Kiat Ang Choon, Leung Dominic Y C, Lo Sidney, French John K, Juergens Craig P
Department of Cardiology, Sarawak General Hospital, Kuching, Malaysia.
Int J Cardiol. 2007 Apr 4;116(3):321-6. doi: 10.1016/j.ijcard.2006.04.045. Epub 2006 Aug 10.
There is no consensus with respect to the use of analgesia during femoral arterial sheath removal after percutaneous coronary intervention (PCI). We performed a randomized controlled trial to assess the impact of intravenous sedation and local anesthesia during femoral sheath removal after PCI on patient comfort and the incidence of vasovagal reactions.
All patients undergoing PCI whose femoral sheaths were to be removed with assisted manual compression were eligible. Patients were randomized to receive either intravenous sedation (Fentanyl and Midazolam) or local anesthesia (1% lignocaine) infiltrated around the sheath site or both or neither. The primary endpoint of the study was the patients reported worst pain according to a Visual Analogue scale (VAS) after sheath removal. The incidence and predictors of vasovagal reactions during sheath removal and occurrence of vascular complications was also determined.
A total of 611 patients were randomized into this study. The mean pain score was highest in the local anesthesia only arm as compared to the sedation only arm, the combined local and sedation arm and the neither sedation or local arm (p=0.001). vasovagal reactions were experienced by 35 patients (5.1%) with the highest percentage in the local anesthesia only group (9.8%). Multivariate logistic regression analysis identified a higher pain score (OR 1.18, 95% CI 1.12-1.24, p=0.001), use of glyceryl trinitrate during sheath removal (OR 9.05, 95% CI 5.06-16.1, p<0.001), a lower body mass index (OR 1.12, 95% CI 1.08-1.18, p=0.009) and the left anterior descending artery as the treated vessel (OR 5.2, 95% CI 3.41-7.87, p<0.001) as independent predictors of the occurrence of a vasovagal reaction. There was no significant difference in vascular complications between the 4 study groups.
The routine use of fentanyl and midazolam prior to sheath removal leads to a reduction in pain perception and vasovagal incidence, whilst the routine use of local infiltration during sheath removal should be discouraged as it leads to more pain and a trend to more vasovagal reactions.
经皮冠状动脉介入治疗（PCI）后拔除股动脉鞘管时镇痛方法的使用尚无共识。我们进行了一项随机对照试验，以评估PCI后拔除股动脉鞘管时静脉镇静和局部麻醉对患者舒适度及血管迷走神经反应发生率的影响。
所有接受PCI且计划通过手法辅助压迫拔除股动脉鞘管的患者均符合入选标准。患者被随机分为四组，分别接受静脉镇静（芬太尼和咪达唑仑）、鞘管周围局部浸润麻醉（1%利多卡因）、两者联合或两者均不使用。研究的主要终点是患者拔除鞘管后根据视觉模拟评分法（VAS）报告的最严重疼痛程度。同时还确定了拔除鞘管期间血管迷走神经反应的发生率及预测因素，以及血管并发症的发生情况。
共有611例患者被随机纳入本研究。与仅接受镇静组、局部麻醉与镇静联合组以及既不接受镇静也不接受局部麻醉组相比，仅接受局部麻醉组的平均疼痛评分最高（p = 0.001）。35例患者（5.1%）发生血管迷走神经反应，其中仅接受局部麻醉组的发生率最高（9.8%）。多因素logistic回归分析确定，较高的疼痛评分（OR 1.18，95%CI 1.12 - 1.24，p = 0.001）、拔除鞘管期间使用硝酸甘油（OR 9.05，95%CI 5.06 - 16.1，p < 0.001）、较低的体重指数（OR 1.12，95%CI 1.08 - 1.18，p = 0.009）以及左前降支作为治疗血管（OR 5.2，95%CI 3.41 - 7.87，p < 0.001）是血管迷走神经反应发生的独立预测因素。四个研究组之间血管并发症无显著差异。
拔除鞘管前常规使用芬太尼和咪达唑仑可减轻疼痛感知并降低血管迷走神经反应的发生率，而不建议常规在拔除鞘管时进行局部浸润麻醉，因为这会导致更多疼痛且有增加血管迷走神经反应的趋势。
