麻醉心脏保护与远程缺血预处理对心脏手术患者生存的叠加效应：一项随机试验的贝叶斯网络荟萃分析
Additive Effect on Survival of Anaesthetic Cardiac Protection and Remote Ischemic Preconditioning in Cardiac Surgery: A Bayesian Network Meta-Analysis of Randomized Trials.
作者信息
Zangrillo Alberto, Musu Mario, Greco Teresa, Di Prima Ambra Licia, Matteazzi Andrea, Testa Valentina, Nardelli Pasquale, Febres Daniela, Monaco Fabrizio, Calabrò Maria Grazia, Ma Jun, Finco Gabriele, Landoni Giovanni
机构信息
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
Department of Medical Sciences "M. Aresu", Cagliari University, Cagliari, Italy.
出版信息
PLoS One. 2015 Jul 31;10(7):e0134264. doi: 10.1371/journal.pone.0134264. eCollection 2015.
INTRODUCTION
Cardioprotective properties of volatile agents and of remote ischemic preconditioning have survival effects in patients undergoing cardiac surgery. We performed a Bayesian network meta-analysis to confirm the beneficial effects of these strategies on survival in cardiac surgery, to evaluate which is the best strategy and if these strategies have additive or competitive effects.
METHODS
Pertinent studies were independently searched in BioMedCentral, MEDLINE/PubMed, Embase, and the Cochrane Central Register (updated November 2013). A Bayesian network meta-analysis was performed. Four groups of patients were compared: total intravenous anesthesia (with or without remote ischemic preconditioning) and an anesthesia plan including volatile agents (with or without remote ischemic preconditioning). Mortality was the main investigated outcome.
RESULTS
We identified 55 randomized trials published between 1991 and 2013 and including 6,921 patients undergoing cardiac surgery. The use of volatile agents (posterior mean of odds ratio = 0.50, 95% CrI 0.28-0.91) and the combination of volatile agents with remote preconditioning (posterior mean of odds ratio = 0.15, 95% CrI 0.04-0.55) were associated with a reduction in mortality when compared to total intravenous anesthesia. Posterior distribution of the probability of each treatment to be the best one, showed that the association of volatile anesthetic and remote ischemic preconditioning is the best treatment to improve short- and long-term survival after cardiac surgery, suggesting an additive effect of these two strategies.
CONCLUSIONS
In patients undergoing cardiac surgery, the use of volatile anesthetics and the combination of volatile agents with remote preconditioning reduce mortality when compared to TIVA and have additive effects. It is necessary to confirm these results with large, multicenter, randomized, double-blinded trials comparing these different strategies in cardiac and non-cardiac surgery, to establish which volatile agent is more protective than the others and how to best apply remote ischemic preconditioning.
引言
挥发性药物和远程缺血预处理的心脏保护特性对接受心脏手术的患者具有生存益处。我们进行了一项贝叶斯网络荟萃分析，以证实这些策略对心脏手术患者生存的有益影响，评估哪种是最佳策略，以及这些策略是否具有相加或竞争效应。
方法
在生物医学中心、MEDLINE/ PubMed、Embase和Cochrane中心注册库（2013年11月更新）中独立检索相关研究。进行了贝叶斯网络荟萃分析。比较了四组患者：全静脉麻醉（有或无远程缺血预处理）和包括挥发性药物的麻醉方案（有或无远程缺血预处理）。死亡率是主要研究结局。
结果
我们确定了1991年至2013年间发表的55项随机试验，包括6921例接受心脏手术的患者。与全静脉麻醉相比，使用挥发性药物（比值比的后验均值=0.50，95%可信区间0.28 - 0.91）以及挥发性药物与远程预处理的联合使用（比值比的后验均值=0.15，95%可信区间0.04 - 0.55）与死亡率降低相关。每种治疗成为最佳治疗的概率的后验分布表明，挥发性麻醉剂与远程缺血预处理的联合是改善心脏手术后短期和长期生存的最佳治疗方法，提示这两种策略具有相加效应。
结论
在接受心脏手术的患者中，与全静脉麻醉相比，使用挥发性麻醉剂以及挥发性药物与远程预处理的联合可降低死亡率并具有相加效应。有必要通过大型、多中心、随机、双盲试验来证实这些结果，比较这些不同策略在心脏和非心脏手术中的效果，以确定哪种挥发性药物比其他药物更具保护作用，以及如何最佳应用远程缺血预处理。
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