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全麻与程序性镇静对脑卒中血栓切除术患者功能预后的影响
作者:小柯机器人 发布时间:2019/10/2 15:50:10

近日,德国海德堡大学医院教授Julian Bösel及其研究组,对急性缺血性脑卒中血栓切除术患者全身麻醉与程序性镇静和功能预后的关系进行了系统回顾和荟萃分析。该研究于2019年10月1日在线发表于《美国医学会杂志》。

研究组检索了MEDLINE数据库中1980年1月1日至2019年7月31日发表的文章,筛选出美国国立卫生研究院卒中量表(NIHSS)评分10分及以上、患有前循环急性缺血性卒中的成人患者,接受全身麻醉或程序性镇静进行血栓切除术的随机临床试验。最终选择了3个单中心、随机、平行、开放标签治疗试验,共有368名患者,平均年龄71.5岁,44.3%为女性,NIHSS中位评分为17分,183名接受全身麻醉,185名接受程序性麻醉。

采用改良Rankin评分量表(MRS)对患者的残疾程度进行评估,0-6分,分数越低预后越好。在术后3个月,全麻组的平均MRS评分为2.8分,程序镇静组为3.2分,差异显著。全麻组中低血压和血压变异等不良反应的发生率较高。

总之,对于接受血栓切除术的前循环急性缺血性卒中患者,采用全身麻醉与程序性镇静相比,可显著降低致残率。但因为试验均为单中心试验,仍需进一步研究来确定该结论。

附:英文原文

Title: Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy: A Systematic Review and Meta-analysis

Author: Silvia Schnenberger, Pia Lwhagen Hendén, Claus Z. Simonsen, Lorenz Uhlmann, Christina Klose, Johannes A. R. Pfaff, Albert J. Yoo, Leif H. Srensen, Peter A. Ringleb, Wolfgang Wick, Meinhard Kieser, Markus A. Mhlenbruch, Mads Rasmussen, Alexandros Rentzos, Julian Bsel

Issue&Volume: 2019/10/01

Abstract: 

Importance  General anesthesia during thrombectomy for acute ischemic stroke has been associated with poor neurological outcome in nonrandomized studies. Three single-center randomized trials reported no significantly different or improved outcomes for patients who received general anesthesia compared with procedural sedation.

Objective  To detect differences in functional outcome at 3 months between patients who received general anesthesia vs procedural sedation during thrombectomy for anterior circulation acute ischemic stroke.

Data Source  MEDLINE search for English-language articles published from January 1, 1980, to July 31, 2019.

Study Selection  Randomized clinical trials of adults with a National Institutes of Health Stroke Scale score of at least 10 and anterior circulation acute ischemic stroke assigned to receive general anesthesia or procedural sedation during thrombectomy.

Data Extraction and Synthesis  Individual patient data were obtained from 3 single-center, randomized, parallel-group, open-label treatment trials with blinded end point evaluation that met inclusion criteria and were analyzed using fixed-effects meta-analysis.

Main Outcomes and Measures  Degree of disability, measured via the modified Rankin Scale (mRS) score (range 0-6; lower scores indicate less disability), analyzed with the common odds ratio (cOR) to detect the ordinal shift in the distribution of disability over the range of mRS scores.

Results  A total of 368 patients (mean [SD] age, 71.5 [12.9] years; 163 [44.3%] women; median [interquartile range] National Institutes of Health Stroke Scale score, 17 [14-21]) were included in the analysis, including 183 (49.7%) who received general anesthesia and 185 (50.3%) who received procedural sedation. The mean 3-month mRS score was 2.8 (95% CI, 2.5-3.1) in the general anesthesia group vs 3.2 (95% CI, 3.0-3.5) in the procedural sedation group (difference, 0.43 [95% CI, 0.03-0.83]; cOR, 1.58 [95% CI, 1.09-2.29]; P = .02). Among prespecified adverse events, only hypotension (decline in systolic blood pressure of more than 20% from baseline) (80.8% vs 53.1%; OR, 4.26 [95% CI, 2.55-7.09]; P < .001) and blood pressure variability (systolic blood pressure >180 mm Hg or <120 mm Hg) (79.7 vs 62.3%; OR, 2.42 [95% CI, 1.49-3.93]; P < .001) were significantly more common in the general anesthesia group.

Conclusions and Relevance  Among patients with acute ischemic stroke involving the anterior circulation undergoing thrombectomy, the use of protocol-based general anesthesia, compared with procedural sedation, was significantly associated with less disability at 3 months. These findings should be interpreted tentatively, given that the individual trials examined were single-center trials and disability was the primary outcome in only 1 trial.

DOI: 10.1001/jama.2019.11455

Source: https://jamanetwork.com/journals/jama/article-abstract/2752061

期刊信息

JAMA-Journal of The American Medical Association:《美国医学会杂志》,创刊于1883年。隶属于美国医学协会,最新IF:51.273
官方网址:https://jamanetwork.com/
投稿链接:http://manuscripts.jama.com/cgi-bin/main.plex