【罂粟摘要】传统标志性触诊与术前超声在非产科患者椎管内麻醉中的比较：一项应用Meta分析和试验序贯分析对随机对照试验进行系统评价
传统标志性触诊与术前超声在非产科患者椎管内麻醉中的比较：一项应用Meta分析和试验序贯分析对随机对照试验进行的系统评价
贵州医科大学 高鸿教授课题组
翻译：佟睿 编辑：佟睿 审校：曹莹
椎管内麻醉有时可能很难实施，特别是在患者潜在解剖结构改变或模糊的情况下。
在非产科成人患者中比较术前超声与标志性触诊的效果、效率和安全性。
应用Meta分析和试验序贯分析对随机对照试验进行系统评价。
系统检索Central、CINAHL、Embase、Global Health、MEDLINE、Scopus和Web of Science数据库直至2020年2月13日的病例。
对接受诊断和/或治疗性椎管内麻醉的非产科成年患者进行随机对照试验，将操作者使用标准术前超声诊断的患者分为干预组，进行传统标志性触诊的患者作为对照组。
皮肤穿刺被定义为通过皮肤插入或重新插入穿刺针；针重定向是指穿刺针在没有从皮肤内取出的情况下向前移动向后移动；首次皮肤穿刺是指有或没有针重定向的第一次皮肤穿刺；首次通过是没有针重定向的首次皮肤穿刺。
结果
总共纳入了18项随机对照试验，涉及1800名患者。首次通过成功率在传统标志性触诊方法和超声方法之间没有差异[风险比1.46；95%可信区间(CI)，0.99~2.16；P=0.06，I2=76%；证据质量中等]，试验序贯分析表明，患者进一步随机化分组并不影响这一结果。术前超声检查总时间增加(平均差值110.8秒；95%可信区间31.01~190.65；P=0.006；I2=96%；证据质量一般)。亚组分析显示椎管内麻醉的预测难度对结果没有影响。与标志性方法相比，超声提高了首次皮肤穿刺成功率(危险度比1.36；95%可信区间1.18~1.5 7；P<0.001；I2=70%)，减少了3次或3次以上皮肤穿刺(危险度比0.46；95%可信区间0.33~0.64；P<0.001；I2=29%)，减少了针刺次数(平均差值-1.24；95%可信区间-2.32~-0.17；P=0.020；I2=83%)。使用超声可降低血性腰椎穿刺的发生率(风险比0.61；95%可信区间0.40~0.93；P=0.020；I2=42%)。
结论
在非产科成人患者中，使用术前超声进行椎管内麻醉并不能提高首次通过成功率，并且在临床上不显著地增加了所需的总时间。次要观察指标的改善，包括其他疗效指标的改善，应谨慎解读。
Desire Onwochei, Ganeshkrishna Nair, Bruce Young, et al. Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients: A systematic review with meta-analysis and trial sequential analysis of randomised controlled trials.[J].Eur J Anaesthesiol 2021; 38 (Suppl 2):S73–S86
Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients: A systematic review with meta-analysis and trial sequential analysis of randomised controlled trials
Abstract
BACKGROUND Central neuraxial modalities can occasionally be challenging to perform, particularly if the underlying anatomy is altered or obscured.
OBJECTIVES To compare the efficacy, efficiency and the safety of preprocedural ultrasound to landmark palpation in the nonobstetric adult population.
DESIGN Systematic review of randomised controlled trials with meta-analysis and trial sequential analysis.
DATA SOURCES Systematic search of Central, CINAHL, Embase, Global Health, MEDLINE, Scopus and Web of Science to 13th February 2020.
ELIGIBILITY CRITERIA Randomised controlled trials of nonobstetric adult patients having diagnostic and/or therapeutic neuraxial procedures using standard preprocedural ultrasound interpreted by the operator as the intervention and conventional landmark palpation as the comparator.
KEY DEFINITIONS A skin puncture was defined as the insertion or reinsertion of the needle through the skin; needle redirection was the backward followed by the forward movement of the needle without its removal from the skin; first skin puncture referred to a single skin puncture with or without needle redirections; and first pass was a single skin puncture with no needle redirection.
RESULTS In all, 18 randomised controlled trials with 1800 patients were included. The first pass success rate was not different between landmark and ultrasound methods [risk ratio 1.46; 95% confidence interval (CI), 0.99 to 2.16; P=0.06, I2=76%; moderate quality of evidence] and the trial sequential analysis demonstrated the futility of further randomisation of patients in modifying this finding. Preprocedural ultrasound increased the total time taken (mean difference 110.8 s; 95% CI, 31.01 to 190.65; P=0.006; I2=96%; moderate quality of evidence). Subgroup analyses revealed no influence of the predicted difficulty of the neuraxial procedure on outcomes. Compared with the landmark method, ultrasound increased the firstskinpuncture success rate (risk ratio 1.36; 95% CI, 1.18 to 1.57; P<0.001; I2=70%), and decreased the need for three or more skin punctures (risk ratio 0.46; 95% CI, 0.33 to 0.64; P<0.001; I2=29%) and the number of needle redirections (mean difference -1.24; 95% CI, -2.32 to -0.17; P=0.020; I2=83%). The incidence of bloody tap was reduced with the use of ultrasound (risk ratio 0.61; 95% CI, 0.40 to 0.93; P=0.020; I2=42%).
CONCLUSIONS The use of preprocedural ultrasound for neuraxial procedures in the nonobstetric adult population did not enhance the first pass success rate and increased the total time taken to a clinically insignificant extent. Improvement in secondary outcomes, including other markers of efficacy, should be interpreted with caution.