版社,2015:88-89.
[3]孟秀丽,王丽薇,周阳,等.两种静脉麻醉技术在需行脊髓功能监测的脊柱矫形手术中的应用[J].北京大学学报,2013,53(3):474-479.
[4]周翔,王庆利,季蒙,等.异丙酚联合瑞芬太尼靶控输注与恒速输注模在颅脑外科手术中效果比较[J].实用医学杂志,2009,25(8):1254-1255.
[5]YEGANEH N,ROSHANI B,YARI M,et al.Targetcontrolled infusion anesthesia with Propofol and Remifentanil compared with manually controlled infusion anesthesia in mastoidectomy surgeries[J].Middle East J Anaesthesiol,2010,20(6):785-793.
[6]YEGANEH N,ROSHANI B.A bispectral index guided comparison of target-controlled versus manually-controlled infusion of Propofol and Remifentanil for attenuation of pressor response to laryngoscopy and tracheal intubation in non cardiac surgery[J].J Res Med Sci,2006,11(5):302-308.
[7]WITKOWSKA M,KARWACKI Z,RZASKA M,et al.Comparison of target controlled infusion and total intravenous anaesthesia with Propofol and Remifentanil for lumbar microdiscectomy[J].Anaesthesiol Intensive Ther,2012,44(6):138-144.
[8]WANG X,WANG T,TIAN Z,et al.Asleep-awake-asleep regimen for epilepsy surgery:A prospective study of targetcontrolled infusion versus manually controlled infusion technique[J].J Clin Anesth,2016,32:92-100.
[9]詹新华,蔡爱球.异丙酚和瑞芬太尼不同输注方式在颅内动脉瘤介入治疗中的应用效果比较[J].实用心脑肺血管病杂志,2014,22(4):79-80.
[10]王亚群,王玲.两种给药方式对术中气管插管后血流动力学与心率变异性的影响[J].广东医学,2011,32(1):113-115.
[11]张宇帆.靶控输注丙泊酚、瑞芬太尼在整形外科短小手术中的镇静效果[J].中国乡村医药,2016,23(15):6-7.
[12]尹秀荣.丙泊酚联合瑞芬太尼靶控输注麻醉在老年腹腔镜手术中的应用价值[J].现代中西医结合杂志,2015,24(5):541-543.
[13]宿亚敏,薛占微,于亚敬.瑞芬太尼复合异丙酚靶控输注用于青年男性患者胸腔镜肺叶切除术效果观察[J].现代中西医结合杂志,2015,24(26):2943-2945.
[14]宋甲,倪新颖,林永峰,等.靶控输注丙泊酚瑞芬太尼在腹腔镜手术中的应用[J].中国医药指南,2011,9(1):68-70.
[15]孟光.丙泊酚复合瑞芬太尼靶控输注诱导用于腹腔镜胆囊切除术的观察[J].中国医药指南,2015,13(21):149.
[16]丁海燕.观察丙泊酚复合雷米芬太尼靶控输注对老年腹腔镜胆囊切除术麻醉效果[J].世界最新医学信息文摘,2016,16(26):95-96.
[17]赵艳,张俊,霍旭芳.丙泊酚复合雷米芬太尼靶控输注在腹腔镜胆囊切术的应用[J].江苏医药,2008,34(7):732-733.
[18]卢贵明,黄锦联,劳国连,等.瑞芬太尼和异丙酚效应室靶控输注全静麻醉的临床研究[J].实用医学杂志,2006,22(18):2187-2189.
[19]王若松.靶控输注静脉麻醉[J].中华麻醉学杂志,2001,21(10):589-590.
[20]SCHNIDER T W,MINTO C F,STRUYS M M,et al.The safety of target-controlled infusions[J].Anesth Analg,2016,122(1):79-85.
[21]FECHNER J,HERING W,IHMSEN H,et al.Modelling the pharmacodynamics interaction between Remifentanil and Propofol by EEG-controlled dosing[J].Eur J Anaesthesiol,2003,20(5):373-379.
[22]SCOTT H B,CHOI S W,WONG G T,et al.The effect of Remifentanil on Propofol requirements to achieve loss of response to command vs.loss of response to pain[J].Anaesthesia,2017,72(4):479-487.
[23]纪宏新,张兴安,吴群林,等.靶控输注瑞芬太尼和异丙酚麻醉诱导时镇静催眠效应的相互作用[J].中华麻醉学杂志,2010,30(3):269-272.
[24]阳婷婷,唐轶洋,张兴安.瑞芬太尼与芬太尼复合丙泊酚全凭静脉麻醉用于神经外科的系统评价[J].循证医学,2014,14(2):109-115.
[25]PURI G D,MATHEW P J,BISWAS I,et al.A multicenter evaluation of a closed-loop anesthesia delivery system:Arandomized controlled trial[J].Anesth Analg,2016,122(1):106-114.
[26]HUANG J W,LU Y Y,NAYAK A,et al.Depth of anesthesia estimation and control[J].IEEE Trans Biomed Eng,1999,46(1):71-81.
[27]DE V A,AGNOLETTI V,BERRETTINI S,et al.Druginduced sleep endoscopy:Conventional versus target controlled infusion techniques-a randomized controlled study[J].Eur Arch Otorhinolaryngol,2011,268(3):457-462.
[28]de CASTRO V,GODET G,MENCIA G,et al.Target-controlled infusion for Remifentanil in vascular patients improves hemodynamics and decreases Remifentanil requirement[J].Anesth Analg,2003,96(1):33-38.
[29]MINTO C F,SCHNIDER T W,GREGG K M,et al.Using the time of maximum effect site concentration to combine pharmacokinetics and pharmacodynamics[J].Anesthesiology,2003,99(2):324-333.2018-06-21
[2]张兴安,秦再生,屠伟峰.静脉麻醉理论与实践[M].广州:广东科技出版社,2015:88-89.
[3]孟秀丽,王丽薇,周阳,等.两种静脉麻醉技术在需行脊髓功能监测的脊柱矫形手术中的应用[J].北京大学学报,2013,53(3):474-479.
[4]周翔,王庆利,季蒙,等.异丙酚联合瑞芬太尼靶控输注与恒速输注模在颅脑外科手术中效果比较[J].实用医学杂志,2009,25(8):1254-1255.
[5]YEGANEH N,ROSHANI B,YARI M,et al.Targetcontrolled infusion anesthesia with Propofol and Remifentanil compared with manually controlled infusion anesthesia in mastoidectomy surgeries[J].Middle East J Anaesthesiol,2010,20(6):785-793.
[6]YEGANEH N,ROSHANI B.A bispectral index guided comparison of target-controlled versus manually-controlled infusion of Propofol and Remifentanil for attenuation of pressor response to laryngoscopy and tracheal intubation in non cardiac surgery[J].J Res Med Sci,2006,11(5):302-308.
[7]WITKOWSKA M,KARWACKI Z,RZASKA M,et al.Comparison of target controlled infusion and total intravenous anaesthesia with Propofol and Remifentanil for lumbar microdiscectomy[J].Anaesthesiol Intensive Ther,2012,44(6):138-144.
[8]WANG X,WANG T,TIAN Z,et al.Asleep-awake-asleep regimen for epilepsy surgery:A prospective study of targetcontrolled infusion versus manually controlled infusion technique[J].J Clin Anesth,2016,32:92-100.
[9]詹新华,蔡爱球.异丙酚和瑞芬太尼不同输注方式在颅内动脉瘤介入治疗中的应用效果比较[J].实用心脑肺血管病杂志,2014,22(4):79-80.
[10]王亚群,王玲.两种给药方式对术中气管插管后血流动力学与心率变异性的影响[J].广东医学,2011,32(1):113-115.
[11]张宇帆.靶控输注丙泊酚、瑞芬太尼在整形外科短小手术中的镇静效果[J].中国乡村医药,2016,23(15):6-7.
[12]尹秀荣.丙泊酚联合瑞芬太尼靶控输注麻醉在老年腹腔镜手术中的应用价值[J].现代中西医结合杂志,2015,24(5):541-543.
[13]宿亚敏,薛占微,于亚敬.瑞芬太尼复合异丙酚靶控输注用于青年男性患者胸腔镜肺叶切除术效果观察[J].现代中西医结合杂志,2015,24(26):2943-2945.
[14]宋甲,倪新颖,林永峰,等.靶控输注丙泊酚瑞芬太尼在腹腔镜手术中的应用[J].中国医药指南,2011,9(1):68-70.
[15]孟光.丙泊酚复合瑞芬太尼靶控输注诱导用于腹腔镜胆囊切除术的观察[J].中国医药指南,2015,13(21):149.
[16]丁海燕.观察丙泊酚复合雷米芬太尼靶控输注对老年腹腔镜胆囊切除术麻醉效果[J].世界最新医学信息文摘,2016,16(26):95-96.
[17]赵艳,张俊,霍旭芳.丙泊酚复合雷米芬太尼靶控输注在腹腔镜胆囊切术的应用[J].江苏医药,2008,34(7):732-733.
[18]卢贵明,黄锦联,劳国连,等.瑞芬太尼和异丙酚效应室靶控输注全静麻醉的临床研究[J].实用医学杂志,2006,22(18):2187-2189.
[19]王若松.靶控输注静脉麻醉[J].中华麻醉学杂志,2001,21(10):589-590.
[20]SCHNIDER T W,MINTO C F,STRUYS M M,et al.The safety of target-controlled infusions[J].Anesth Analg,2016,122(1):79-85.
[21]FECHNER J,HERING W,IHMSEN H,et al.Modelling the pharmacodynamics interaction between Remifentanil and Propofol by EEG-controlled dosing[J].Eur J Anaesthesiol,2003,20(5):373-379.
[22]SCOTT H B,CHOI S W,WONG G T,et al.The effect of Remifentanil on Propofol requirements to achieve loss of response to command vs.loss of response to pain[J].Anaesthesia,2017,72(4):479-487.
[23]纪宏新,张兴安,吴群林,等.靶控输注瑞芬太尼和异丙酚麻醉诱导时镇静催眠效应的相互作用[J].中华麻醉学杂志,2010,30(3):269-272.
[24]阳婷婷,唐轶洋,张兴安.瑞芬太尼与芬太尼复合丙泊酚全凭静脉麻醉用于神经外科的系统评价[J].循证医学,2014,14(2):109-115.
[25]PURI G D,MATHEW P J,BISWAS I,et al.A multicenter evaluation of a closed-loop anesthesia delivery system:Arandomized controlled trial[J].Anesth Analg,2016,122(1):106-114.
[26]HUANG J W,LU Y Y,NAYAK A,et al.Depth of anesthesia estimation and control[J].IEEE Trans Biomed Eng,1999,46(1):71-81.
[27]DE V A,AGNOLETTI V,BERRETTINI S,et al.Druginduced sleep endoscopy:Conventional versus target controlled infusion techniques-a randomized controlled study[J].Eur Arch Otorhinolaryngol,2011,268(3):457-462.
[28]de CASTRO V,GODET G,MENCIA G,et al.Target-controlled infusion for Remifentanil in vascular patients improves hemodynamics and decreases Remifentanil requirement[J].Anesth Analg,2003,96(1):33-38.
[29]MINTO C F,SCHNIDER T W,GREGG K M,et al.Using the time of maximum effect site concentration to combine pharmacokinetics and pharmacodynamics[J].Anesthesiology,2003,99(2):324-333.2018-06-21