The Efficacy of Hypotensive Agents on Intraoperative Bleeding and Recovery Following General Anesthesia for Nasal Surgery: A Network Meta-Analysis

OBJECTIVES

A systematic review of the literature was conducted to evaluate hypotensive agents in terms of their adverse effects and associations with perioperative morbidity in patients undergoing nasal surgery.

METHODS

Two authors independently searched databases (Medline, Scopus, and Cochrane databases) up to February 2020 for randomized controlled trials comparing the perioperative administration of a hypotensive agent with a placebo or other agent. The outcomes of interest for this analysis were intraoperative morbidity, operative time, intraoperative bleeding, hypotension, postoperative nausea/vomiting, and postoperative pain. Both a standard pairwise meta-analysis and network meta-analysis were conducted.

RESULTS

Our analysis was based on 37 trials. Treatment networks consisting of six interventions (placebo, clonidine, dexmedetomidine, beta-blockers, opioids, and nitroglycerine) were defined for the network meta-analysis. Dexmedetomidine resulted in the greatest differences in intraoperative bleeding (-0.971; 95% confidence interval [CI], -1.161 to -0.781), intraoperative fentanyl administration (-3.683; 95% CI, -4.848 to -2.518), and postoperative pain (-2.065; 95% CI, -3.170 to -0.960) compared with placebo. The greatest difference in operative time compared with placebo was achieved with clonidine (-0.699; 95% CI, -0.977 to -0.421). All other agents also had beneficial effects on the measured outcomes. Dexmedetomidine was less likely than other agents to cause adverse effects.

CONCLUSION

This study demonstrated the superiority of the systemic use of dexmedetomidine as a perioperative hypotensive agent compared with the other five tested agents. However, the other agents were also superior to placebo in improving operative time, intraoperative bleeding, and postoperative pain.

Pre-induction fentanyl dose-finding study for controlled hypotension during functional endoscopic sinus surgery

Background and Aims:

Fentanyl can facilitate controlled intraoperative hypotension by its sympatholytic effect in patients undergoing functional endoscopic sinus surgery (FESS). We investigated the effects of different doses of pre-induction fentanyl on controlled hypotension profile during FESS.

Methods:

This prospective, randomised study included 120 patients randomly allocated to three groups (40 each) based on administration of pre-induction fentanyl; 2 μg/kg group, 3 μg/kg group and 4 μg/kg group. The primary objective was to assess effect on intraoperative heart rate and mean arterial pressure. Use of additional hypotensive agents, surgical field condition and surgeon satisfaction were also analysed.

Results:

Controlled hypotension was achieved adequately in all participants. Patients belonging to fentanyl 4 μg/kg group had significantly lower heart rate for the duration of controlled hypotension intraoperatively versus fentanyl 2 μg/kg group (P < 0.05). Trinitroglycerin [TNG] and metoprolol were administered to 3 [7.5%] and 9 [22.5%] patients respectively in the fentanyl 3 μg/kg group, and to 3 [7.5%] and 5 [12.5%] patients respectively in the 4 μg/kg group, compared to 14 [35%] and 20 [50%] in the fentanyl 2 μg/kg group, respectively (TNG, P < 0.001). Surgical field conditions and surgeon satisfaction scores were significantly superior in fentanyl 3 μg/kg and 4 μg/kg groups than in fentanyl 2 μg/kg group.

Conclusion:

Pre-induction fentanyl 3 μg/kg and 4 μg/kg group showed superior controlled hypotension facilitation than 2 μg/kg fentanyl during FESS in terms of measurable haemodynamic endpoints and favourable operative conditions, surgeon's satisfaction and sparing of additional hypotensive agents.

Total intravenous versus inhaled anesthesia in transsphenoidal tumor surgery

PURPOSE

Visualization of the surgical field is essential for patient safety during endoscopic transsphenoidal tumor surgery. In this retrospective chart review and data analysis of patients undergoing endoscopic transsphenoidal resection of pituitary tumors under general anesthesia we sought to determine if total intravenous anesthesia with propofol and remifentanil leads to decreased bleeding, surgical duration, time to extubation and/or length of stay in the recovery room compared to inhaled anesthesia with sevoflurane or desflurane.

METHODS

After IRB approval, chart reviews of 193 American Society of Anesthesiologists class 1 to 3 patients were conducted who had undergone transsphenoidal, endonasal resections of pituitary tumors under total intravenous or inhaled anesthesia at an academic teaching hospital in the United States over a seven-year time period. One hundred four patients fulfilled the inclusion criteria and were further reviewed. Primary outcome was intraoperative blood loss; secondary outcomes were surgical duration, time to extubation and length of stay in the recovery room.

RESULTS

Gender, age, and Lund-Mackay-Scores were equally distributed between the two anesthetic groups. We found no significant effect of the anesthetic technique, age, gender, or Lund Mackay score on any of the primary or secondary outcomes. The only significant predictor for recovery room length of stay was intraoperative blood loss.

CONCLUSION

Our study shows no evidence that total intravenous anesthesia is superior to inhaled anesthesia or vice versa during endoscopic transsphenoidal sinus surgery with regard to relevant clinical outcome parameters.

Anesthesia for functional endoscopic sinus surgery

PURPOSE OF REVIEW

The present article summarizes anesthetic techniques used during functional endoscopic sinus surgery to decrease bleeding and aid in creating a clear surgical field. The applicable physiology behind these anesthetic techniques is reviewed with emphasis on the effect on bleeding and the surgical field. Deliberate hypotension, reverse Trendelenburg positioning, regional anesthesia, and cerebral monitoring are discussed.

RECENT FINDINGS

There are mixed data as to whether traditional inhalation anesthesia or total intravenous anesthesia is superior with respect to better surgical fields and decreased blood loss. A review of the literature tends to favor total intravenous anesthesia. Cerebral oximetry and transcranial Doppler ultrasound are emerging techniques to monitor cerebral perfusion during deliberate hypotension.

SUMMARY

Total intravenous anesthesia using propofol and remifentanil is the current favored technique for producing deliberate hypotension during endoscopic sinus surgery due to its hemodynamic stability and smooth rapid emergence.

Use of α2-Adrenergic Agonists to Improve Surgical Field Visibility in Endoscopy Sinus Surgery: A Systematic Review of Randomised Controlled Trials

PURPOSE

We assessed the evidence for the use of α₂-adrenergic agonists (A2AAs) in bleeding control and field quality in endoscopic sinus surgery.

METHODS

We systematically reviewed randomized clinical trials (RCTs) assessing A2AAs in endoscopic sinus surgery. Abstracts were reviewed by 2 investigators for eligibility, and selected articles were fully reviewed. Data on study design, population, A2AA drug and control groups, bleeding and surgical field quality outcomes, and adverse effects were extracted and synthesized.

FINDINGS

A total of 13 RCTs that included 896 individuals (7 double-blind trials, 5 single-blind trials, and 1 open-label trial) were selected that assessed the efficacy of clonidine (6 RCTs, 407 patients), dexmedetomidine (6 RCT, 423 patients), or both (1 RCT, 66 patients). Clonidine was compared with placebo (3 RCTs), midazolam (1 RCT), and remifentanil (2 RCTs). Dexmedetomidine was compared with esmolol (2 RCTs), remifentanil (2 RCTs), nitroglycerin and esmolol (1 RCT), and magnesium sulfate (1 RCT). Clonidine and dexmedetomidine were compared in 1 RCT. Clonidine reduced the proportion of individuals with an impaired surgical field by 23% vs placebo (number needed to treat = 4). Clonidine was better than midazolam and remifentanil in 2 trials, and dexmedetomidine was better than magnesium sulfate and esmolol in 2 trials but was not superior to esmolol, remifentanil, or nitroglycerin in 4 trials. Dexmedetomidine produced significantly better differences in bleeding outcomes versus clonidine. Adverse events were infrequent and mainly caused by hypotension or bradycardia.

IMPLICATIONS

RCTs consistently report that A2AAs reduce bleeding and improve surgical field quality during endoscopic sinus surgery. Adverse event reporting was often omitted in RCTs. Well-designed RCTs with appropriate sample sizes are desirable to identify the best A2AAs and confirm their potential effects on clinical outcomes.

Clonidine or remifentanil for adequate surgical conditions in patients undergoing endoscopic sinus surgery: a randomized study

Background

Deliberate hypotension is one way to achieve a bloodless surgical field in endoscopic sinus surgery (ESS). We compared two anaesthesia regimens to induce deliberate hypotension and attempted to determine the most efficient one.

Methods

Fifty-nine patients undergoing ESS were minimized into two groups. In the CLO group, patients received I.V. sufentanil 0.15 µg/kg together with I.V. clonidine 2–3 µg/kg. In the REMI group, patients received remifentanil at a rate of up to 1 µg/kg/min. Fromme scores were collected 15 min after the incision and at the end of the procedure. Mean arterial pressure readings (MAP), heart rate readings, time to eyes opening, time to extubation, pain scores, analgesic requirements, and oxygen needs were collected and compared.

Results

There were no significant differences in Fromme scores between the two groups. The averaged MAP from 15 min to the end of the procedure was significantly lower in the REMI group; these patients also received more ephedrine. Significantly fewer patients in the CLO group needed oxygen therapy to keep their Pulse Oximeter Oxygen Saturation within 3% of their preoperative values. Patients in this group also needed less piritramide in the recovery room, and their pain scores were lower at discharge from the recovery room.

Discussion

Although both anaesthesia regimens offered a similar quality of surgical field, this study suggests that clonidine had a better average safety profile. Furthermore, patients who received this regimen required fewer painkillers immediately after surgery.

Preoperative β-blockade and hypertension in the first hour of functional endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (β) adrenoceptor blockade.

STUDY DESIGN

A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital.

METHODS

The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist.

RESULTS

There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative β-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881.

CONCLUSIONS

Preoperative β-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic β-blockade, and caution should be applied to use of epinephrine-containing solutions.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1496-1505, 2017.

Effect of the premedication with oral clonidine on surgical comfort in patients undergoing fess due to advanced nasal polyposis: A randomized double blind clinical trial

OBJECTıVE: The objective of this randomized double blind study was to evaluate effect of the premedication with oral clonidine on blood pressure, cleaning of surgical site and bleeding in the ESS performed due to advanced NP.

METHODS

A total of 52 patients who underwent functional endoscopic sinus surgery (FESS) due to Kennedy grade 4 nasal polyposis (NP) were included. Patients were randomized into two groups. Group 1 (n=26) received 0.2mg oral clonodine one hour before the operation in addition to standard anesthesia procedure. Group 2 (n=26) was administered standard anesthesia procedure alone. The amount of bleeding during surgery, cleaning of surgical site and surgeon's satisfaction were evaluated in comparison between the groups.

RESULTS

The amount of bleeding and mean arterial pressure were significantly lower in the Group 1 compared to the Group 2. The cleaning of surgical site was found to be significantly better and surgeon's satisfaction significantly higher in the Group 1 than in the Group 2. Systolic, diastolic and mean arterial pressures during surgery were significantly lower in the Group 1 compared to the Group 2.

CONCLUSION

Premedication with oral clonidine provides a clearer view of surgical site, reduces the amount of bleeding and significantly increases surgeon's satisfaction during the operation in FESS performed due to NP. Premedication with oral clonidine is a safe, inexpensive and effective methods in order to increase the surgical success and comfort and reduce complications in the FESS surgery.