Abstract：
OBJECTIVE: The objective of this umbrella review was to examine various pharmacologic interventions for their potential to reduce etomidate-induced myoclonus. A secondary objective was to compare the relative effectiveness of those medications in reducing the incidence of myoclonus when etomidate is utilized for the induction of general anesthesia.
BACKGROUND: Etomidate is the drug of choice when inducing general anesthesia in hemodynamically unstable patients. However, its use is limited among the general surgical population due to its ability to cause adrenal suppression, vomiting, and myoclonus. Myoclonus can lead to damage of muscle fibers, myalgias, and patient discomfort, and can also be detrimental in patients with low cardiac reserve. Several systematic reviews have reported on the effectiveness of various intravenous medications in reducing mild, moderate, and severe myoclonus; however, a more thorough examination of their influence was lacking.
METHODS: This review included systematic reviews and meta-analyses of randomized controlled trials involving the use of pharmacologic interventions to reduce etomidate-induced myoclonus. Reviews in English and conducted after 1965 were considered for inclusion.
METHODS: A comprehensive search of 11 databases was conducted to identify published and unpublished reviews up to March 2022. Critical appraisal was conducted by 2 independent reviewers using the standardized JBI appraisal tool. Quantitative findings were summarized according to the dose, timing of administration, and relative risk using a data matrix, and were synthesized in tabular format with supporting narrative text. Results were organized by severity of myoclonus (overall, mild, moderate, and severe) and by type of intervention.
RESULTS: Eight systematic reviews were included in this umbrella review, which included 48 relevant studies, after removal of duplicates (3909 participants included in the primary studies). Five of the systematic reviews examined the effectiveness of various types of opioids in the prevention of myoclonus, and 3 systematic reviews examined the effectiveness of non-opioid interventions, such as lidocaine, midazolam, and dexmedetomidine. Seven reviews searched at least 4 databases for pertinent studies and specifically indicated that blinded reviewers appraised the articles. All reviews used a published and validated appraisal instrument. The overall quality of all included reviews was judged to be moderate to high. The absolute risk reduction indicating the effectiveness of the prophylactic medications ranged from 47% to 81% for mild, 52% to 92% for moderate, and 61% to 96% for severe myoclonus. Opioids demonstrated the most consistent and substantial effect on the reduction in myoclonus.
CONCLUSIONS: All pharmacologic interventions identified in this review demonstrated a statistically significant reduction in the incidence of myoclonus. Future studies and reviews should focus on elucidating the particular dose range and timing that is most effective. Anesthesia providers should consider a pre-treatment dose of one of the medications described in this umbrella review as a means to reduce myoclonus and the untoward effects of that condition.
BACKGROUND: Etomidate is the drug of choice when inducing general anesthesia in hemodynamically unstable patients. However, its use is limited among the general surgical population due to its ability to cause adrenal suppression, vomiting, and myoclonus. Myoclonus can lead to damage of muscle fibers, myalgias, and patient discomfort, and can also be detrimental in patients with low cardiac reserve. Several systematic reviews have reported on the effectiveness of various intravenous medications in reducing mild, moderate, and severe myoclonus; however, a more thorough examination of their influence was lacking.
METHODS: This review included systematic reviews and meta-analyses of randomized controlled trials involving the use of pharmacologic interventions to reduce etomidate-induced myoclonus. Reviews in English and conducted after 1965 were considered for inclusion.
METHODS: A comprehensive search of 11 databases was conducted to identify published and unpublished reviews up to March 2022. Critical appraisal was conducted by 2 independent reviewers using the standardized JBI appraisal tool. Quantitative findings were summarized according to the dose, timing of administration, and relative risk using a data matrix, and were synthesized in tabular format with supporting narrative text. Results were organized by severity of myoclonus (overall, mild, moderate, and severe) and by type of intervention.
RESULTS: Eight systematic reviews were included in this umbrella review, which included 48 relevant studies, after removal of duplicates (3909 participants included in the primary studies). Five of the systematic reviews examined the effectiveness of various types of opioids in the prevention of myoclonus, and 3 systematic reviews examined the effectiveness of non-opioid interventions, such as lidocaine, midazolam, and dexmedetomidine. Seven reviews searched at least 4 databases for pertinent studies and specifically indicated that blinded reviewers appraised the articles. All reviews used a published and validated appraisal instrument. The overall quality of all included reviews was judged to be moderate to high. The absolute risk reduction indicating the effectiveness of the prophylactic medications ranged from 47% to 81% for mild, 52% to 92% for moderate, and 61% to 96% for severe myoclonus. Opioids demonstrated the most consistent and substantial effect on the reduction in myoclonus.
CONCLUSIONS: All pharmacologic interventions identified in this review demonstrated a statistically significant reduction in the incidence of myoclonus. Future studies and reviews should focus on elucidating the particular dose range and timing that is most effective. Anesthesia providers should consider a pre-treatment dose of one of the medications described in this umbrella review as a means to reduce myoclonus and the untoward effects of that condition.
摘要：
目的：本综述的目的是研究各种药物干预措施对减少依托咪酯诱导的肌阵挛症的潜力。次要目的是比较当依托咪酯用于诱导全身麻醉时，这些药物在降低肌阵挛症发生率方面的相对有效性。
背景：依托咪酯是血流动力学不稳定患者诱导全身麻醉的首选药物。然而,由于其引起肾上腺抑制的能力，其在普外科人群中的使用受到限制，呕吐,和肌阵挛症.肌阵挛会导致肌纤维损伤，肌痛,患者不适,并且对低心脏储备的患者有害。一些系统评价已经报道了各种静脉药物在减少轻度，中度,和严重的肌阵挛症；然而，缺乏对他们影响的更彻底的检查。
方法：本综述包括使用药物干预减少依托咪酯诱导的肌阵鸣的随机对照试验的系统评价和荟萃分析。考虑纳入1965年以后进行的英文评论。
方法：对11个数据库进行了全面搜索，以确定截至2022年3月已发表和未发表的评论。由2名独立审稿人使用标准化的JBI评估工具对8项系统评价进行了批判性评估。根据剂量对定量结果进行了总结，管理的时机,和使用数据矩阵的相对风险，并以表格格式合成，并附有支持的叙述性文字。结果按肌阵挛症的严重程度组织(总体上，温和,中度,和严重)和干预类型。
结果：本综述包括8项系统综述，其中包括48项相关研究，在删除重复项之后(主要研究中包括3909名参与者).五个系统评价检查了各种类型的阿片类药物在预防肌阵挛症中的有效性，和3个系统评价检查了非阿片类药物干预的有效性，比如利多卡因,咪达唑仑,和右美托咪定.七篇评论在至少4个数据库中搜索了相关研究，并特别指出盲文审稿人对文章进行了评估。所有评论均使用已发布并经过验证的评估工具。所有纳入的评论的总体质量被认为是中等到高。表明预防性药物有效性的绝对风险降低范围为47％至81％，轻度，52％至92％为中度，和61％至96％的严重肌阵挛症。阿片类药物对肌阵挛症的减少表现出最一致和实质性的作用。
结论：所审查的所有药物干预措施均显示肌阵挛症发生率的统计学显著降低。未来的研究和评论应集中在阐明最有效的特定剂量范围和时机上。麻醉提供者应考虑使用本综述中描述的一种药物的治疗前剂量，以减少肌阵挛症和该病症的不利影响。
背景：依托咪酯是血流动力学不稳定患者诱导全身麻醉的首选药物。然而,由于其引起肾上腺抑制的能力，其在普外科人群中的使用受到限制，呕吐,和肌阵挛症.肌阵挛会导致肌纤维损伤，肌痛,患者不适,并且对低心脏储备的患者有害。一些系统评价已经报道了各种静脉药物在减少轻度，中度,和严重的肌阵挛症；然而，缺乏对他们影响的更彻底的检查。
方法：本综述包括使用药物干预减少依托咪酯诱导的肌阵鸣的随机对照试验的系统评价和荟萃分析。考虑纳入1965年以后进行的英文评论。
方法：对11个数据库进行了全面搜索，以确定截至2022年3月已发表和未发表的评论。由2名独立审稿人使用标准化的JBI评估工具对8项系统评价进行了批判性评估。根据剂量对定量结果进行了总结，管理的时机,和使用数据矩阵的相对风险，并以表格格式合成，并附有支持的叙述性文字。结果按肌阵挛症的严重程度组织(总体上，温和,中度,和严重)和干预类型。
结果：本综述包括8项系统综述，其中包括48项相关研究，在删除重复项之后(主要研究中包括3909名参与者).五个系统评价检查了各种类型的阿片类药物在预防肌阵挛症中的有效性，和3个系统评价检查了非阿片类药物干预的有效性，比如利多卡因,咪达唑仑,和右美托咪定.七篇评论在至少4个数据库中搜索了相关研究，并特别指出盲文审稿人对文章进行了评估。所有评论均使用已发布并经过验证的评估工具。所有纳入的评论的总体质量被认为是中等到高。表明预防性药物有效性的绝对风险降低范围为47％至81％，轻度，52％至92％为中度，和61％至96％的严重肌阵挛症。阿片类药物对肌阵挛症的减少表现出最一致和实质性的作用。
结论：所审查的所有药物干预措施均显示肌阵挛症发生率的统计学显著降低。未来的研究和评论应集中在阐明最有效的特定剂量范围和时机上。麻醉提供者应考虑使用本综述中描述的一种药物的治疗前剂量，以减少肌阵挛症和该病症的不利影响。
