Zhang Kang-Da, Wang Lin-Yu, Zhang Dan-Xu, Zhang Zhi-Hua, Wang Huan-Liang
Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, China.
Shenzhen Research Institute of Shandong University, Shenzhen, China.
Front Med (Lausanne). 2022 Apr 26;9:799156. doi: 10.3389/fmed.2022.799156. eCollection 2022.
Myoclonic movement is a very common but undesirable phenomenon during the induction of general anesthesia using etomidate. Such movement may cause unnecessary problems. Currently, there is an increasing number of drugs for preventing etomidate-induced myoclonus (EM). However, direct comparisons of various drugs are lacking, and this interferes with clinical decision-making. Our network meta-analysis (NMA) aimed to compare the efficacy of different drugs for the prevention of moderate-to-severe general myoclonus.
Using several biomedical databases, randomized controlled trials (RCTs) published in English from inception to August 22, 2021 were searched. Among the various interventions, we selected nine types of intervention drugs (dexmedetomidine, etomidate, lidocaine, NMDA receptor antagonist, κ opioid receptor agonist, μ opioid receptor agonist, muscle relaxant, gabapentin, and midazolam) for comparison, according to the number of studies. Bayesian NMA was performed using STATA16 and R softwares. The relative risk of EM was assessed using risk ratios (RRs) and the corresponding 95% confidence intervals (CI).
A total of 31 RCTs (3209 patients) were included. NMA results showed that, compared with a placebo, etomidate (RR 4.0, 95%CI 2.1-7.8), κ opioid receptor agonist (RR 2.9, 95%CI 1.9-4.6), μ opioid receptor agonist (RR 3.1, 95%CI 2.3-4.3), NMDA receptor antagonist (RR 1.7, 95%CI 1.0-2.8), dexmedetomidine (RR 2.4, 95%CI 1.5-3.9), lidocaine (RR 2.1, 95%CI 1.2-3.9), and midazolam (RR 2.2, 95%CI 1.5-3.2) can significantly reduce the risk of EM. In contrast, the effects of muscle relaxants (RR 2.1, 95%CI 0.81-5.3) and gabapentin (RR 2.8, 95%CI 0.92-9.3) were inconclusive. Further subgroup analyses showed that preoperative low-dose etomidate, μ-opioid receptor agonist, and κ-opioid receptor agonist were significantly better than other interventions in the prevention of moderate to severe EM.
Preoperative use of small doses of etomidate or opioids may be the most effective way to avoid EM, especially moderate and severe EM, which makes anesthesia induction safer, more stable, and aligns better with the requirements of comfortable medicine.
[https://www.crd.york.ac.uk/prospero/], [CRD4202127706].
肌阵挛运动是使用依托咪酯进行全身麻醉诱导期间非常常见但不良的现象。这种运动可能会导致不必要的问题。目前，用于预防依托咪酯诱发肌阵挛（EM）的药物越来越多。然而，缺乏对各种药物的直接比较，这干扰了临床决策。我们的网络荟萃分析（NMA）旨在比较不同药物预防中度至重度全身性肌阵挛的疗效。
使用多个生物医学数据库，检索从创刊到2021年8月22日以英文发表的随机对照试验（RCT）。在各种干预措施中，根据研究数量，我们选择了九种干预药物（右美托咪定、依托咪酯、利多卡因、NMDA受体拮抗剂、κ阿片受体激动剂、μ阿片受体激动剂、肌肉松弛剂、加巴喷丁和咪达唑仑）进行比较。使用STATA16和R软件进行贝叶斯NMA。使用风险比（RR）和相应的95%置信区间（CI）评估EM的相对风险。
共纳入31项RCT（3209例患者）。NMA结果显示，与安慰剂相比，依托咪酯（RR 4.0，95%CI 2.1 - 7.8）、κ阿片受体激动剂（RR 2.9，95%CI 1.9 - 4.6）、μ阿片受体激动剂（RR 3.1，95%CI 2.3 - 4.3）、NMDA受体拮抗剂（RR 1.7，95%CI 1.0 - 2.8）、右美托咪定（RR 2.4，95%CI 1.5 - 3.9）、利多卡因（RR 2.1，95%CI 1.2 - 3.9）和咪达唑仑（RR 2.2，95%CI 1.5 - 3.2）可显著降低EM风险。相比之下，肌肉松弛剂（RR 2.1，95%CI 0.81 - 5.3）和加巴喷丁（RR 2.8，95%CI 0.92 - 9.3）的效果尚无定论。进一步的亚组分析表明，术前低剂量依托咪酯、μ-阿片受体激动剂和κ-阿片受体激动剂在预防中度至重度EM方面明显优于其他干预措施。
术前使用小剂量依托咪酯或阿片类药物可能是避免EM，尤其是中度和重度EM的最有效方法，这使得麻醉诱导更安全、更稳定，并且更符合舒适医疗的要求。
