Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, Denmark.
Research Center for Emergency Medicine, University of Aarhus, Aarhus, Denmark.
Br J Anaesth. 2018 Jun;120(6):1381-1393. doi: 10.1016/j.bja.2017.11.106. Epub 2018 Apr 4.
Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random-effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19-21.49, P<0.00001, TSA-adjusted CI 1.85-95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49-7.15, P<0.00001, TSA-adjusted CI 1.20-20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09-1.74, P=0.008, TSA-adjusted CI 1.00-1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53-4.21, P=0.0003, TSA-adjusted CI 0.27-21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.
队列研究表明，避免使用神经肌肉阻滞剂（NMBA）是困难气管插管的一个危险因素。然而，在随机试验的系统评价中，尚未评估避免 NMBA 对气管插管、可能的不良反应和术后不适的影响。我们在几个数据库中搜索了截至 2017 年 1 月发表的试验。我们纳入了比较避免使用与使用 NMBA 效果的随机对照试验。两名独立作者评估了偏倚风险并提取了数据。通过试验序贯分析（TSA）评估随机误差的风险。我们纳入了 34 项试验（3565 名参与者）。在四项被认为偏倚风险低的试验中，不使用 NMBA 会增加困难气管插管的风险[随机效应模型，风险比（RR）13.27，95%置信区间（CI）8.19-21.49，P<0.00001，TSA 调整 CI 1.85-95.04]。当包括所有试验时，结果得到了证实（RR 5.00，95%CI 3.49-7.15，P<0.00001，TSA 调整 CI 1.20-20.77）。避免 NMBA 会显著增加上呼吸道不适或损伤的风险（RR=1.37，95%CI 1.09-1.74，P=0.008，TSA 调整 CI 1.00-1.86）。没有试验报告死亡率。避免 NMBA 与喉镜检查困难显著相关（RR 2.54，95%CI 1.53-4.21，P=0.0003，TSA 调整 CI 0.27-21.75）。在临床环境中，在进行气管插管时，必须权衡使用 NMBA 的利弊。
