【罂粟摘要】对乙酰氨基酚和非甾体抗炎药加用糖皮质激素治疗术后疼痛：一项荟萃分析和试验序贯分析的系统综述

对乙酰氨基酚和非甾体抗炎药加用糖皮质激素治疗术后疼痛：一项荟萃分析和试验序贯分析的系统综述

贵州医科大学      麻醉与心脏电生理课题组

翻 译：马艳燕   编 辑：柏雪   审 校：曹莹

背景：对乙酰氨基酚和非甾体抗炎药 （NSAID） 被推荐作为大多数手术的基本疼痛治疗方案。糖皮质激素具有广为人知的抗炎和止吐特性，也可能具有镇痛作用。我们评估了在对乙酰氨基酚和非甾体抗炎药联合使用中添加糖皮质激素用于术后疼痛管理的益处和危害。

方法：我们在Embase、Medline和CENTRAL中检索随机临床试验，这些试验调查了在接受任何类型手术的成人中加入糖皮质激素与安慰剂(对乙酰氨基酚和非甾体抗炎药中不加干预)的止痛效果。评估三个主要结果：术后24小时累积阿片类药物使用量、严重不良事件和术后24小时静息疼痛。进行meta分析和试验序贯分析（TSA），使用Risk of Bias 2工具评估偏倚风险，并使用GRADE(建议分级评估、制定和评价)评分来评估证据的质量。

结果：确定12项相关试验，其中9项试验随机纳入了804名受试者进行定量分析。当加入对乙酰氨基酚和非甾体抗炎药时，我们发现糖皮质激素与安慰剂(无干预措施)在术后24小时累积阿片类药物消耗量(平均差[MD]-0.28，TSA调整的95%置信区间[CI]-1.90至1.33，p=0.68，中等质量证据），严重不良事件（风险比[RR]0.99，TSA调整的95%置信区间[CI]0.27至0.63，p=0.93，极低质量证据）或术后24小时数字量表上的疼痛评分（平均差[MD] -0.39，TSA调整的95%置信区间[CI]-0.84至0.17，p=0.10，中等质量证据）没有差异。所有结果都被评估为存在高偏倚风险，TSA显示我们对大多数结果没有足够的信息。

结论：在对乙酰氨基酚和非甾体抗炎药中添加糖皮质激素对术后24小时累积阿片类药物消耗量和静息疼痛几乎没有影响。此外，关于对严重不良事件影响的证据非常不确定。对于大多数结局，我们没有足够的信息来得出确切的结论，证据的质量从中等到极低不等。

原始文献来源 ：Stormholt ER, Steiness J, Derby CB, Larsen ME, Maagaard M, Mathiesen O. Glucocorticoids added to paracetamol and NSAIDs for post-operative pain: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand. 2023 Mar 14. doi: 10.1111/aas.14237.

 Glucocorticoids added to paracetamol and NSAIDs for post-operative pain: A systematic review with meta-analysis and trial sequential analysis

Background: Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the basic pain treatment regimen for most surgeries. Glucocorticoids have well-known anti-inflammatory and anti-emetic properties and may also demonstrate analgesic effects. We assessed benefit and harm of adding glucocorticoids to a combination of paracetamol and NSAIDs for post-operative pain management.

Methods: We searched Embase, Medline and CENTRAL for randomised clinical trials investigating the addition of glucocorticoids versus placebo/no intervention to paracetamol and an NSAID in adults undergoing any type of surgery. We assessed three primary outcomes: cumulative opioid consumption at 24 h postoperatively, serious adverse events and pain at rest at 24 h postoperatively. We performed meta-analysis and trial sequential analysis (TSA), assessed risk of bias using the Risk of Bias 2 tool and used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the certainty of the evidence.

Results: We identified 12 relevant trials of which nine trials randomising 804 participants were included in quantitative analysis. When added to paracetamol and NSAIDs, we found no evidence of a difference of glucocorticoids versus placebo/no intervention in cumulative opioid consumption at 24 h postoperatively (mean difference [MD] −0.28, TSA-adjusted 95% confidence interval [CI] −1.90 to 1.33, p=0.68, moderate certainty of evidence), serious adverse events (risk ratio (RR) 0.99, TSA-adjusted 95% CI 0.27–3.63, p=0.93, very low certainty of evidence) or pain on the Numeric Rating Scale at 24 h postoperatively (MD −0.39, TSA-adjusted 95% CI −0.84 to 0.17, p=0.10, moderate certainty of evidence). All outcomes were assessed to be at high risk of bias and TSA showed that we had insufficient information for most outcomes.

Conclusions: Glucocorticoids added to a baseline therapy of paracetamol and an NSAID likely result in little to no difference in cumulative opioid consumption and pain at rest at 24 h postoperatively. In addition, the evidence is very uncertain about the effect on serious adverse events. For most outcomes we did not have sufficient information to draw firm conclusions and the certainty of the evidence varied from moderate to very low.

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