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[BMJ发表论文]:危重病患者胃肠道出血预防的效果及安全性:系统回顾与网络meta分析
2020年01月27日 时讯速递, 进展交流 暂无评论

Research

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

Ying Wang, Zhikang Ye, Long Ge, et al

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.l6744 (Published 06 January 2020) Cite this as: BMJ 2020;368:l6744

Abstract

Objective 背景

To determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.

确定质子泵抑制剂(PPIs),H2受体阻滞剂(H2RAs)、硫糖铝或无胃肠道出血预防(或应激性溃疡预防)对危重病患者重要预后指标的影响。

Design 设计

Systematic review and network meta-analysis.

系统回顾及网络meta分析

Data sources 数据来源

Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.

Medline, PubMed, Embase, 对照试验的Cochrane 中央注册,试验注册及灰色文献,直至2019年3月。

Eligibility criteria for selecting studies and methods 选择研究的筛查标准及方法

We included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.

我们纳入了比较PPIs, H2RAs, 或硫糖铝相互比较,或与安慰剂或无预防措施相比较,对于成年危重病患者胃肠道出血的预防效果。两名研究者独立筛查研究,获取数据,并评估偏倚风险。一个平行的指南委员会 (BMJ Rapid Recommendation) 对于系统回顾提供严格监管,包括确定对患者重要的预后指标。我们进行了随机效应成对网络meta分析,针对每项预后指标采用GRADE评估证据的确定性。如果低危与高危偏倚研究结果不同,我们采用前者作为最佳估计。

Results 结果

Seventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).

共有72项临床试验(纳入 12 660 名患者)符合入选标准。对于出血最高危 (>8%) 或高危 (4-8%) 患者,与安慰剂或无预防措施相比,PPIs 和 H2RAs 可能减少临床重要的胃肠道出血 (PPIs 比数比 0.61 (95% 可信区间 0.42 to 0.89), 最高危患者减少3.3%,高危患者减少2.3%,中等确定性;H2RAs比数比 0.46 (0.27 to 0.79), 最高危患者减少4.6%,高危患者减少3.1%,中等确定性)。与安慰剂或无预防措施相比,两者可能增加肺炎风险 (PPIs比数比 1.39 (0.98 to 2.10), 增加5.0%, 低度确定性; H2RAs 比数比 1.26 (0.89 to 1.85), 增加3.4%, 低度确定性)。 PPIs 和 H2RAs 很可能均不影响病死率 (PPIs 1.06 (0.90 to 1.28), 增加1.3%, 中等确定性; H2RAs 0.96 (0.79 to 1.19), 减少0.9%, 中等确定性)。另外,结果不支持对病死率,难辨梭状芽孢杆菌感染,ICU住院日,总住院日及机械通气时间有任何影响 (证据确定性各异)。

Conclusions 结论

For higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.

对于高危危重病患者,与无预防措施相比,PPIs 和 H2RAs 可能显著减少胃肠道出血;对于低危患者,出血风险的降低可能并不重要。PPIs 和 H2RAs 可能导致肺炎风险显著增加。质量各异的证据提示,干预措施对病死率或其他院内预后指标不产生重要影响。

Systematic review registration 系统回顾注册

PROSPERO CRD42019126656.

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