不同干预措施预防依托咪酯肌阵挛的有效性和安全性：基于贝叶斯的网状Meta分析-现代医学

不同干预措施预防依托咪酯肌阵挛的有效性和安全性：基于贝叶斯的网状Meta分析

单位：昆明医科大学第一附属医院麻醉科, 云南昆明 650032

分类号：R614

出版年·卷·期（页码）：2025·53·第七期（1059-1068）

摘要：

目的：基于贝叶斯理论的网状Meta分析评估不同干预措施预防依托咪酯肌阵挛的有效性和安全性，旨在临床上减少并改善依托咪酯肌阵挛的发生。方法：通过Pubmed、Embase、the Cochrane Central Register of Controlled Trials(CENTRAL)、中国知网、万方数据知识服务平台、维普中文期刊服务平台、中国生物医学文献数据库(CBM)等数据库检索不同干预措施预防依托咪酯肌阵挛的以中、英文文献发表的随机对照试验(RCTs)，检索时间为建库至 2024年8月。使用Cochrane风险偏倚评估工具对文献质量进行评价，使用Revman 5.4及Stata 18.0软件进行贝叶斯网状Meta分析，使用相对危险度(RR)和相应的95%置信区间(CI )评估依托咪酯肌阵挛的干预措施有效性和安全性。结果：共纳入37篇文章，包含3 078例受试者，涉及8种干预措施：咪达唑仑、布托啡诺、地佐辛、右美托咪定、瑞芬太尼、舒芬太尼、芬太尼和生理盐水/空白对照。网状Meta分析结果显示，舒芬太尼(RR＝0.10，95%CI 0.04～0.27)、瑞芬太尼(RR＝0.14，95%CI 0.08～0.24)、地佐辛(RR＝0.18，95%CI 0.09～0.34)、布托啡诺(RR＝0.19，95%CI 0.10～0.35)、右美托咪定(RR＝0.20，95%CI 0.12～0.33)、咪达唑仑(RR＝0.22，95%CI 0.12～0.41)6种干预措施预防效果均优于生理盐水/空白对照(均P＜0.05)；舒芬太尼(RR＝0.22，95%CI 0.06～0.84)、瑞芬太尼(RR＝0.32，95%CI 0.12～0.89)2种干预措施预防效果优于芬太尼(均P＜0.05)。SUCRA概率排序结果显示，舒芬太尼(89.0%)＞瑞芬太尼(78.3%)＞地佐辛(60.4%)＞布托啡诺(56.9%)＞右美托咪定(51.1%)＞咪达唑仑(45.7%)＞芬太尼(18.0%)＞生理盐水/空白对照(0.5%)。对纳入研究进行发表偏倚分析，发现结局指标存在一定的不对称性，提示存在一定的发表偏倚风险。结论：通过网状Meta分析整合不同药物之间直接或间接证据结果发现，阿片类药物能够有效降低依托咪酯所致肌阵挛的发生率，其中舒芬太尼的效果最好，其次为瑞芬太尼。但使用阿片类药物预处理时应注意胸壁僵直、心率减慢等并发症的发生。

Objective:To evaluate the effectiveness and safety of different interventions to prevent etomidate-induced myoclonus based on Bayesian network Meta-analysis, aiming at reducing and improving the occurrence of etomidate myoclonus clinically.Methods:Pubmed, Embase, the Cochrane Central Register of Controlled Trials(CENTRAL), China National Knowledge Infrastructure(CNKI), Wanfang Data Knowledge Service Platform, VIP Chinese Journal Service Platform and Chinese Biomedical Literature Database(CBM) were used to retrieve randomized controlled trials(RCTs) published in Chinese and English on different interventions for the prevention of etomidate-induced myoclonus from the establishment of the database to August 2024. Revman 5.4 and Stata 18.0 software were used for Bayesian network meta-analysis. The relative risk(RR) and corresponding 95% confidence interval(CI) were used to evaluate the efficacy and safety of different interventions for etomidate myoclonus. Results:A total of 37 articles with 3 078 subjects were included, involving 8 interventions: midazolam, butorphanol, dezocine, dexmedetomidine, remifentanil, sufentanil, fentanyl and placebo. The results of network meta-analysis showed that sufentanil(RR=0.10, 95%CI 0.04-0.27), remifentanil(RR=0.14, 95%CI 0.08-0.24), dezocine(RR=0.18, 95%CI 0.09-0.34), butorphanol(RR=0.19, 95%CI 0.04-0.27), dexmedetomidine(RR=0.20, 95%CI 0.12-0.33), midazolam(RR=0.22, 95%CI 0.12-0.41) were better than placebo(all P<0.05). Sufentanil(RR=0.22, 95%CI 0.06-0.84) and remifentanil(RR=0.32, 95%CI 0.12-0.89) had a better preventive effect than fentanyl(both P<0.05). SUCRA probability ranking results showed that sufentanil(89.0%)>remifentanil(78.3%)>dezocine(60.4%)>butorphanol(56.9%)>dexmedetomidine(51.1%)>midazolam(45.7%)>fentanyl(18.0%)>placebo(0.5%). The publication bias analysis of the included studies showed that there was a certain asymmetry in the outcome indicators, suggesting that there was a certain risk of publication bias. Conclusion:Through network Meta-analysis integrating direct or indirect evidence between different drugs, it is found that opioids can effectively reduce the incidence of etomidate-induced myoclonus, among which sufentanil has the best effect, followed by remifentanil. However, attention should be paid to the occurrence of complications such as chest wall rigidity and slow heart rate when using opioid pretreatment.

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