不同自控镇痛方式对胸腹部手术术后并发症影响的Meta分析

目的评价硬膜外和静脉不同自控镇痛方法对胸、腹部手术术后并发症的影响。方法计算机检索PubMed、EBSCO、Springer、Ovid、CNKI等数据库,并追溯纳入文献的参考文献,收集发表于1985年至2009年行胸、腹部手术术后应用硬膜外和静脉自控镇痛的随机对照试验,按Cochrane系统评价员手册5.0对纳入文献进行质量评价和资料提取,而后采用RevMan 4.2.10软件进行统计分析。结果共纳入13篇随机对照试验,包括3055例患者。Meta分析结果显示：①对肺部并发症和肺功能的影响：硬膜外镇痛较静脉镇痛能显著降低患者术后肺炎的发生率[RR=0.66,95%CI（0.53,0.83）],提高患者术后第一秒用力呼气量（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）],但在降低患者术后呼吸衰竭[RR=0.77,95%CI（0.58,1.02）]和术后机械通气延长方面[RR=0.75,95%CI（0.51,1.13）]与静脉镇痛无显著差异;②对心血管事件的影响：硬膜外镇痛较静脉镇痛能显著降低术后患者心肌梗死[RR=0.58,95%CI（0.35,0.95）]和心律失常[RR=0.64,95%CI（0.47,0.88）]的发生率,但对降低患者术后心力衰竭[RR=0.79,95%CI（0.47,1.34）]和低血压[RR=1.21,95%CI（0.63,2.29）]的发生率无明显差;③其他系统并发症：两者在降低患者术后肾功能不全[RR=0.78,95%CI（0.53,1.14）]、消化道出血[RR=0.78,95%CI（0.49,1.23）]、术后感染[RR=0.89,95%CI（0.70,1.12）]及恶心呕吐方面[RR=1.03,95%CI（0.38,2.81）]无明显差异。结论硬膜外镇痛较静脉镇痛能显著降低术后发生肺炎、心肌梗死及严重心律失常的发生率,改善术后患者肺功能。

Comparison of Patient-controlled Intravenous and Epidural Analgesia on Postoperative Complications after Abdominal and Thoracic Surgery:A Meta-Analysis

Objective To compare the effect of intravenous and epidural analgesia on postoperative complications after abdominal and thoracic surgery.Methods A literature search was conducted by using computerized database on PubMed,EBSCO,Springer,Ovid,and CNKI from 1985 to Jan 2009.Further searches for articles were conducted by checking all references describing postoperative complications with intravenous and epidural anesthesia after abdomi-nal and thoracic surgery.All included randomized controlled trials（RCTs） were assessed and data were extracted by the standard of Cochrane systematic review.The homogeneous studies were pooled using RevMan 4.2.10 software.Re-sults Thirteen RCTs involving 3055 patients met the inclusion criteria.The results of meta-analyses showed that,a） pul-monary complications and lung function： patient-controlled epidural analgesia can signi cantly decrease the incidence of pneumonia（RR=0.66,95%CI 0.53 to 0.83） and improve the FEV1（WMD=0.17,95%CI 0.05 to 0.29） and FVC（WMD=0.21,95%CI 0.1 to 0.32） of lung function after abdominal and thoracic surgery,but no differences in decreasing postoperative respiratory failure（RR=0.77,95%CI 0.58 to 1.02） and prolonged ventilation（RR=0.75,95%CI 0.51 to 1.13） compared with intravenous analgesia;b） cardiovascular event： epidural analgesia could signi cantly decrease the incidence of myocardial infarction（RR=0.58,95%CI 0.35 to 0.95） and arrhythmia（RR=0.64,95%CI 0.47 to 0.88） than the control group,but could not better reduce the risk of heart failure（RR=0.79,95%CI 0.47 to 1.34） and hypotension（RR=1.21,95%CI 0.63 to 2.29）;and c） Other complications： epidural and intravenous analgesia had no difference in decreasing the risk of postoperative renal insu cient（RR=0.78,95%CI 0.53 to 1.14）,gastrointestinal hemorrhage（RR=0.78,95%CI 0.49 to 1.23）,infection（RR=0.89,95%CI 0.70 to 1.12） and nausea（RR=1.03,95%CI 0.38 to 2.81）.Conclusions Epidural analgesia can obvi-ously decrease the risk of pneumonia,myocardial infarction and severe arrhythmia,and can improve the lung function after abdominal or thoracic surgery.