使用辅助药物减少神经肌肉阻滞剂剂量：一项系统评价和荟萃分析。
Reducing the dose of neuromuscular blocking agents with adjuncts: a systematic review and meta-analysis.
作者信息
Weber Valentin, Abbott Tom E F, Ackland Gareth L
机构信息
Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK.
Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK; William Harvey Research Institute, Queen Mary University of London, London, UK.
出版信息
Br J Anaesth. 2021 Mar;126(3):608-621. doi: 10.1016/j.bja.2020.09.048. Epub 2020 Nov 17.
BACKGROUND
Acute global shortages of neuromuscular blocking agents (NMBA) threaten to impact adversely on perioperative and critical care. The use of pharmacological adjuncts may reduce NMBA dose. However, the magnitude of any putative effects remains unclear.
METHODS
We conducted a systematic review and meta-analysis of RCTs. We searched Medline, Embase, Web of Science, and Cochrane Database (1970-2020) for RCTs comparing use of pharmacological adjuncts for NMBAs. We excluded RCTs not reporting perioperative NMBA dose. The primary outcome was total NMBA dose used to achieve a clinically acceptable depth of neuromuscular block. We assessed the quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) criteria. Data are presented as the standardised mean difference (SMD); I indicates percentage of variance attributable to heterogeneity.
RESULTS
From 3082 records, the full texts of 159 trials were retrieved. Thirty-one perioperative RCTs met the inclusion criteria for meta-analysis (n=1962). No studies were conducted in critically ill patients. Reduction in NMBA dose was associated with use of magnesium (SMD: -1.10 [-1.44 to -0.76], P<0.001; I=85%; GRADE=moderate), dexmedetomidine (SMD: -0.89 [-1.55 to -0.22]; P=0.009; I=87%; GRADE=low), and clonidine (SMD: -0.67 [-1.13 to -0.22]; P=0.004; I=0%; GRADE=low) but not lidocaine (SMD: -0.46 [-1.01 to -0.09]; P=0.10; I=68%; GRADE=moderate). Meta-analyses for nicardipine, diltiazem, and dexamethasone were not possible owing to the low numbers of studies. We estimated that 30-50 mg kg magnesium preoperatively (8-15 mg kg h intraoperatively) reduces rocuronium dose by 25.5% (inter-quartile range, 14.7-31).
CONCLUSIONS
Magnesium, dexmedetomidine, and clonidine may confer a clinically relevant sparing effect on the required dose of neuromuscular block ing drugs in the perioperative setting.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO: CRD42020183969.
背景
神经肌肉阻滞剂（NMBA）的急性全球短缺可能会对围手术期和重症监护产生不利影响。使用药理学辅助药物可能会减少NMBA的剂量。然而，任何假定效果的程度仍不清楚。
方法
我们对随机对照试验（RCT）进行了系统评价和荟萃分析。我们在Medline、Embase、科学网和Cochrane数据库（1970 - 2020年）中检索了比较使用药理学辅助药物与NMBA的RCT。我们排除了未报告围手术期NMBA剂量的RCT。主要结局是用于达到临床上可接受的神经肌肉阻滞深度的总NMBA剂量。我们使用GRADE（推荐分级、评估、制定和评价）标准评估证据质量。数据以标准化均数差（SMD）表示；I表示归因于异质性的方差百分比。
结果
从3082条记录中，检索到159项试验的全文。31项围手术期RCT符合荟萃分析的纳入标准（n = 1962）。没有针对重症患者进行的研究。NMBA剂量的减少与镁（SMD：-1.10 [-1.44至-0.76]，P < 0.001；I = 85%；GRADE = 中等）、右美托咪定（SMD：-0.89 [-1.55至-0.22]；P = 0.009；I = 87%；GRADE = 低）和可乐定（SMD：-0.67 [-1.13至-0.22]；P = 0.004；I = 0%；GRADE = 低）的使用相关，但与利多卡因无关（SMD：-0.46 [-1.01至-0.09]；P = 0.10；I = 68%；GRADE = 中等）。由于研究数量较少，无法对尼卡地平、地尔硫卓和地塞米松进行荟萃分析。我们估计术前30 - 50 mg/kg镁（术中8 - 15 mg/kg·h）可使罗库溴铵剂量减少25.5%（四分位间距，14.7 - 31）。
结论
镁、右美托咪定和可乐定在围手术期可能对所需的神经肌肉阻滞药物剂量产生临床相关的节约效应。
系统评价注册
PROSPERO：CRD42020183969。
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