From the Department of Anesthesiology and Pain Medicine, Institute of the Research of the Perioperative Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, Republic of Korea (S-KP, YGS, SY, TL, WHK, J-TK).
Eur J Anaesthesiol. 2018 Nov;35(11):867-875. doi: 10.1097/EJA.0000000000000884.
Previous studies have reported that deep neuromuscular block (posttetanic-count 1 to 2 twitches) improves surgical conditions during laparoscopy compared with moderate block (train-of-four count: 1 to 2 twitches). However, comparisons of surgical conditions were made using different scales and assessment intervals with variable results.
To explore the heterogeneity of previous comparisons between deep and moderate neuromuscular block.
Systematic review and meta-analysis of randomised controlled trials (RCTs).
Medline, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to October 2017.
Our meta-analysis included RCTs comparing the effects of deep with moderate neuromuscular block on surgical field conditions during laparoscopic surgery. The frequency of excellent or good operating conditions on a surgical rating scale was compared. Heterogeneity was assessed by subgroup analyses.
Eleven RCTs involving 844 patients were included. On the surgical rating scale, the frequency of excellent or good operating conditions was higher with deep block compared with a moderate block (odds ratio 2.83, 95% confidence interval 1.34 to 5.99, P = 0.007, I = 59%). We analysed surgical rating according to the number of assessments made. There was a significant difference in surgical rating with multiple assessments, but no difference when the assessment was made on only one occasion. A significant difference in rating was noted with variable abdominal pressures; there was no significant difference with the same fixed abdominal pressure. Trial sequential analysis demonstrated that the cumulative z-curve crossed the O'Brien-Fleming significance boundary. However, required information size was not achieved.
Deep block was associated with excellent or good surgical rating more frequently than moderate block. However, this finding was not consistent on subgroup analyses based on frequencies of assessment of surgical conditions and abdominal pressure. Further studies are required to address the heterogeneity and power shortage demonstrated by the trial sequential analysis.
先前的研究报告称，与中度阻滞（四个成串刺激计数：1 到 2 次抽搐）相比，深度神经肌肉阻滞（强直后计数 1 到 2 次抽搐）可改善腹腔镜手术中的手术条件。然而，不同研究使用不同的手术条件评估标准和评估间隔，结果存在差异。
探讨先前深度和中度神经肌肉阻滞比较的异质性。
随机对照试验（RCT）的系统评价和荟萃分析。
从开始到 2017 年 10 月，检索 Medline、EMBASE 和 Cochrane 中央对照试验注册库。
我们的荟萃分析包括比较深度和中度神经肌肉阻滞对腹腔镜手术中手术视野条件影响的 RCT。比较手术评分量表上优秀或良好手术条件的频率。通过亚组分析评估异质性。
纳入 11 项 RCT，共 844 例患者。在手术评分量表上，深度阻滞的优秀或良好手术条件频率高于中度阻滞（比值比 2.83，95%置信区间 1.34 至 5.99，P=0.007，I=59%）。我们根据评估次数对手术评分进行了分析。多次评估时手术评分有显著差异，仅评估一次时无差异。腹部压力不同时评分有显著差异，相同固定腹部压力时无显著差异。试验序贯分析表明，累积 z 曲线穿过了 O'Brien-Fleming 显著性边界。但是，没有达到所需的信息大小。
与中度阻滞相比，深度阻滞与优秀或良好的手术评分更相关。然而，基于手术条件评估频率和腹部压力的亚组分析，这一发现并不一致。需要进一步的研究来解决试验序贯分析中表现出的异质性和效力不足的问题。
