Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands.
Department of Anaesthesia, University Hospital RWTH Aachen, Aachen, Germany.
Anaesthesia. 2018 Jul;73(7):875-888. doi: 10.1111/anae.14210. Epub 2018 Jan 13.
Combined spinal-epidural and single-shot spinal anaesthesia are both used for caesarean section. It has been claimed in individual trials that combined spinal-epidural is associated with higher sensory spread and greater cardiovascular stability. We set out to gather all available evidence. We performed: a systematic literature search to identify randomised controlled trials comparing combined spinal-epidural with spinal anaesthesia for caesarean section: conventional meta-analysis; trial-sequential analysis; and assessment of trial quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Fifteen trials with high heterogeneity, including 1015 patients, were analysed. There was no significant difference between combined spinal-epidural and spinal anaesthesia for our primary outcomes maximum sensory height and vasopressor use (mg ephedrine equivalents). However, trial-sequential analysis suggested insufficient data and the GRADE scores showed 'very low' quality of evidence for these outcomes. The secondary outcomes hypotension, time for sensory block to recede to the level of T10, and the combined outcome of nausea and vomiting, did not differ significantly between the interventions. The block times were statistically significantly longer for combined spinal-epidural in individual trials, but only one trial showed a clinically meaningful difference (11 min). Based on this analysis, and taking into consideration all comparisons irrespective of whether drugs had been applied via the epidural route, there is not enough evidence to postulate any advantage compared with the spinal technique. Future analyses and studies need to examine the potential advantages of the combined spinal-epidural technique by using the epidural route intra- and/or postoperatively.
蛛网膜下腔-硬膜外联合麻醉和单次蛛网膜下腔麻醉均用于剖宫产。在个别试验中声称，蛛网膜下腔-硬膜外联合麻醉与更高的感觉扩散和更大的心血管稳定性相关。我们旨在收集所有可用的证据。我们进行了：系统文献检索，以确定比较剖宫产时蛛网膜下腔-硬膜外联合麻醉与单纯蛛网膜下腔麻醉的随机对照试验：常规荟萃分析；试验序贯分析；使用推荐评估、制定和评估（GRADE）系统评估试验质量。分析了 15 项具有高度异质性的试验，共包括 1015 例患者。在我们的主要结局（最大感觉高度和血管加压药使用量[麻黄碱当量]）方面，蛛网膜下腔-硬膜外联合麻醉与单纯蛛网膜下腔麻醉之间没有显著差异。然而，试验序贯分析表明数据不足，GRADE 评分显示这些结局的证据质量为“非常低”。次要结局（低血压、感觉阻滞消退至 T10 水平的时间、恶心和呕吐的联合结局）在干预措施之间没有显著差异。在个别试验中，蛛网膜下腔-硬膜外联合麻醉的阻滞时间在统计学上显著延长，但只有一项试验显示出具有临床意义的差异（11 分钟）。基于这项分析，并考虑到所有比较，无论药物是否通过硬膜外途径应用，都没有足够的证据假设与脊髓技术相比有任何优势。未来的分析和研究需要通过在手术期间和/或手术后使用硬膜外途径来检查蛛网膜下腔-硬膜外联合技术的潜在优势。
