颈动脉窦区浸润阻滞在颈动脉支架成形术中的应用

Application of carotid sinus area infiltration block with lidocaine during carotid angioplasty and stenting

目的观察颈动脉窦区浸润阻滞在颈动脉支架成形术(CAS)中预防颈动脉窦反射(CSR)的作用。方法选择2019年8月至2020年1月择期症状性颈动脉C 1段狭窄行CAS的患者40例,男27例,女13例,年龄54~81岁,BMI 19~32 kg/m^(2),ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:颈动脉窦区浸润阻滞组(B组)和阿托品预防组(C组),每组20例。B组在超声引导下应用1%利多卡因5 ml在颈动脉窦区进行浸润阻滞,注射后5 min球囊引导导管到位,行球囊扩张,并置入颈动脉支架;C组预防性静脉注射阿托品0.5 mg,注射后5 min球囊引导导管到位后,开始球囊扩张及置入颈动脉支架。所有患者在局麻监测下完成CAS。记录颈动脉窦浸润阻滞后/静脉注射阿托品后5 min(T_(1))、球囊扩张即刻(T_(2))、支架置入后5 min(T_(3))、10 min(T_(4))、20 min(T_(5))及术毕即刻(T_(6))的HR及T_(1)和T_(3)—T_(6)时的SBP,并计算T_(2)—T_(6)时HR与T_(3)—T_(6)时SBP降低幅度。CSR定义为:与T_(1)时比较,T_(2)—T_(6)时HR降低幅度>10%、或心动过缓(HR<60次/分)、或低血压(SBP<90 mmHg),分别记录HR降低幅度>10%、心动过缓和低血压的发生情况。记录应用阿托品及多巴胺补救例数。记录声音嘶哑、呼吸困难、局麻药中毒、误伤血管、心脏骤停及术后心脑血管相关不良反应的发生情况。结果T_(2)时B组HR降低幅度明显小于C组(P<0.05),T_(3)—T_(6)时两组SBP、HR降低幅度差异无统计学意义。B组心动过缓发生率明显低于C组(P<0.05),阿托品补救发生率明显低于C组(P<0.05)。C组于T_(2)时出现心脏骤停1例,20 s后逐渐恢复自主循环,术后3 d死于大面积脑梗死1例;B组发生声音嘶哑4例,于术后1 h内恢复正常;其余未发生呼吸困难、局麻药中毒、误伤血管、心脏骤停及术后心脑血管相关不良反应。结论超声引导下1%利多卡因颈动脉窦区浸润阻滞,可有效地预防颈动脉支架成形术中颈动脉窦反射,维持血流动力学稳定。

Objective To observe the prophylaxis of the carotid sinus reflex(CSR)via the blockade in carotid sinus area with lidocaine in patients undergoing carotid angioplasty and stenting.Methods Forty patients with symptomatic carotid artery stenosis(C 1 segment stenosis)undergoing carotid angioplasty and stenting(CAS),27 males and 13 females,aged 54-81 years,BMI 19-32 kg/m^(2),ASA physical statusⅡorⅢ,were recruited and divided randomly into two groups:lidocaine infiltration in carotid sinus area group(group B)and prophylactic intravenous atropine group(group C),20 patients in each group.In group B,1%lidocaine 5 ml was injected in the carotid sinus area guided under B type ultrasound,while in the group C,atropine 0.5 mg was injected intravenously before balloon dilatation.Balloon dilatation and stent implantation were performed 5 minutes later.Monitoring anesthesia care was performed for all patients during the procedure.HR was recorded at carotid sinus area block or atropine intravenous injection 5 minutes later(T_(1)),balloon dilatation(T_(2)),5 minutes(T_(3)),10 minutes(T_(4))and 20 minutes(T_(5))after stenting and the end of the procedure(T_(6))and blood pressure was recorded at T_(1)and T_(3)-T_(6).CSR was defived as the incidence of HR drops more than 10 percent at T_(2)-T_(6)compared with T_(1),bradycardia(HR<60 beats per minute),and hypotension(SBP<90 mmHg),the number of cases of the above three conditions were recorded.The number of cases injected with atropine or dopamine was recorded.Adverse events were recorded,including hoarseness,dyspnea,local anesthetic intoxication,vascular injury,cardiac arrest and relevant adverse events.Results The decrease of HR in group B was significantly lower than that in group C at T_(2)(P<0.05).There was no significant difference in the decrease of SBP and HR between the two groups at T_(3)-T_(6).The overall occurrence rate of bradycardia in group B were less than group C(P<0.05).The incidence of CSR rescued with atropine in group B was significantly lower than that in group C(P<0.05).In group C,one patient occurred cardiac arrest at T_(1)and restoration of spontaneous circulation arrived surprisingly 20 seconds later,one patient died due to large volume cerebral infarction 3 days after procedure.In group B,hoarseness showed up in 4 patients and recovered one hour later,no other adverse events came up.Conclusion The infiltration with 1%lidocaine in carotid sinus area guided by ultrasound is effective to prevent carotid sinus reflex and stabilize hemodynamics during carotid angioplasty and stenting.