Adequacy of Anesthesia and Pupillometry for Endoscopic Sinus Surgery.

Michał Jan Stasiowski,Anna Missir,Przemysław Jałowiecki,Izabela Szumera,Piotr Wardas,Ewa Niewiadomska,Lech Krawczyk,Beniamin Oskar Grabarek,Seweryn Król,Aleksandra Pluta,Jakub Żak

doi:10.3390/jcm10204683

Abstract

Inadequate intraoperative analgesia causes the deterioration of the condition of the surgical field (CSF) as a result of hemodynamic instability. Analgesia monitors are used to guide remifentanil) infusion to optimize intraoperative analgesia. The main aim of the current randomized controlled trial was to investigate the potential advantages of intraoperative analgesia monitoring using surgical Pleth index (SPI)- or pupillometry (PRD)-guided remifentanil administration for managing the volume of total intraoperative blood loss (TEIBL), CSF, and length of operation (LOP) in comparison with the standard practice in patients undergoing endoscopic sinus surgery (ESS). The 89 patients in our study were grouped as follows: 30 patients were assigned to the general analgesia (GA) group, 31 patients were assigned to the SPI group, and 28 patients were assigned to the PRD group. The speed of remifentanil infusion was accelerated by 50% when SPI, PRD, or BSS were increased by >15 points, >5%, or >2, respectively, in adjacent groups until their normalization. The SPI group showed significantly lower TEIBL in comparison to the GA group (165.2 ± 100.2 vs. 283.3 ± 193.5 mL; p < 0.05) and a higher mean arterial pressure (MAP; 73.9 ± 8 vs. 69.2 ± 6.8 mmHg; p < 0.05). In the PRD group, a shorter LOP compared with the GA group was observed (63.1 ± 26.7 min vs. 82.6 ± 33.1 min; p < 0.05). It was noted that the PRD group had a lower total remifentanil consumption than the SPI group (1.3 ± 1.4 vs. 1.8 ± 0.9 mg; p < 0.05). In ASA I-III patients undergoing ESS, intraoperative monitoring based on state entropy and SPI values can optimize the CSF and reduce TEIBL, whereas monitoring based on state entropy and PRD measurements can optimize the cost effectiveness of anesthetic drugs and the use of the operation room.

Highlights

Endoscopic sinus surgery (ESS) is currently the surgical treatment of choice for sinonasal disease, and its outcome is dependent on the intraoperative condition of the surgical field (CSF) [1]
The appropriate adjustment of intraoperative remifentanil infusion constitutes a major challenge in response to the observed fluctuations of the abovementioned hemodynamic parameters accompanied by anesthesiological intuition, since insufficient intraoperative analgesia may not necessarily be reflected in tachycardia and hypertension as anesthetics tend to blunt the hemodynamic response to nociceptive stimulation [17]
pupillary dilatation reflex (PRD) groups were patientwhile withdrew participation included in the study, excluded from final the following reasons: presence an excluded irregular while three, two,the and fiveanalysis patients for allocated to the GA, surgical pleth index (SPI), andthe groupsof were heart rhythm in one patient, the necessity of the administration from the final impairing analysis for themonitoring following reasons: the presence of an irregular heart rhythm impairing

Summary

Introduction

Endoscopic sinus surgery (ESS) is currently the surgical treatment of choice for sinonasal disease, and its outcome is dependent on the intraoperative condition of the surgical field (CSF) [1]. A wide variety of maneuvers have been proposed to decrease the potential risk of harming the surrounding structures by reducing the amount of total intraoperative blood loss (TEIBL) during ESS performed under general anesthesia. Surgical maneuvers in the operation field provoke painful afferent stimulation (nociceptive effect), which can induce the release of stress hormones in the absence of sufficient intraoperative analgesia; trigger heart rate and arterial blood pressure increments, resulting in potentially excessive TEIBL; and lead to the administration of recall of awareness tests (ROA attenuates this activity (anti-nociceptive effect)). The appropriate adjustment of intraoperative remifentanil infusion constitutes a major challenge in response to the observed fluctuations of the abovementioned hemodynamic parameters accompanied by anesthesiological intuition, since insufficient intraoperative analgesia may not necessarily be reflected in tachycardia and hypertension as anesthetics tend to blunt the hemodynamic response to nociceptive stimulation [17]

Methods

Results

Conclusion