作者：罂粟花
围手术期应用苯二氮卓类药物对术中意识和术后谵妄的影响：随机对照试验和观察性研究的系统回顾和meta分析
贵州医科大学 麻醉与心脏电生理课题组
翻译：佟睿 编辑：柏雪 审校：曹莹
背景：应用苯二氮卓类药物可能会导致谵妄，指南中建议老年和危重患者避免使用苯二氮卓。由于临床观察到具有的实际益处，其在围手术期中的使用仍然很普遍。
方法：我们检索了从最开始到2021年6月CENTAL、MEDLINE、CINAHL、PhycInfo和Web of Science数据库中的所有文献。两位评价者分析了随机对照试验和前瞻性观察性研究，比较了手术患者围手术期苯二氮卓类药物与其他药物或安慰剂的使用情况。两位评价者独立地提取了数据，我们使用随机效应模型进行了组合。我们的主要观察指标是谵妄、术中知晓和死亡率。
结果：我们纳入了34项随机对照试验(4354项)和9项观察性研究(3309项)，并对观察性研究进行了单独考虑。围手术期服用苯二氮卓类药物不会增加谵妄的风险(n=1352；风险比[RR]1.43；95%可信区间[CI]:0.9-2.27；I2=72%；P=0.13；证据质量极低)。然而，与右美托咪定相比，使用苯二氮卓类药物确实增加了谵妄的风险(5项研究；n=429；RR1.83；95%CI:1.24-2.72；I2=13%；P=0.002)。围手术期苯二氮卓类药物的应用降低了术中知晓的风险(n=2245；RR0.26；95%CI:0.12-0.58；I2=35%；P=0.001；证据质量很低)。当考虑到非事件时，围手术期应用苯二氮卓类药物增加了未出现术中知晓的概率(RR1.07；95%CI:1.01-1.13；I2=98%；P=0.03；证据质量很低)。一项随机对照试验报告了死亡率(n=800；RR 0.90；95%CI:0.20-3.1；P=0.80；质量很低)。
结论：在这项系统回顾和meta分析中表明，围手术期使用苯二氮卓类药物并没有增加术后谵妄和降低术中知晓。以前观察到的苯二氮卓类药物与谵妄的关系可以通过与右美托咪定的比较来解释。
原始文献来源：Eugene Wang, Emilie P. Belley-Cote, et al. Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies.[J]Br J Anae, doi: 10.1016/j.bja.2022.12.001.
英文原文：
Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies
Background:Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits.
Method:We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality.
Results:We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n¼2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality).
Conclusion:In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine
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