关节腔内注射利多卡因与静脉麻醉在急性肩关节前脱位中的应用-Meta分析

发布时间：2018-12-12 21:10

【摘要】：背景：肩关节脱位占全身关节脱位的40%以上,是骨科急诊最常见的疾病之一。其社区发病率为每年每十万人口中发生11.2例。虽然早在2000年前,医学之父希波克拉底便详细描述了肩关节的解剖以及脱位类型和闭合复位的方法。迄今为止,人们对于如何治疗外伤性肩关节脱位仍缺乏共识。调查研究显示,国内大多数医生认为在进行手法复位时需要采取合适的麻醉方式,且选择最多的3种麻醉方式依次为：①臂丛神经阻滞；②静脉麻醉；③关节腔内注射利多卡因麻醉法。臂丛神经阻滞位点周围解剖结构复杂,操作难度较高且并发症多见。因此,静脉麻醉成为了国外医生在肩关节脱位手法复位麻醉方式中的首选。然而,近年来关节腔内注射利多卡因的麻醉方式以其操作简单,并发症少,治疗费用低等优势逐渐走进了人们的研究视野。虽然国外开展了大量关于静脉麻醉与关节腔内注射利多卡因麻醉法的随机对照试验。然而对于其确切疗效,结果仍存在部分争议。目的：本研究将通过Meta分析的方式,对国内外有关静脉麻醉以及关节腔内注射利多卡因麻醉方式的临床研究展开深入的整合分析。针对两种麻醉方式各自的优势,结合高质量的随机对照试验研究,试图得到关于两者在肩关节脱位手法复位中应用价值的更为强有力的证据,为临床治疗决策提供帮助。方法：计算机检索MEDLINE(1950至2013),EMBASE(1980至2013)及CENTRAL (Cochrane Central Register of Controlled Trials,最新版),以"shoulder dislocation, lidocaine or lignocaine, intra-articular"为英文检索词,结合Cochrane协作网推荐使用的针对MEDLINE随机对照试验的高敏感性检索策略进行检索。根据文章题名及摘要进行初筛,对符合要求的文献获取全文进一步筛查。质量评价采用Cochrane协作网推荐的偏倚风险评价工具,纳入文献的质量越高,Meta分析的结果可信度越高。根据所纳入文献的异质性高低选择使用固定效应模型或随机效应模型分析数据。本研究使用的软件为Ravman5.2版本。结果：经过对1539篇文章进行初筛后,我们对剩下的11篇文章进行了全文筛选.最后排除4篇文献,纳入7篇随机对照试验.总共有317名患者符合纳入条件。关节腔内注射利多卡因组在复位成功率、复位中患者的主观疼痛体验以及复位3-4次后的成功率上与静脉麻醉组均无明显差异。而在并发症的发生率以及院内治疗时间上,关节腔内注射利多卡因麻醉组明显优于静脉麻醉组。且在复位1-2次后的成功率这个指标上关节腔内注射利多卡因组也表现出了明显的优势。结论：关节腔内注射利多卡因麻醉法在复位疗效以及疼痛控制上与静脉麻醉相当,但其并发症更少,费用更低,需要的治疗时间更短。
[Abstract]:Background: shoulder dislocation, which accounts for more than 40% of the total dislocation, is one of the most common diseases in orthopedic department. The community incidence rate is 11.2 per 100,000 population per year. Although Hippocrates, the father of medicine, described in detail the anatomy of the shoulder joint, the type of dislocation and the method of closed reduction as early as 2000 years ago. So far, there is still a lack of consensus on how to treat traumatic dislocation of the shoulder. The investigation shows that most doctors in China think that the appropriate anesthesia should be adopted when performing manual reduction, and the three most selected anesthesia methods are as follows: (1) brachial plexus block; (2) intravenous anesthesia; 3 intraarticular injection of lidocaine. The anatomic structure around the block site of brachial plexus is complex, the operation is difficult and the complications are common. Therefore, intravenous anesthesia has become the first choice for foreign doctors in manual reduction anesthesia of shoulder dislocation. However, in recent years, the intraarticular injection of lidocaine has gradually come into the research field because of its advantages of simple operation, less complications and low treatment cost. A large number of randomized controlled trials of intravenous anesthesia and intraarticular lidocaine anesthesia have been conducted abroad. However, there are still some controversies about the exact effect. Objective: to analyze the clinical study of intravenous anesthesia and intraarticular lidocaine by Meta analysis. According to the advantages of the two anaesthesia methods, combined with a high quality randomized controlled trial, we try to obtain more powerful evidence about the application value of the two methods in the manual reduction of shoulder dislocation, so as to provide help for the clinical treatment decision. Methods: MEDLINE (from 1950 to 2013), EMBASE (1980 to 2013) and the latest edition of CENTRAL (Cochrane Central Register of Controlled Trials, were searched by computer. "shoulder dislocation, lidocaine or lignocaine, intra-articular" was used as the key word in English. A highly sensitive search strategy for MEDLINE randomized controlled trials recommended by Cochrane Cooperative Network is used. According to the title and abstract of the article, the full text of the document obtained in accordance with the requirements was screened further. The bias risk assessment tool recommended by Cochrane Cooperative Network was used in the quality evaluation. The higher the quality of the literature included, the higher the reliability of the results of the Meta analysis. A fixed effect model or a random effect model is used to analyze the data according to the heterogeneity of the literature involved. The software used in this study is Ravman5.2 version. Results: after screening 1539 articles, we screened the remaining 11 articles. Finally, 4 articles were excluded and 7 randomized controlled trials were included. A total of 317 patients were eligible for inclusion. There was no significant difference in the success rate of reduction, the experience of subjective pain and the success rate after 3-4 times of reduction between the group of intraarticular injection of lidocaine and the group of intravenous anesthesia. In the incidence of complications and hospital treatment time, intraarticular injection of lidocaine anesthesia group was significantly better than intravenous anesthesia group. The success rate of the upper articular injection of lidocaine also showed obvious advantages after 1-2 times reduction. Conclusion: intraarticular lidocaine anesthesia is comparable to intravenous anesthesia in terms of reduction efficacy and pain control, but it has fewer complications, lower cost and shorter treatment time.
【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R684.7;R614

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