甘露醇和高张盐水治疗颅内压增高症的比较:一项针对随机临床试验的荟萃分析
研究背景:
甘露醇一直作为临床治疗颅内高压的一线药物,其本身也存在许多副作用,如肾功能衰竭和低血容量。
高张盐水因其较小的肾毒性越来越受到关注。目前已有许多随机研究表明,高张盐水治疗颅内压增高的效果优于甘露醇。
但是这些研究对临床实践的影响有限。部分原因是这些研究的样本量均较小,且研究中采用的甘露醇和高张盐水渗透浓度不同。
本荟萃分析比较了高张盐水和甘露醇治疗颅内压增高的效果。
数据来源:
MEDLINE
EMBASE
Cochrane随机对照试验注册中心
Scopus
ISI Web of Knowledge
发表年份:1967年1月---2010年4月
入选标准:
随机对照试验
研究中的甘露醇和高张盐水具有相等的渗透浓度
试验中进行颅内压监测(如脑实质监测,腰穿等方法)
数据采集:
两名调查员独自完成合格试验的筛选和数据的收集
采集项目:
病人的基线资料
颅内病理类型
基础颅内压水平
每次输注药物的渗透浓度
颅内压的变化
潜在的不良事件
结果:
ü 共纳入5项研究
112例病人
184次颅内压增高事件
ü 甘露醇治疗89次,有效69次,有效率为78%,95%CI为67%-86%。
高张盐水治疗95次,有效88次,有效率为93%,95%CI为85%-97%
高张盐水治疗颅内压增高的相对危险度RR比甘露醇是1.16(95%CI介于1.00-1.33),p=0.046
ü 应用高张盐水组比甘露醇组颅内压的平均降低幅度的加权均数差(WMD)为2.0mmHg (95%介于-1.6-5.7),p=0.276
讨论:
有7例观察性研究发现甘露醇治疗失败后,高张盐水表现出有效性,这和本荟萃分析结果一致。
一项观察性研究认为,二者在疗效方面没有显著性差异,但高张盐水的作用更持久。
此外,在选择药物时,除了考虑临床证据外,还需考虑对患者生理状态的影响。如高张盐水有利于改善心输出量,改善免疫调节,改善脑的血流动力学状态。甘露醇则可以降低血液粘稠度,降低自由基的清除,抑制细胞凋亡。
总而言之,该荟萃研究受到入组试验数目和大小的限制,以及试验方法上的差异,还存在不足之处。仍然需要大型、多中心的随机对照试验以确定高张盐水作为治疗颅内高压的一线治疗药物。
结论:
高张盐水治疗颅内压增高比甘露醇更加有效
高张盐水的治疗效果优于现行标准的治疗策略
需要大型、多中心的随机对照试验以确定高张盐水作为治疗颅内高压的一线治疗药物
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