硬膜外间断注射局麻药用于分娩镇痛的效果与安全性比较：系统综述与Meta分析
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硬膜外间断注射局麻药用于分娩镇痛的效果与安全性比较：系统综述与Meta分析
翻译：佟睿 编辑：冯玉蓉 审校：曹莹
背景：连续硬膜外输注(CEI)通常用于分娩镇痛，但考虑到潜在的运动阻滞、第二产程并发症和晚期分娩镇痛无效，促使人们研究间歇性硬膜外注射(IEB)作为替代方案。然而，比较这些镇痛模式的证据是相互矛盾的。本Meta分析旨在评估CEI与IEB的镇痛效果。
方法：搜索数据库中比较CEI和IEB用于分娩镇痛的试验。这两种模式共同的主要结果是爆发性疼痛的风险，主要差异为在硬膜外镇痛启动最初4h后疼痛评分的曲线下面积(AUC)。此外还评估了局部麻醉药用量、产妇结果(即分娩方式、产程和产妇满意度)以及硬膜外镇痛的副作用。使用随机效应模型将结果汇集，并采用试验序贯分析(TSA)评价证据可靠性。
结果：对27项研究(3133名患者)进行了分析。与CEI组比较，IEB组爆发性疼痛风险降低38%[95%CI}为0.62[0.48，0.81]；P＝0.0004；I2＝7%；1164例患者)；4h间期内疼痛AUC值降低32.9%(平均差值[95%CI]为-16.7mm h-1[-18.9，-14.4]；P<0.0001；1638例患者)。间歇性硬膜外注射提高了产妇满意度，缩短了产程，减少了运动阻滞，并减少了局部麻醉药的使用量。在硬膜外副作用或分娩方式方面，两组之间的差异没有统计学意义。TSA表明有足够证据支持结果的可靠性。
结论：间歇性硬膜外注射可改善硬膜外镇痛启动后前4小时内的分娩阵痛，并减少爆发性疼痛。间歇性硬膜外注射可替代持续硬膜外注射作为安全有效的分娩镇痛方案，并具有中-高质量的证据支持。
原始文献来源：Nasir Hussain, Christopher M, Lagnese, et al. Comparative analgesic efficacy and safety of intermittent local anaesthetic epidural bolus for labour: a systematic review and meta-analysis.[J].Br J Anaesth, 2020, Jul 21;[Epub ahead of print].
Comparative analgesic efficacy and safety of intermittent local anaesthetic epidural bolus for labour: a systematic review and meta-analysis
Abstract
Background: Continuous epidural infusion (CEI) is commonly used for labour analgesia, but concerns over potential motor block, second-stage labour complications, and ineffective analgesia in late labour have prompted examining intermittent epidural bolus (IEB) as an alternative. However, evidence comparing these modalities is conflicting. The meta-analysis evaluates the analgesic efficacy of CEI vs IEB.
Methods: Databases were searched for trials comparing CEI to IEB for labour analgesia. The two co-primary outcomes were risk of breakthrough pain and difference in area under the curve (AUC) for pain scores during the first 4 h post-epidural initiation. Local anaesthetic consumption, maternal outcomes (i.e. delivery mode, labour duration, and maternal satisfaction), and side-effects of epidural analgesia were also evaluated. Results were pooled using random-effects modelling. Trial sequential analysis (TSA) was used to evaluate evidence reliability.
Results: Twenty-seven studies (3133 patients) were analysed. Compared with CEI, IEB decreased risk of breakthrough pain by 38% (risk ratio [95% confidence interval {CI}] of 0.62 [0.48, 0.81]; P＝0.0004; I2＝47%; 1164 patients) and reduced AUC of pain during the 4 h interval by 32.9% (mean difference [95% CI] of -16.7 mm h-1[-18.9, -14.4]; P<0.0001; 1638 patients). Intermittent epidural bolus enhanced maternal satisfaction, shortened labour duration, decreased motor block, and reduced local anaesthetic consumption. The difference between the two groups was not statistically significant for epidural side-effects or mode of delivery. The TSA indicated adequate power for reliable inferences.
Conclusions: Intermittent epidural bolus provides improved labour pain control during the first 4 h after epidural initiation with less breakthrough pain. Moderate- to high-quality evidence of intermittent epidural bolus superiority support its use as a safe and effective continuous epidural infusion alternative for labour analgesia.
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