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Naloxone for shock

  • Review
  • Intervention

Authors


Abstract

Background

There is pre-clinical evidence, involving several animal species, suggesting that opioid peptides play a role in the physiopathology of shock (endotoxic, hypovolemic, cardiogenic, spinal, anaphylactic). Many case reports have suggested that naloxone (an opiate antagonist) might be an effective treatment for shock in humans, but others have not supported such a point of view. This controversy led us to undertake a meta-analysis of the available evidence on the efficacy of naloxone as a treatment measure for shock in humans.

Objectives

To evaluate the effectiveness and safety of naloxone in human shock and to estimate the methodological quality of the clinical trials.

Search methods

We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (Ovid SP), PubMed, EMBASE (Ovid SP), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), and ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (to December 2008). In order to identify further studies the reference lists of all included papers were examined and the primary investigators of eligible studies were contacted.

Selection criteria

Randomized controlled trials evaluating naloxone in human shock, regardless of the patient's age (adult, child, or neonate).

Data collection and analysis

Three independent review authors extracted data on study design, intervention, outcomes, and methodological quality.

Main results

Three independent readers reviewed 120 publications and selected six clinical trials. Overall agreement on study selection was perfect (concordance: 100%). The meta-analysis includes six studies involving 126 patients with septic, cardiogenic, hemorrhagic, or spinal shock.

Naloxone therapy was associated with statistically significant hemodynamic improvement (odds ratio 0.24; 95% confidence interval (CI) 0.09 to 0.68). The mean arterial pressure was significantly higher in the naloxone groups than in the placebo groups (weighted mean difference +9.33 mm Hg; 95% CI 7.07 to 11.59). No heterogeneity was found for this outcome. The death rate was lower in the naloxone group (odds ratio 0.59; 95% CI 0.21 was 1.67) but this was consistent with the play of chance. A significant heterogeneity was detected for the latter outcome (P < 0.05).

Authors' conclusions

Naloxone improves blood pressure, especially mean arterial blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined and additional randomized controlled trials are needed to assess its usefulness.

摘要

背景

Naloxone用於休克

有臨床前(preclinical)的證據指出,包含幾個動物物種,認為opioid peptides在休克(內毒素的,低血容量的,心因性的,脊髓的,過敏性的)的病理生理學中扮演重要的角色。許多病例報告認為naloxone(一種opiate拮抗劑)對於人類休克也許是有效的,但其他的研究並未支持這種觀點。這項爭議使得我們進行現有證據關於naloxone作為人類休克治療策略之效益的統合分析。

目標

評估naloxone對於人類休克的效果及安全性,並估計臨床試驗的方法學品質。

搜尋策略

電腦化參考書目的檢索至2002年12月止,回顧主題相關文章的參考文獻並聯絡合格研究的主要研究人員。

選擇標準

評估naloxone用於人類休克的隨機對照試驗,不論病患的年齡(成人,兒童或新生兒)。

資料收集與分析

三名獨立的回顧者摘錄研究設計,介入措施,結果及方法學品質的資料。

主要結論

三名獨立的檢閱者回顧80篇有關人體的發表文章並選定六篇臨床試驗。整體上研究選擇的一致性是理想的(一致性:100%)。統合分析包括六篇研究,共126名敗血病,心臟病因,出血性或脊髓的休克病患。Naloxone治療與血流動力學的改善有統計上顯著相關(odds ratio 0.24; 95% confidence interval [95%CI] 0.09 – 0.68)。naloxone組其平均動脈壓顯著高於安慰劑組(weighted mean difference: +9.33 mmHg; 95%CI 7.07 – 11.59)。這項結果沒有異質性被發現。naloxone組的死亡率較低(odds ratio 0.59; 95%CI 0.21 – 1.67),但這項結果是隨機一致的。後者結果有顯著的異質性被發現(p<0.05)。

作者結論

Naloxone可以改善血壓,尤其是平均的動脈壓。然而,naloxone用以治療休克的效用仍待確定,且需要其他的對照試驗以評估它的效用。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

Naloxone也許會改善休克者的血壓,但需要更多的試驗以顯示是否會減少死亡率。當人進入休克狀態,他們的血壓會下降且也許會下降的太低以致於無法維持生活。一項理論說明會造成這個的原因是大量失血或創傷後身體會產生opiates的效果。Naloxone是一種藥物,可以對抗opiates的效果。它已被嘗試作為減少休克影響的一種治療方式。回顧試驗後發現給予休克者naloxone可以改善他們的血壓,但目前不清楚這是否改善它們的整體狀況並減少他們的死亡機會。需要更多的研究。

Plain language summary

Naloxone may improve blood pressure in people who are in shock but more trials are needed to show whether this reduces deaths

When people go into shock, their blood pressure drops and may be too low to sustain life. One theory about the cause of this is the effect of the opiates that the body produces after major blood loss or trauma. Naloxone is a drug that counteracts the effects of opiates. It has been tried as a treatment to reduce the impact of shock. This review of trials found that giving naloxone to people in shock improves their blood pressure. It is not clear whether or not this improves their overall condition or reduces their chances of dying. More trials are needed.

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