Evaluation of cerebral oxygen saturation during hypotensive anesthesia in functional endoscopic sinus surgery

Comparison of Intraoperative Propofol-Dexmedetomidine and Ketofol-Dexmedetomidine Infusions on Recovery from Anesthesia in Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgeries: A Randomized Controlled Trial

BACKGROUND

A rapid and smooth emergence is essential in patients undergoing transsphenoidal pituitary surgeries. Ketofol has been used as an anesthetic agent with good recovery characteristics. We conducted this study to compare the recovery profile of the patients receiving propofol-dexmedetomidine or ketofol-dexmedetomidine infusions for transsphenoidal excision of pituitary tumors.

METHODS

Forty adult patients undergoing endoscopic pituitary surgery received either an infusion of propofol (Group P) or ketofol, 1:5 (Group KP) at 0.6-0.9 ml/kg/h. Dexmedetomidine (0.5 μg/kg/h) was administered in both groups. Our aim was to assess the recovery time, extubation time, and emergence time. We also assessed the intraoperative hemodynamics, cerebral oxygenation, quality of the surgical field, and postoperative pain.

RESULTS

The recovery time (Group KP v/s P; 16.5 ± 4.3 vs 8.3 ± 2.7 minutes, P < 0.01), emergence time (12.9 ± 3.9 vs 5.7 ± 2.7 minutes, P < 0.01), and extubation time (14.3 ± 4.2 vs 7.2 ± 2.8 minutes, P < 0.01) were longer in Group KP as compared to Group P. However, the patients in Group KP had lower cough scores and pain scores, along with better maintenance of hemodynamic stability and cerebral oxygenation. The agitation score, cognition score, and quality of the surgical field were comparable.

CONCLUSIONS

The use of ketofol resulted in a longer recovery time compared to the use of propofol alone. However, ketofol was associated with a better quality of extubation, maintenance of hemodynamic stability, and enhanced postoperative analgesia. Further research is needed to conclusively establish its efficacy and optimal dosage in pituitary surgery.

Comparison of the effects of dexmedetomidine and nitroglycerin on cerebral oxygen saturation using near-infrared spectroscopy in patients undergoing controlled hypotensive anaesthesia: A randomised controlled non-inferiority trial

Background and Aims

There is limited literature wherein the hypotensive drugs have been compared to know the cerebral effects by monitoring regional cerebral oxygen saturation (rScO2). This study aimed to compare the effects of dexmedetomidine and nitroglycerin on rScO2 during controlled hypotensive anaesthesia using near-infrared spectroscopy (NIRS). The primary objective was to evaluate the non-inferiority of dexmedetomidine versus nitroglycerin in the occurrence of cerebral desaturation events (CDEs) during hypotensive anaesthesia.

Methods

Adult patients scheduled to undergo head and neck surgery under general anaesthesia randomised to receive either dexmedetomidine or nitroglycerin infusion for controlled hypotensive anaesthesia. Cerebral oximetry was monitored with NIRS, and data regarding CDEs, bilateral rScO2, and peri-operative haemodynamics were collected. Continuous data were analysed using unpaired Student's t-tests except for intra-group analyses, which were analysed using paired t-tests. Categorical data were analysed using the Chi-square test. For comparison of time to CDEs, Kaplan-Meier survival analysis with log-rank test was performed.

Results

Of the 82 patients in both groups, CDEs were observed in 15 patients each. A decrease from baseline by 20% was observed in three patients: one in Group N and two in Group D. Statistically, there was an equal risk of getting CDEs in the groups. The time to CDE was comparable (P > 0.05). The difference in heart rate was statistically significant (P < 0.001).

Conclusion

Dexmedetomidine is non-inferior to nitroglycerin in terms of the occurrence of cerebral desaturation events when used for controlled hypotensive anaesthesia in head and neck surgeries.

Hemostasis in endoscopic sinus and skull base surgery

PURPOSE OF REVIEW

Bleeding during endoscopic endonasal procedures can quickly obscure critical anatomic landmarks. This increases both the difficulty of the surgical procedure and the risk of complications faced by the patient. As the indications for surgical management of sinonasal pathology grow, it is important to review techniques to minimize bleeding and facilitate safe surgery.

RECENT FINDINGS

Evidence continues to accumulate for best practices in the surgical management of sinonasal disease. Recently, international guidelines have attempted to summarize this body of evidence, lending further support to several interventions which have been advocated as methods to decrease bleeding during endoscopic endonasal surgery. Additional studies have specifically investigated the safety of certain commonly employed techniques. The utility of preoperative corticosteroid therapy and the use of total intravenous anesthetic techniques in increasingly validated. Further evidence supports the safety of reverse Trendelenburg positioning for surgical management of inflammatory disease.

SUMMARY

Recent wide scale systematic review of the literature regarding perioperative and intraoperative management of hemostasis has reinforced the utility of certain interventions, while others remain ambiguous.

Effects of different levels of controlled hypotension on regional cerebral oxygen saturation and postoperative cognitive function in patients undergoing total knee arthroplasty

Background

Controlled hypotension technique was usually used to reduce intraoperative bleeding, and it could improve visualization of the surgical field during total knee arthroplasty (TKA). However, inappropriate controlled hypotension, through reducing cerebral blood flow or cerebral perfusion pressure, may cause postoperative cognitive dysfunction (POCD), so it is important to identify the appropriate level of controlled hypotension. Objective: To investigate the effects of different levels of controlled hypotension on regional cerebral oxygen saturation and postoperative cognitive function in patients undergoing TKA.

Methods

Patients meeting inclusion criteria were enrolled through preoperative visits and basic information was obtained. The patients were randomly divided into three groups: Group A, MAP was maintained at 90–100% of the baseline; Group B, MAP was maintained at 80–90% of the baseline; Group C, MAP was maintained at 70–80% of the baseline. The MAP, HR, and rSO₂ were observed and recorded during the operation. The C-reactive protein (CRP), hemoglobin (Hb) and MMSE score at 1, 3, and 7 days after operation were recorded. SPSS25.0 was used for data analysis.

Result

When the MAP had a decrease among the three groups, rSO₂ did not decrease significantly, and none of the patients experienced POCD which was measured by MMSE. And there was no correlation between the decline in rSO₂ and that in MAP.

Conclusion

No POCD was experienced in the three groups, and we recommend that the controlled hypotensive target indicated by MAP was maintained at 70–80% of the baseline which not only decreases intraoperative bleeding and improve the quality of the surgical field, but also is still within safe levels.

Effect of Deliberate Hypotension on Regional Cerebral Oxygen Saturation During Functional Endoscopic Sinus Surgery: A Randomized Controlled Trial

Background: Deliberate hypotension can reduce bleeding and improve visualization of the surgical field during functional endoscopic sinus surgery (FESS). However, hypotension may cause brain hypoperfusion and subsequent ischemic injuries, such as delayed awakening, stroke, postoperative delirium, and postoperative cognitive dysfunction. Near-infrared spectroscopy (NIRS) can be used to monitor real-time regional cerebral oxygen saturation (rSO₂) levels to estimate brain perfusion. The present study aimed to evaluate the change in rSO₂ induced by deliberate hypotension during FESS, and assess the impact of deliberate hypotension on the surgical process.

Material and Methods: A randomized controlled trial was registered with the Chinese clinical trial registry (ChiCTR2000039846). A total of 40 patients were enrolled and randomly divided into the control and intervention groups, and finally, 39 patients were analyzed. Deliberate hypotension was induced in the intervention group using nicardipine and esmolol, whereas the control group received general anesthesia without deliberate hypotension. We recorded mean arterial pressure (MAP), saturation of pulse oximetry (SpO₂), rSO₂, and heart rate (HR) before induction of anesthesia (T0), immediately after induction of anesthesia (T1), at the beginning of the operation (corresponding with the establishment of deliberate hypotension) (T2), 10 min (T3) and 20 min (T4) after the operation began, at the end of the operation (corresponding with the end of deliberate hypotension) (T5), and 5 min (T6) and 15 min (T7) after the operation. The partial pressure of end-tidal carbon dioxide (PetCO₂) was recorded at T1, T2, T3, T4, T5, and T6. The duration of surgery, intraoperative blood loss, tracheal extubation time, and the number of patients that experienced cerebral desaturation events (CDEs) were recorded. The surgical field was estimated postoperation based on the Fromme score.

Results: A 30% decrease from the baseline MAP resulted in a decrease of intraoperative bleeding, improvement in the quality of the surgical field, and the shortening of the duration of surgery during FESS in the intervention group compared with the control group. In addition, rSO₂ was reduced and no CDEs were experienced in the intervention group. Linear regression analysis demonstrated a correlation between the decline in rSO₂ and that in MAP.

Conclusions: A decrease in MAP to a certain level will cause a decrease of rSO₂ in patients undergoing FESS under general anesthesia. Based on our findings, we recommend that the deliberate hypotensive target indicated by MAP be reduced by 30%, while PetCO₂ is maintained at 35–40 mmHg and HR is maintained at about 60 beats per minute during FESS.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.