尚勇 李帆 胡振飛 鄒田田

[摘要] 目的 評估硫酸鎂預(yù)防剖宮產(chǎn)術(shù)產(chǎn)婦寒戰(zhàn)的臨床應(yīng)用效果。 方法 計算機檢索PubMed、The Cochrane Library（2019年第8期）、EMbase、萬方數(shù)據(jù)知識服務(wù)平臺（WanFang Data）、中國知網(wǎng)（CNKI）、中國生物醫(yī)學(xué)文獻數(shù)據(jù)庫（CBM），查找有關(guān)硫酸鎂對實施剖宮產(chǎn)術(shù)的產(chǎn)婦寒戰(zhàn)影響的隨機對照試驗（RCT），檢索時限為建庫—2019年8月。根據(jù)所納入RCT參考文獻的相關(guān)文獻進行追溯。采用RevMan 5.3軟件進行meta分析，GRADE證據(jù)質(zhì)量評價評估m(xù)eta分析結(jié)果的證據(jù)等級。 結(jié)果 最終納入15篇文獻，1043例患者，使用硫酸鎂患者532例。meta分析結(jié)果顯示：試驗組產(chǎn)婦寒戰(zhàn)發(fā)生率低于對照組（RR = 0.48，95%CI：0.37～0.63，P < 0.000 01）。靜脈注射亞組產(chǎn)婦寒戰(zhàn)發(fā)生率低于對照組（RR = 0.46，95%CI：0.33～0.66，P < 0.0001）;蛛網(wǎng)膜下腔注射亞組產(chǎn)婦寒戰(zhàn)發(fā)生率與對照組比較，差異無統(tǒng)計學(xué)意義（P = 0.12）;硬膜外注射亞組產(chǎn)婦寒戰(zhàn)發(fā)生率低于對照組（RR = 0.38，95%CI：0.21～0.67，P = 0.0009）。蛛網(wǎng)膜下腔麻醉亞組產(chǎn)婦寒戰(zhàn)發(fā)生率低于對照組（RR = 0.53，95%CI：0.36～0.78，P = 0.001）;腰硬聯(lián)合麻醉亞組產(chǎn)婦寒戰(zhàn)發(fā)生率低于對照組（RR = 0.45，95%CI：0.29～0.68，P = 0.0002）。不同給藥方式亞組meta分析結(jié)果質(zhì)量等級均為“Moderate”。 結(jié)論 靜脈注射、硬膜外注射硫酸鎂能夠預(yù)防行剖宮產(chǎn)術(shù)產(chǎn)婦寒戰(zhàn)的發(fā)生，但蛛網(wǎng)膜下腔注射硫酸鎂預(yù)防行剖宮產(chǎn)術(shù)產(chǎn)婦寒戰(zhàn)的效果尚待評估。

[關(guān)鍵詞] 硫酸鎂;剖宮產(chǎn)術(shù);寒戰(zhàn);meta分析

[中圖分類號] R714.3? ? ? ? ? [文獻標識碼] A? ? ? ? ? [文章編號] 1673-7210（2020）07（c）-0103-06

Meta-analysis of Magnesium Sulfate to prevent shivering during cesarean section

SHANG Yong? ?LI Fan? ?HU Zhenfei? ?ZOU Tiantian

Department of Anesthesiology， the First Affiliated Hospital of Xinjiang Medical University， Xinjiang Uygur Autonomous Region， Urumqi? ?830054， China

[Abstract] Objective To evaluate the effect of Magnesium Sulfate to prevent shivering during cesarean section. Methods Databases including PubMed， The Cochrane Library （Issue 8， 2019）， EMbase， Wanfang Data Knowledge Service Platform （WanFang Data）， China National Knowledge Infrastructure （CNKI）， China Biology Medicine disc （CBM） were searched for computer to collect the randomized controlled trails （RCT） about the effect of Magnesium Sulfate on shivering for cesarean section. The retrieval time limit from repository to August 2019. The literature was tracked based on the references included in the RCT. Meta-analysis was conducted using RevMan 5.3 software， GRADE of evidence quality was used to evaluate the evidence level of meta-analysis results. Results Finally， 15 references were included， including 1043 patients and 532 patients with Magnesium Sulfate. The results of meta-analysis showed that： the incidence of shivering in experimental group was lower than that in control group （RR = 0.48， 95%CI：0.37-0.63， P < 0.000 01）. The incidence of shivering in intravenous subgroup was lower than that in control group （RR = 0.46， 95%CI：0.33-0.66， P < 0.0001）; the incidence of shivering in subarachnoid injection subgroup had no statistically significant difference compared with control group （P = 0.12）; the incidence of shivering in epidural injection subgroup was lower than that in control group （RR = 0.38， 95%CI：0.21-0.67， P = 0.0009）. The incidence of shivering in subarachnoid anesthesia subgroup was lower than that in control group （RR = 0.53， 95%CI： 0.36-0.78， P = 0.001）; the incidence of shivering in combined lumbar and epidural anesthesia subgroup was lower than that in control group （RR = 0.45， 95%CI： 0.29-0.68， P = 0.0002）. Meta-analysis results for different administration subgroups were all evaluated as “Moderate”. Conclusion Intravenous injection and epidural injection of Magnesium Sulfate can prevent shivering in cesarean section， but the effect of subarachnoid injection of Magnesium Sulfate to prevent the occurrence of shivering in cesarean section remains to be evaluated.

蛛網(wǎng)膜下腔麻醉是剖宮產(chǎn)術(shù)常用的麻醉方式，具有起效快、麻醉效果確切等諸多優(yōu)點。硫酸鎂具有抑制子宮收縮、治療胎兒宮內(nèi)窘迫的作用。本研究中有6篇[9，11，13，15-17]經(jīng)蛛網(wǎng)膜下腔注射硫酸鎂，但亞組分析結(jié)果卻顯示，硫酸鎂蛛網(wǎng)膜下腔注射亞組產(chǎn)婦寒戰(zhàn)發(fā)生率與對照組比較，差異無統(tǒng)計學(xué)意義（P = 0.12），在預(yù)防剖宮產(chǎn)術(shù)寒戰(zhàn)方面并未體現(xiàn)出明顯優(yōu)勢。在3種給藥方式中，靜脈注射硫酸鎂能夠使藥物快速發(fā)揮其藥理作用。研究顯示[8，17]，蛛網(wǎng)膜下腔注射、硬膜外注射硫酸鎂具有較高安全性。與蛛網(wǎng)膜下腔注射比較，硬膜外注射后，藥物沿硬膜外間隙上下擴散，在此過程中部分藥物經(jīng)毛細血管吸收入血而發(fā)揮作用，但蛛網(wǎng)膜下腔注射給藥并無上述過程[24]。因此，蛛網(wǎng)膜下腔注射與硬膜外注射的上述區(qū)別可能是導(dǎo)致蛛網(wǎng)膜下腔注射硫酸鎂在預(yù)防寒戰(zhàn)方面效果不佳的原因。

本研究共納入15篇[7-21]RCT，其中7篇[8，11-12，14-15，17-18]采用分配隱藏，納入研究整體質(zhì)量尚可但仍存在局限性。首先，所納入部分研究未報告研究對象年齡、各研究間硫酸鎂用藥劑量不同，可能影響本研究結(jié)果的可靠性;其次，15篇[7-21]RCT均為小樣本量，所得結(jié)論仍需進一步加以明確;最后，硫酸鎂不同給藥方式的亞組meta分析結(jié)果質(zhì)量等級均為“Moderate（中）”，故所得結(jié)論仍需更多高質(zhì)量RCT加以驗證。

綜上所述，靜脈注射、硬膜外注射硫酸鎂能夠預(yù)防行剖宮產(chǎn)術(shù)產(chǎn)婦寒戰(zhàn)的發(fā)生，但蛛網(wǎng)膜下腔注射硫酸鎂預(yù)防行剖宮產(chǎn)術(shù)產(chǎn)婦寒戰(zhàn)的效果尚待評估。

[參考文獻]

[1]? Nasseri K，Ghadami N，Nouri B. Effects of intrathecal dexm-edetomidine on shivering after spinal anesthesia for cesarean section：a double-blind randomized clinical trial [J]. Drug Des Devel Ther，2017，11：1107-1113.

[2]? Khezri MB，Mosallaei MA，Ebtehaj M，et al. Comparison of preemptive effect of intravenous ketorolac versus meperidine in patients undergoing cesarean section：A prospective，randomized，double-blind study [J]. Caspian J Intern Med，2018，9（2）：151-157.

[3]? Nallam SR，Cherukuru K，Sateesh G. Efficacy of intravenous ondansetron for prevention of postspinal shivering during lower segment cesarean section：A double-blinded randomized trial [J]. Anesth Essays Res，2017，11（2）：508-513.

[4]? Lopez MB. Postanaesthetic shivering–from pathophysiology to prevention [J]. Rom J Anaesth Intensive Care，2018， 25（1）：73-81.

[5]? Jain A，Gray M，Slisz S，et al. Shivering Treatments for Targeted Temperature Management：A Review [J]. J Neurosci Nurs，2018，50（2）：63-67.

[6]? Higgins JPT，Green S（editors）. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration. 2011. Available at：www.cochrane-handbook.org.

[7]? Agrawal J，Singh K，Mittal R，et al. A randomized clinical study to evaluate the effect of intravenous magnesium sulphate for postoperative pain relief in patients undergoing lower segment caesarean section [J]. J Evolution Med Dent Sci，2015，72（4）：12478-12484.

[8]? Elsharkawy RA，F(xiàn)arahat TE，Abdelhafez MS. Analgesic effect of adding magnesium sulfate to epidural levobupivacaine in patients with pre-eclampsia undergoing elective cesarean section [J]. J Anaesthesiol Clin Pharmacol，2018， 34（3）：328-334.

[9]? Faiz SH，Rahimzadeh P，Imani F，et al. Intrathecal injection of magnesium sulfate：shivering prevention during cesarean section：a randomized，double-blinded，controlled study [J]. Korean J Anesthesiol，2013，65（4）：293-298.

[10]? Maulik SG，Chaudhuri A，Mallick S，et al. Role of Magnesium Sulfate In Prolonging The Analgesic Effect of Spinal Bupivacaine For Cesarean Section In Severe Preeclamptics [J]. J Basic Clin Reprod Sci，2015，4（1）：24-28.

[11]? Paleti S，Prasad PK，Lakshmi BS. A randomized clinical trial of intrathecal magnesium sulfate versus midazolam with epidural administration of 0.75% ropivacaine for patients with preeclampsia scheduled for elective cesarean section [J]. J Anaesthesiol Clin Pharmacol，2018，34（1）：23-28.

[12]? Sachidananda R，Basavaraj K，Shaikh SI，et al. Comparison of Prophylactic Intravenous Magnesium Sulfate with Tramadol for Postspinal Shivering in Elective Cesarean Section：A Placebo Controlled Randomized Double-blind Pilot Study [J]. Anesth Essays Res，2018，12（1）：130-134.

[13]? Sayed JA，F(xiàn)athy MA. Maternal and Neonatal Effects of Adding Two Different Doses of Intrathecal Magnesium Sulphate to Bupivacain Fentanyl Spinal Anesthesia in Mild Preeclamptic Patients Undergoing Caesarean Section [J]. J Am Sci，2012，8（6）：435-441.

[14]? Sun J，Wu X，Xu X，et al. A Comparison of Epidural Magnesium and/or Morphine With Bupivacaine for Postoperative Analgesia After Cesarean Section [J]. Int J Obstet Anesth，2012，21（4）：310-316.

[15]? Unlugenc H，Ozalevli M，Gunes M，et al. Comparison of intrathecal magnesium，fentanyl，or placebo combined with bupivacaine 0.5% for parturients undergoing elective cesarean delivery [J]. Acta Anaesthesiol Scand，2009， 53（3）：346-353.

[16]? Xiao F，Liu L，Zhang WP，et al. Effect of adding magnesium sulfate to intrathecal low-dose of bupivacaine for patients with severe pre-eclampsia undergoing cesarean delivery [J]. Int J Clin Exp Med，2016，9（10）：19749-19756.

[17]? Xiao F，Xu W，F(xiàn)eng Y，et al. Intrathecal magnesium sulfate does not reduce the ED50 of intrathecal hyperbaric bupivacaine for cesarean delivery in healthy parturients：a prospective，double blinded，randomized dose-response trial using the sequential allocation method [J]. BMC Anesthesiol，2017，17（1）：8.

[18]? Yousef AA，Amr YM. The effect of adding magnesium sulphate to epidural bupivacaine and fentanyl in elective caesarean section using combined spinal-epidural anaesthesia：a prospective double blind randomised study [J]. Int J Obstet Anesth，2010，19（4）：401-404.

[19]? Zhong HY，Zhang WP. Effect of intravenous magnesium sulfate on bupivacaine spinal anesthesia in preeclamptic patients [J]. Biomed Pharmacother，2018，108：1289-1293.

[20]? 王奎，朱宇麟.硫酸鎂對剖宮產(chǎn)產(chǎn)婦行舒芬太尼復(fù)合布比卡因腰硬聯(lián)合麻醉的效果及術(shù)后鎮(zhèn)痛的影響[J].醫(yī)學(xué)臨床研究，2018，35（10）：1984-1986.

[21]? 王新妃.小劑量硫酸鎂預(yù)防剖宮產(chǎn)術(shù)中寒戰(zhàn)發(fā)生的臨床觀察[J].中國藥師，2012，15（10）：1467-1468.

[22]? 張紅，馮藝，潘芳，等.全身麻醉術(shù)后寒戰(zhàn)相關(guān)危險因素的研究[J].臨床麻醉學(xué)雜志，2010，26（3）：203-205.

[23]? Wu LX，Huang X，Sun L. The efficacy of N-methyl-d-aspartate receptor antagonists on improving the postoperative pain intensity and satisfaction after remifentanil-based anesthesia in adults：a meta-analysis [J]. J Clin Anesth，2015，27（4）：311-324.

[24]? Martin-Flores M. Epidural and Spinal Anesthesia [J]. Vet Clin North Am Small Anim Pract，2019，49（6）：1095-1108.

（收稿日期：2019-12-06）