Does tranexamic acid, deliberate hypotension, and anti-Trendelenburg position improve the quality and outcome for functional endoscopic sinus surgery

Abstract

EnAbstract Objectives To improve the control of bleeding during functional endoscopic sinus surgery (FESS) by means of positional changes, controlled hypotensive anesthesia, and an intraoperative (IO) intravenous injection of tranexamic acid. Patients and methods The study included 45 patients assigned to undergo FESS. Patients were divided randomly into three equal groups: group A received an IO injection of tranexamic acid 10 mg/kg as a bolus injection after induction of anesthesia. Group B included patients placed on a table inclined by ∼30π in the anti-Trendelenburg position and received an IO injection of tranexamic acid 10 mg/kg after induction of anesthesia. Group C included patients maintained supine who did not receive an IO injection of tranexamic acid. All patients received a maintenance anesthetic regimen that used combined intravenous/inhalational anesthesia. Operative field visibility was evaluated using the Fromme scale. The total amount of bleeding as judged by the amount evacuated was recorded. Results The anesthetic maneuver used reduced blood pressure and heart rate significantly at the end of surgery compared with the measures estimated at the time of induction of anesthesia. Groups A and C showed significantly higher blood pressure and heart rate estimated at the end of surgery compared with group B. All surgeries were conducted completely without IO complications. No extensive bleeding was recorded and no patient had a visibility score of 0 or 5. Four patients had a visibility score of 1, nine patients had a visibility score of 2, 15 patients had a visibility score of 3, and 17 patients had a visibility score of 4. The frequency of patients who had higher field visibility was significantly higher in group B compared with groups A and C, with a significantly higher frequency in group A compared with group C. Manipulations applied for group B significantly reduced the amount of IO bleeding, with a subsequent significant improvement in the mean field visibility score compared with groups A and C. Tranexamic acid significantly reduced the amount of bleeding and improved field visibility in group A compared with group C. Conclusion A combination of maintaining patients in the anti-Trendelenburg position, anesthetic manipulation using combined intravenous and inhalational anesthesia, and an IO intravenous injection of tranexamic acid could minimize bleeding and improve field visibility during FESS and this combination of manipulations could be recommended as strategy for this type of surgery.