静脉单剂量氯胺酮对剖宫产单次腰麻后镇痛有效性的分析

孙文冲; 周珩; 裴凌

doi:10.12019/j.issn.1671-5144.2019.03.009

静脉单剂量氯胺酮对剖宫产单次腰麻后镇痛有效性的分析

Efficiency and Safety of Intravenous Injected Ketamine for Postoperative Pain during Spinal Anaesthesia for Caesarean Section: A Meta-Analysis

摘要

摘要: 目的系统评价氯胺酮用于剖宫产术后临床镇痛的效果及安全性,为临床实践提供证据。方法计算机检索Cochrane图书馆、PubMed、Springer、EBSCO、CNKI和CBM等数据库,查找关于单次腰麻下行剖宫产手术的产妇予静脉单剂量氯胺酮注射、术后镇痛效果对比的随机对照试验,检索时限为1990年1月1日至2018年3月17日。按Cochrane系统评价方法对纳入的文献进行质量评价及数据提取,采用RevMan 5.3进行统计学分析。结果共纳入13篇随机对照试验,包括1 435例患者。Meta分析结果显示: 与对照组相比,静脉单剂量注射氯胺酮可显著降低产妇术后2 h均数差=-1.26,95%可信区间（-1.88,-0.63）,P<0.000 1和12 h均数差=-2.22,95%可信区间（-3.74,-0.70）,P=0.004的视觉疼痛模拟评分;但1 h均数差=-3.21,95%可信区间（-9.27,2.84）,P=0.30和3 h均数差=-1.41,95%可信区间（-3.52,0.69）,P=0.19视觉疼痛模拟评分较对照组差异无统计学意义。单剂量静注氯胺酮能显著减少术后第一天均数差=-86.48,95%可信区间（-128.52,-44.43）,P < 0.000 1及第二天均数差=-12.23,95%可信区间（-22.80,-1.67）,P=0.02静脉非甾体类抗炎镇痛药双氯芬酸的累计使用量。氯胺酮组术后首次要求使用镇痛药物时间明显延长均数差=59.68,95%可信区间（43.98,75.38）,P<0.000 01。氯胺酮组术后瘙痒均数差=0.55,95%可信区间（0.32,0.95）,P=0.03及寒战均数差=0.07,95%可信区间（0.01,0.71）,P=0.02发生率较对照组明显下降,但产妇术后幻觉发生率明显增高均数差=2.65,95%可信区间（1.23,5.69）,P=0.01。在术后恶心均数差=0.70,95%可信区间（0.49,1.01）,P=0.06、呕吐均数差=-0.77,95%可信区间（0.54,1.11）,P=0.17、头痛均数差=1.29,95%可信区间（0.27,6.14）,P=0.75等不良反应方面两组间未见明显差异。结论静脉单次注射氯胺酮可显著增强腰麻下行剖宫产手术患者术后镇痛满意度,明显减少非甾体类抗炎镇痛药的不良反应,并且不增加产妇及胎儿的不良反应。

Abstract: Objective To systematically evaluate the efficacy and safety of Ketamine on postoperative pain and side effects after spinal anaesthesia for caesarean section. Methods A systematic literature search was conducted in the Cochrane Library, PubMed, Springer, EBSCO, CNKI and CBM databases from January 1^st, 1990 to March 17^th, 2018 to identify randomized controlled trials （RCTs） on intravenous Ketamine during spinal anaesthesia for caesarean section. All included RCTs were assessed and the data were extracted according to the standard of Cochrane systematic review. The homogenous studies were pooled using RevMan 5.3 software. Results 13 RCTs, in total of 1 435 patients, were included herein. The results indicated that compare to the control group, intravenous infusion of Ketamine significantly reduced the visual analog scale （VAS） scores after 2^nd MD=-1.26,95%CI （-1.88,-0.63）,P<0.000 1 and 12^thMD=-2.22,95%CI （-3.74,-0.70）,P=0.004 hours since the spinal anaesthesia for ceasrean section. But the VAS scores after 1^st MD=-3.21,95%CI （-9.27,2.84）,P=0.30 and 3^rd MD=-1.41,95%CI （-3.52,0.69）,P=0.19 hours showed no significant difference to control groups. Bolus injected Ketamine considerably decreased the cumulative dose of non-steroid anti-inflammatory drug Diclofenac in the first MD=-86.48,95%CI （-128.52,-44.43）,P < 0.000 1 and second 24 h MD=-12.23,95%CI （-22.80,-1.67）,P=0.02 postoperatively. Meanwhile, the first requirement of analgesic MD=59.68,95%CI （43.98,75.38）,P<0.000 01 was dramatically prolonged in the Ketamine-treated groups. Ketamine attenuated the morbidity of pruritus MD=0.55,95%CI （0.32,0.95）,P=0.03, shivering MD=0.07,95%CI （0.01,0.71）,P=0.02 and illusion MD=2.65,95%CI （1.23,5.69）,P=0.01, respectively. Nevertheless, the incidents of postoperative nausea MD=0.70,95%CI （0.49,1.01）,P=0.06, vomit MD=0.77,95%CI （0.54,1.11）,P=0.17 and headache MD=1.29,95%CI （0.27,6.14）,P=0.75 were similar to control groups. Conclusion The intravenous Ketamine during spinal anaesthesia for caesarean section can dramatically decrease the postoperative pain and side effects, which can extremely enhance the satisfactory of maternal patients.

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