抑酸药预防术后应激性溃疡出血的系统评价
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摘要
目的:评价抑酸药预防术后应激性溃疡出血的疗效和安全性方法:检索Cochrane图书馆、MEDLINE、Embase、CNKI、CBM、VIP、万方和相关临床实验注册网站。检索时间均为建库至2016年5月1日,收集抑酸药与安慰剂(或空白对照)比较用于预防术后应激性溃疡出血的RCT,资料提取和偏倚风险评价,采用Statal2.0软件进行meta分析,结果以相对危险度(RR)以及95%置信区间(CI)表示,并应用Grade分别评价终点指标的证据质量等级,漏斗图和Eggers test检验判断是否存在发表偏倚。结果:共纳入16项RCT,其中15项(971名患者)用于meta分析。Meta分析结果显示抑酸药在预防应激性溃疡出血发生率方面优于安慰剂或空白对照(RR0.29,95%CI:0.19~0.45)(中等证据强度),两组在死亡和不良反应发生率方面无统计学意义(RR0.49,95%CI:0.17~1.38;RR0.78,95%CI:0.33~1.85)(极低强度证据)。亚组分析显示预防使用PPI术后SUB的发生率(RR=0.27)低于使用H_2RA的研究(RR=0.33);心脏科手术的研究术后SUB的发生率(RR=0.20)分别低于普通外科(RR=0.23)和神经外科(RR=0.37)的研究:术前给药的研究术后SUB的发生率(RR=0.3 1)高于术后给药的研究(RR=0.26)。结论:预防用抑酸药可有效降低术后SUB的发生率,且不增加不良反应发生率和死亡率。但纳入研究方法学质量普遍偏低,部分文献的结局指标不全面,缺乏肺炎、难辨梭菌感染等安全性指标。今后尚需进一步开展高质量、大样本的临床研究验证其临床效果。
引文
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[18]周晔,王建华,刘冰等.泮托拉唑对体外循环手术患者胃内酸碱度的影响[J].心肺血管病杂志,2010,29(03):197-199
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[21]陈念平,祝胜美,叶青山等.泮托拉唑在颅内肿瘤手术中的应用[J].北京大学学报,2010,42(02):228-230
[2]Choung RS,Talley NJ.Epidemiology and clinical presentation of stress-related peptic damage and chronic peptic ulcer[J].Curr Mol Med,2008,8(4):253-257
[3]Bardou M,Quenot JP,Barkun A.Stress-related mucosal disease in the critically ill patient[J].Nat Rev Gastroenterol Hepatol,2015,12(2):98-107.
[4]Cook DJ,Griffith LE,Walter SD,et al.The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients[J].Crit Care,2001,5(6):368-375
[5]Krag M,Perner A,Wetterslev J,et al:Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients.A systematic review of randomized clinical trials with meta-analysis and trial sequential analysis.Intensive Care Med 2014;40:11-2
[6]Nagasue,N,Yukaya,H,Ogawa,Y,et al.Prophylaxis of upper gastrointestinal bleeding with cimetidine in patients undergoing partial hepatectomy.Ann ChirGynaecol.l984;l(72):6-10
[7]Iwasaka,H,Ito,K,Kitano,T,et al.A comparison of the effects of omeprazole with those of ranitidine on intragastric pH and volume in patients for elective surgeries.Masui.l992:8(41);1292-1295
[8]李兆申,雷银雪,邹多武.西咪替丁对颅脑手术病人胃内pH的影响及对上消化道出血预防的临床研究[J].中华消化杂志,1999,19(04):278
[9]Escolano F,Castano J,L6pez R,et al.Effects of omeprazole,ranitidine,famotidine and placebo on gastric secretion in patients undergoing elective surgery.Br J Anaesth.199269(4):404-6.
[10]Powell H,Morgan M,Li SK.Inhibition of gastric acid secretion in the intensive care unit after coronary artery bypass graft.A pilot control study of intravenous omeprazole by bolus and infusion,ranitidine and placebo.Theor Surg 8:125-130
[11]Takakura Kl.Harada J.Mizogami M,et al.Prophylactic effects of pirenzepine(Ml-blocker)on intraoperative stress ulcer:comparison with an H2-blocker.Anesth Analg.1994;78(l):84-6.
[12]Chan,K H,Lai,E C,Tuen,H,et al.Prospective double-blind placebo-controlled randomized trial on the use of ranitidine in preventing postoperative gastroduodenal complications in high-risk neurosurgical patients.J Neurosurg.1995;3(82):413-417
[13]李庆华,肖建军,常乐等.甲氰咪胍对普胸术后应激性溃疡出血的预防作用[J].临床军医杂志,2004,32(06):32-33
[14]饶丹,张勤斌,王媾等.埃索美拉唑对体外循环心脏手术应激性溃疡保护作用的临床观察[J].心肺血管病杂志,2011,30(01):17-19
[15]雷银雪,李兆申,湛先保等.奥美拉唑对颅脑手术病人胃内pH的影响及对上消化道出血预防的临床研究[J].解放军医学杂志,1995,06:404-406
[16]王利敏.拉唑类药物对非高因素手术患者在应激性溃疡中必要性的临床观察[J].中国医药指南,2012,10(08):559.559
[17]麦伟良,黄坚,陈志生等.洛赛克针剂用于预防颅脑手术应激性溃疡的临床观察[J].中国医药导报,2010,7(14):64,66
[18]周晔,王建华,刘冰等.泮托拉唑对体外循环手术患者胃内酸碱度的影响[J].心肺血管病杂志,2010,29(03):197-199
[19]刘玉梅,张颖,王跃等.泮托拉唑预防肾移植术后消化系统并发症的临床观察[J].中国实验诊断学,2007,11(02):226-228
[20]葛辉敏,申长生,阎跃中等.应用奥美拉唑(OME)预防体外循环术后应激性溃疡[J].长治医学院学报,2003,17(02):114-115
[21]陈念平,祝胜美,叶青山等.泮托拉唑在颅内肿瘤手术中的应用[J].北京大学学报,2010,42(02):228-230
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