From the Affiliation: Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College New York, New York.
Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.
Anesth Analg. 2018 Oct;127(4):988-1001. doi: 10.1213/ANE.0000000000003549.
The intrinsic nature of opioids to suppress respiratory function is of particular concern among patients with obstructive sleep apnea (OSA). The association of OSA with increased perioperative risk has raised the question of whether patients with OSA are at higher risk for opioid-induced respiratory depression (OIRD) compared to the general population. The aims of this systematic review were to summarize current evidence with respect to perioperative OIRD, changes in sleep-disordered breathing, and alterations in pain and opioid sensitivity in patients with OSA. A systematic literature search of studies published between 1946 and October 2017 was performed utilizing the following databases: Medline, ePub Ahead of Print/Medline In-process, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed-NOT-Medline and ClinicalTrials.Gov. Of 4321 initial studies, 40 met the inclusion criteria. The Oxford level of evidence was assessed. Overall, high-quality evidence on the comparative impact of acute opioid analgesia in OSA versus non-OSA patients is lacking. The current body of evidence is burdened by significant limitations including risk of bias and large heterogeneity among studies with regard to OSA severity, perioperative settings, outcome definitions, and the presence or absence of various perioperative drivers. These factors complicate an accurate interpretation and robust analysis of the true complication risk. Nevertheless, there is some consistency among studies with regard to a detrimental effect of opioids in the presence of OSA. Notably, the initial 24 hours after opioid administration appear to be most critical with regard to life-threatening OIRD. Further, OSA-related increased pain perception and enhanced opioid sensitivity could predispose patients with OSA to a higher risk for OIRD without overdosing. While high-quality evidence is needed, retrospective analyses indicate that critical, life-threatening OIRD may be preventable with a more cautious approach to opioid use, including adequate monitoring.
阿片类药物抑制呼吸功能的内在特性在阻塞性睡眠呼吸暂停（OSA）患者中尤其令人关注。OSA 与围手术期风险增加相关，这引发了一个问题，即与一般人群相比，OSA 患者是否有更高的发生阿片类药物引起的呼吸抑制（OIRD）的风险。本系统评价的目的是总结目前关于 OSA 患者围手术期 OIRD、睡眠呼吸障碍变化以及疼痛和阿片类药物敏感性改变的证据。使用以下数据库对 1946 年至 2017 年 10 月期间发表的研究进行了系统的文献检索：Medline、ePub 提前印刷/Medline 处理中、Embase、Cochrane 对照试验中心注册、Cochrane 系统评价数据库、PubMed-NOT-Medline 和 ClinicalTrials.gov。在 4321 项初始研究中，有 40 项符合纳入标准。评估了牛津证据水平。总体而言，缺乏关于急性阿片类镇痛在 OSA 与非 OSA 患者中的比较影响的高质量证据。目前的证据受到严重限制，包括偏倚风险以及研究之间关于 OSA 严重程度、围手术期环境、结果定义以及各种围手术期驱动因素的存在或不存在的很大异质性。这些因素使得对真实并发症风险的准确解释和稳健分析变得复杂。尽管如此，关于阿片类药物在 OSA 存在下的不良影响，研究之间仍存在一定的一致性。值得注意的是，在给予阿片类药物后的最初 24 小时内，与危及生命的 OIRD 最为关键。此外，OSA 相关的疼痛感知增加和增强的阿片类药物敏感性可能使 OSA 患者在没有过量用药的情况下更容易发生 OIRD。虽然需要高质量的证据，但回顾性分析表明，使用更谨慎的阿片类药物方法，包括充分监测，可能可以预防危及生命的 OIRD。
