早期活动对重症监护病房机械通气患者出院后病死率影响的Meta分析

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目的:采用Meta分析方法评价早期活动对重症监护病房(ICU)机械通气患者出院后病死率的影响。方法:应用计算机检索中国生物医学文献服务系统(SinoMed)、中国知网(CNKI)、万方数据、美国国立医学图书馆PubMed数据库、Cochrane图书馆数据库、科学网(Web of Science)和荷兰医学文摘Embase数据库,收集关于早期活动对ICU机械通气患者出院后病死率影响的随机对照试验(RCT),同时追溯纳入文献的参考文献,检索时限均为建库至2020年9月17日。对照组给予ICU常规护理;试验组在对照组基础上进行早期活动,包括床上被动或主动辅助活动、坐于床边、床旁站立、转移至床旁椅和辅助步行。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险。采用Stata 12.0软件进行Meta分析;绘制漏斗图分析文献发表偏倚。结果:最终纳入10项RCT研究,共1 323例患者,其中对照组660例,试验组663例。文献质量评价结果显示,7项研究为A级,3项研究为B级,提示纳入文献整体质量较高。Meta分析结果显示,目前的临床证据表明,早期活动不会增加ICU机械通气患者出院后的病死率〔优势比(n OR)=0.92,95%可信区间(95%n CI)为0.75~1.13,n P=0.449〕;亚组分析显示,早期活动有降低ICU机械通气患者出院后3、6、12个月病死率的趋势,但差异无统计学意义(3个月病死率:n OR=1.02,95%n CI为0.74~1.40,n P=0.927;6个月病死率:n OR=0.95,95%n CI为0.70~1.27,n P=0.712;12个月病死率:n OR=0.60,95%n CI为0.33~1.10,n P=0.101)。漏斗图显示,纳入文献分布不完全对称,提示可能存在发表偏倚。n 结论:ICU机械通气患者进行早期活动并不会增加出院后的病死率,且有降低病死率的趋势,但由于纳入文献较少、样本量较小且各研究早期活动具体实施情况存在差异,仍需要开展大量的高质量RCT研究进一步验证。“,”Objective:To evaluate the effect of early mobilization on mortality in intensive care unit (ICU) patients with mechanical ventilation after discharge by Meta-analysis.Methods:Databases including SinoMed, China National Knowledge Infrastructure (CNKI), Wanfang data, PubMed, the Cochrane Library, Web of Science, and Embase were searched from inception to September 17th, 2020, to collect randomized controlled trials (RCT) about early mobilization on mortality of patients with mechanical ventilation in ICU after discharge, the references included in the literature were traced. The control group was given routine care, the experimental group was given early mobilization on the basis of the control group, including passive or active mobilization on the bed, sitting on the bed, standing by the bed, transferring to the bedside chair and assisting walking. The literature screening, data extracting, and the bias risk assessment of included studies were conducted independently by two reviewers. Stata 12.0 software was then used to perform Meta-analysis. Funnel plot was used to test publication bias.Results:A total of 10 RCT studies involving 1 323 patients were included, with 660 patients in the control group and 663 patients in the experimental group. The results of literature quality evaluation showed that 7 studies were grade A and 3 studies were grade B, indicating that the overall quality of included literatures was high. The Meta-analysis results showed that early mobilization did not increase the mortality of patients with mechanical ventilation in ICU after discharge [odds ratio (n OR) = 0.92, 95% confidence interval (95%n CI) was 0.75-1.13, n P = 0.449]. Subgroup analysis results showed that early mobilization had a tendency to reduce the mortality of ICU patients with mechanical ventilation at 3, 6 and 12 months after discharge, but the difference was not statistically significant (3-month mortality: n OR = 1.02, 95%n CI was 0.74-1.40, n P = 0.927; 6-month mortality: n OR = 0.95, 95%n CI was 0.70-1.27, n P = 0.712; 12-month mortality: n OR = 0.60, 95%n CI was 0.33-1.10, n P = 0.101). Funnel plot showed that the distribution of included literatures was not completely symmetrical, suggesting that publication bias might exist.n Conclusions:Early mobilization does not increase the mortality of ICU patients with mechanical ventilation after discharge. Although it tends to have a favorable outcome in reducing mortality, and has a trend to reduce the mortality. However, due to the small number of included literatures, small sample size and differences in the specific implementation of early mobilization among various studies, a large number of high-quality RCT studies are still needed for further verification.
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