Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
Br J Anaesth. 2024 Mar;132(3):491-506. doi: 10.1016/j.bja.2023.11.050. Epub 2024 Jan 6.
We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications.
We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates.
We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty).
When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.
我们旨在评估在急诊室（ED）和重症监护病房（ICU）中用于程序镇静和镇痛（PSA）的各种静脉内药物的比较疗效和安全性。我们进行了系统评价和网络荟萃分析，以实现可用药物之间的直接和间接比较。
我们从成立到 2023 年 3 月 2 日在 Medline、EMBASE、Cochrane 和 PubMed 上搜索了比较所有需要在 ED 或 ICU 进行紧急手术的患者（成人和>30 天的儿童）使用两种或多种程序镇静和镇痛药物的 RCT。我们专注于镇静恢复时间、患者满意度和不良事件（AE）的结果。我们进行了似然随机效应模型网络荟萃分析，并使用推荐评估、制定与评价（GRADE）方法来评估估计的确定性。
我们纳入了 82 项 RCT（8105 名患者，78 项在 ED 进行，4 项在 ICU 进行），其中 52 项研究包括成人，23 项研究包括儿童，7 项研究同时包括成人和儿童。与咪达唑仑-阿片类药物相比，异丙酚的恢复时间更短（平均差异 16.3 分钟，95%置信区间 [CI] 8.4-24.3 分钟；高确定性），而氯胺酮-异丙酚的患者满意度更高（平均差异 1.5 分，95% CI 0.3-2.6 分，高确定性）。关于 AE，与咪达唑仑-阿片类药物相比，氯胺酮的呼吸 AE 较少（相对风险 [RR] 0.55，95% CI 0.32-0.96；高确定性），氯胺酮-咪达唑仑的胃肠道 AE 更常见（RR 3.08，95% CI 1.15-8.27；高确定性），氯胺酮-异丙酚的神经 AE 更常见（RR 3.68，95% CI 1.08-12.53；高确定性）。
在考虑 ED 和 ICU 中的程序镇静和镇痛时，与咪达唑仑-阿片类药物相比，异丙酚的镇静恢复时间更短，氯胺酮-异丙酚的患者满意度更高，氯胺酮的呼吸不良事件更少。
Zotero 插件