用于预防和治疗剖宫产椎管内麻醉低血压的血管升压药：胎儿和母体结局的贝叶斯网络Meta分析
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用于预防和治疗剖宫产椎管内麻醉低血压的血管升压药：胎儿和母体结局的贝叶斯网络Meta分析
翻译：佟睿 编辑：冯玉蓉 审校：曹莹
背景：处理剖宫产椎管内麻醉期间低血压的血管升压药物的最佳选择尚不明确。尽管苯肾上腺素最近被推荐为共识选择，但在其他医疗机构中，苯肾上腺素与血管加压素的直接比较还很缺乏。因此，我们在综合网络meta分析中通过整理相关研究的数据来间接评估这一点。本文，我们将比较临床上重要的胎儿及母体的结果来提供这些血管升压药可能的排名情况。
方法：分别在MEDLINE、Web of Science、Embase、Cochrane中央对照试验登记册和clinicaltrials.gov(2019年1月31日更新)上独立搜索随机对照试验。主要观察指标是脐动脉血碱剩余。次要胎儿观察指标为脐动脉血pH值和PCO2。产妇观察指标是恶心、呕吐及心动过缓的发生率。
结果：我们纳入52个随机对照试验，共4126名患者。我们的贝叶斯网络meta分析显示，根据去甲肾上腺素、间羟胺和美芬丁胺对脐动脉血碱剩余的影响进行评估，发现它们对胎儿酸碱平衡产生不利影响的可能性最低(概率排序为去甲肾上腺素>间氨基酚>苯肾上腺素>麻黄素)。该等级顺序同样适用于脐动脉血pH值和PCO2指标。除了能导致母体心动过缓外，麻黄素是所有评估结果中最糟糕的药物。由于在整理直接/间接比较时存在固有的不精确性，建议的排名顺序是相对的，而不是绝对排名。
结论：我们的分析提示去甲肾上腺素和间羟胺在剖宫产中与胎儿酸碱失衡的相关性比苯肾上腺素小。因此，我们的结果为聚焦试验奠定了科学基础，以便能够在这些药物和苯肾上腺素之间进行直接比较。
原始文献来源：Preet M. Singh, Narinder P. Singh, Matthew Reschke ,et al. Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes.[J].Br J Anesth 2020 Mar ; 124 (3): e95-e107。
Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes
Abstract
Background: The optimal choice of vasopressor drugs for managing hypotension during neuraxial anaesthesia for Caesarean delivery is unclear. Although phenylephrine was recently recommended as a consensus choice, direct comparison of phenylephrine with vasopressors used in other healthcare settings is largely lacking. Therefore, we assessed this indirectly by collating data from relevant studies in this comprehensive network meta-analysis. Here, we provide the possible rank orders for these vasopressor agents in relation to clinically important fetal and maternal outcomes.
Methods: RCTs were independently searched in MEDLINE, Web of Science, Embase, The Cochrane Central Register of Controlled Trials, and clinicaltrials.gov (updated January 31, 2019). The primary outcome assessed was umbilical arterial base excess. Secondary fetal outcomes were umbilical arterial pH and PCO2. Maternal outcomes were incidences of nausea, vomiting, and bradycardia.
Results: We included 52 RCTs with a total of 4126 patients. Our Bayesian network meta-analysis showed the likelihood that norepinephrine, metaraminol, and mephentermine had the lowest probability of adversely affecting the fetal acid-
base status as assessed by their effect on umbilical arterial base excess (probability rank order: norepinephrine > mephentermine > metaraminol > phenylephrine > ephedrine). This rank order largely held true for umbilical arterial pH and PCO2. With the exception of maternal bradycardia, ephedrine had the highest probability of being the worst agent for all assessed outcomes. Because of the inherent imprecision when collating direct/indirect comparisons, the rank orders suggested are possibilities rather than absolute ranks.
Conclusion: Our analysis suggests the possibility that norepinephrine and metaraminol are less likely than phenylephrine to be associated with adverse fetal acid-base status during Caesarean delivery. Our results, therefore, lay the scientific foundation for focused trials to enable direct comparisons between these agents and phenylephrine.
Keywords: maternal outcomes, hypotension; network meta-analysis, vasopressors; Caesarean section, fetal outcomes; spinal anaesthesia
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