Peterson Kim, Carson Susan, Carney Nancy
Oregon Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon 97239, USA.
J Neurotrauma. 2008 Jan;25(1):62-71. doi: 10.1089/neu.2007.0424.
In this study, we conducted an updated meta-analysis of the effects of hypothermia therapy on mortality, favorable neurologic outcome, and associated adverse effects in adults with traumatic brain injury (TBI) for use by Brain Trauma Foundation (BTF)/American Association of Neurological Surgeons (AANS) task force to develop evidence-based treatment guidelines. Our data sources relied on handsearches of four previous good-quality systematic reviews, which all conducted electronic searches of primarily MEDLINE (OVID), EMBASE, and Cochrane Library. An independent, supplemental electronic search of MEDLINE was undertaken as well (last searched June 2007). Only English-language publications of randomized controlled trials of therapeutic hypothermia in adults with TBI were selected for analysis. Two reviewers independently abstracted data on trial design, patient population, hypothermia and cointervention protocols, patient outcomes, and aspects of methodological quality. Pooled relative risks (RR) and associated 95% confidence intervals (CIs) were calculated for each outcome using random-effects models. In the current study, only 13 trials met eligibility criteria, with a total of 1339 randomized patients. Sensitivity analyses revealed that outcomes were influenced by variations in methodological quality. Consequently, main analyses were conducted based on eight trials that demonstrated the lowest potential for bias (n = 781). Reductions in risk of mortality were greatest (RR 0.51; 95% CI 0.33, 0.79) and favorable neurologic outcomes much more common (RR 1.91; 95% CI 1.28, 2.85) when hypothermia was maintained for more than 48 h. However, this evidence comes with the suggestion that the potential benefits of hypothermia may likely be offset by a significant increase in risk of pneumonia (RR 2.37; 95% CI 1.37, 4.10). In sum, the present study's updated meta-analysis supports previous findings that hypothermic therapy constitutes a beneficial treatment of TBI in specific circumstances. Accordingly, the BTF/AANS guidelines task force has issued a Level III recommendation for optional and cautious use of hypothermia for adults with TBI.
在本研究中，我们对低温疗法对创伤性脑损伤（TBI）成年患者死亡率、良好神经功能预后及相关不良反应的影响进行了一项更新的荟萃分析，以供脑创伤基金会（BTF）/美国神经外科医师协会（AANS）特别工作组制定循证治疗指南使用。我们的数据来源依赖于对之前四项高质量系统评价的手工检索，这四项系统评价均主要对MEDLINE（OVID）、EMBASE和Cochrane图书馆进行了电子检索。我们还对MEDLINE进行了一次独立的补充电子检索（最后检索时间为2007年6月）。仅选择了关于成年TBI患者治疗性低温的随机对照试验的英文出版物进行分析。两名评价者独立提取了关于试验设计、患者人群、低温及联合干预方案、患者预后以及方法学质量方面的数据。使用随机效应模型为每个结局计算合并相对危险度（RR）及相关的95%置信区间（CI）。在本研究中，仅有13项试验符合纳入标准，共有1339例随机分组患者。敏感性分析显示，结局受方法学质量差异的影响。因此，主要分析基于八项显示偏倚可能性最低的试验（n = 781）进行。当低温维持超过48小时时，死亡率降低幅度最大（RR 0.51；95% CI 0.33，0.79），良好神经功能预后更为常见（RR 1.91；95% CI 1.28，2.85）。然而，这一证据伴随着如下提示，即低温的潜在益处可能会被肺炎风险的显著增加所抵消（RR 2.37；95% CI 1.37，4.10）。总之，本研究的更新荟萃分析支持了之前的研究结果，即低温疗法在特定情况下对TBI是一种有益的治疗方法。因此，BTF/AANS指南特别工作组已发布了一项Ⅲ级推荐，即对于成年TBI患者，可选择性且谨慎地使用低温疗法。
