Surgical Field Bleeding Research Articles

”The efficacy of oral versus intravenous tranexamic acid in functional endoscopic sinus surgery”. A prospective, randomized, controlled trial

ABSTRACT Background Functional endoscopic sinus surgery (FESS) is a common procedure for the treatment of chronic sinusitis and minimal bleeding inside the narrow surgical field affects the surgical visualization, prolongs operative time, and increases ocular and intracranial injuries. Our study aims to evaluate and compare the effectiveness of oral versus intravenous Tranexamic acid on surgical field bleeding in endoscopic sinus surgery. Methods A prospective, randomized, controlled trial enrolled 159 participants (ASA I-II, both sex and age 18–40 years) undergoing FESS who were equally randomized into 3 groups. Group O received 2 gm of TXA orally 2 hours before surgery, Group I received 15 mg/kg of IV TXA slowly after induction of anesthesia, and Group C didn’t receive any. Intraoperative surgical field bleeding was assessed by the Wormald grading scale and Surgeon satisfaction on a 5-point Likert scale. At 24 hours post-operatively, the incidence of nasal bleeding, PONV, and D-dimer level were recorded. Results Showed significantly higher surgical field score, duration of surgery, recovery time, and postoperative (24 hours) D-dimer in group-C (p-value <0.001) with no difference between groups-I and O, while surgeon satisfaction was significantly lower in group-C (p-value <0.001) with no difference between groups-I and O. No differences regarding hemodynamic parameters, postoperative bleeding, pain, and PONV were found. Conclusions Oral TXA was safe, cheap, and as effective as IV TXA regarding surgical field visualization, surgeon satisfaction, and operative time during FESS; with limited adverse effects and no evidence of thromboembolic complications.

Hypotensive Anaesthesia during Spine Surgery – A Comparison between Dexmedetomidine and Magnesium Sulphate

A good visualization of the surgical field can be achieved by controlled hypotension with various hypotensive agents. Both dexmedetomidine and Magnesium Sulphate (MgSO4) has powerful analgesic effect and can induce hypotension during surgery. This study is aimed to compare the efficacy of Dexmedetomidine with Magnesium Sulphate in controlled hypotension during spine surgery. This randomized, prospective study was carried out in anesthesiology department of Combined Military Hospital, Dhaka for six-months of period following ethical approval. Total 60 patients, scheduled for spine surgery under GA were included in this study and randomly divided into Group D (Dexmedetomidine, n=30) and Group M (Magnesium sulfate, n=30). Informed written consent was taken from each subject. In every 15 mins, heart rate, systolic &amp; diastolic blood pressure, mean arterial pressure (MAP) are assessed and the surgical field was assessed by the Boezaart surgical field bleeding score. Data were collected in separated case-record form and analyzed by the SPSS 24. Demographic characteristics were similar across the two groups in terms of age, sex, BMI, ASA grading, pre-operative systolic and diastolic blood pressure (p&gt;0.05). Group D had higher mean duration of controlled hypotension (102.50±33.44 vs 85.33±20.25 minutes, p=0.02) and lower mean time to achieve target MAP (34.50±22.68 vs 46.00±10.37 minutes, p=0.016) than Group M. MAP was significantly lower for Group D patients than the Group M patients with time (p&lt;0.05). Boezaart surgical field bleeding score was also significantly lower in Group D compared to Group M (p&lt;0.05). In this study Dexmedetomidine is found more effective than Magnesium Sulphate in achieving controlled hypotension during spine surgery. Better haemodynamic stability is also found in Group D in comparison to Group M. CBMJ 2023 July: vol. 12 no. 02 P: 171-182

Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial

ObjectivesRhinoplasty is one of the most common cosmetic surgeries in the world. Lack of adequate local homeostasis may lead to excessive bleeding during the operation, which increases the time of operation and recovery period, and the prevalence of complications. This study investigated the effects of nasal desmopressin on the quality of the surgical field and the volume of bleeding during rhinoplasty. Materials and methodsThis double-blind randomized clinical trial was performed on 120 patients aged 18–40 years who were candidates for rhinoplasty. Patients were randomly divided into three groups: low-dose desmopressin group and high-dose desmopressin group and placebo group. Hemodynamic changes and surgical field based on BOEZAART criteria, and the volume of bleeding were calculated. ResultsIn this study 115 women (95.8%) and 5 men (4.2%) participated. The mean age of patients was (27 ± 6.8). Bleeding volume in high dose desmopressin group was (21.7 cc ± 12.3), (27.7 cc ± 12.3) in low dose group, and (38.3 cc ± 12.3) in the placebo group, The difference in blood volume among the three groups was statistically significant with p < 0.005. Clean surgical field according to BOEZAART classification was marginally significant in both desmopressin groups. The differences in blood pressure, heart rate, blood and urine sodium, and hemoglobin before and after surgery between groups there not statistically significant. ConclusionBased on the results of the present study topical nasal spray desmopressin can reduce surgical field bleeding during rhinoplasty. To generalize the results to other surgeries in the ENT field it is recommended to conduct studies.

Libération du canal carpien sous WALANT chez les patients hémodialysés avec shunt artério-veineux

IntroductionLong-term hemodialysis patients experience many hand diseases caused by dialysis-related amyloidosis (DRA), with carpal tunnel syndrome (CTS) being the most common. For the patients with arteriovenous (AV) shunt, surgical decompression remains challenging because of the contraindications of a tourniquet. A technique called wide-awake local anesthesia with no tourniquet (WALANT), in which epinephrine provides hemostasis instead of the tourniquet, can be a good option for hemodialysis patients. The purpose of this study was to assess the prevalence of CTS and related factors in hemodialysis patients and to establish the efficacy and safety of WALANT on hemodialysis patients with AV shunt. Materials and methodsThis prospective study included 275 hemodialysis patients between March 2013 and July 2019. Forty-three patients were diagnosed with CTS, involving surgical treatment on 70 wrists. We performed mini-open carpal tunnel release using WALANT on the AV shunt arm (defined as the WALANT group), while using lidocaine and a tourniquet on the arm without an AV shunt (defined as the tourniquet group). The operative time, surgical field bleeding (blood loss and hemostasis score), surgical pain (injection pain and tourniquet pain), outcomes, complications, and satisfaction were compared between the two groups. ResultsThe incidence of CTS in hemodialysis patients was 15.6%. Longer dialysis durations were related to higher proportions of patients with CTS. There was no significant difference in blood loss (p=0.184) and hemostasis score (p=0.165) between the two groups. Clinical symptoms improved in all patients and there were no severe complications. The WALANT group had a significantly longer preparation time of approximately 20minutes, but they had low injection pain and no tourniquet pain. There was also no significant difference in terms of satisfaction levels (p=0.212). DiscussionCTS is a very common disease among hemodialysis patients. WALANT provided sufficient hemostasis without a tourniquet, despite the patients’ high bleeding tendency. The technique also had the advantages of low injection pain, no tourniquet pain, and no major complications. In this respect, WALANT can be a good choice for hemodialysis patients with AV shunt. Level of evidenceII.

Tranexamic acid for the reduction of bleeding during functional endoscopic sinus surgery.

Tranexamic acid for the reduction of bleeding during functional endoscopic sinus surgery.

Evaluation of sub-brow approach to the frontozygomatic suture for Open Reduction and Internal Fixation (ORIF) of Zygomatico maxillary complex (ZMC) fractures: A prospective cohort study.

Contemporary incisions used to access the frontozygomatic (FZ) sutures are the lateral brow and upper blepharoplasty incisions which are associated with specific limitations and complications. The authors describe the use of sub-brow incision as an alternate approach for exposure of the FZ region. This is a prospective cohort study involving patients requiring surgical management of zygomatico maxillary complex (ZMC) fractures with fixation at FZ suture alone or along with fixation at infra-orbital rim and/or zygomaticomaxillary buttress. A sub-brow incision was used to expose the fracture and fixation was done with a 4-hole miniplate. The parameters evaluated were specific to the FZ region (sub-brow incision), namely surgical access, bleeding, fracture exposure time, post-operative scar, and pain. Each patient was reviewed on 1st, 5th, 7th, 10th, 30th, and 90th day. The study sample included eight male patients. The mean age was 30 years. The sub-brow incision demonstrated favorable postoperative outcomes; adequate exposure was achieved in all 8 patients. The scar formation was found to be higher on the 7th day and the least scar formation was seen by the third month. The mean pain score was found to be high on first post-operative day and the least pain was seen by the 10th day. The mean score of surgical field bleeding was found to be 1.75 which signified mild bleeding according to Fromme's scale. The mean time taken for adequate exposure of the fracture was 6.62 min. All the assessment parameters were statistically significant (P value <0.01). Sub-brow incision is an effective approach for ORIF of zygomatic fractures at FZ suture. The technique is quick, simple, and associated with minimal complications.

Efficacy of pterygopalatine fossa injection with local anesthetic agent and adrenaline in reduction of intra-operative bleeding during endoscopic sinus surgery

BackgroundThis study aimed to assess the effect of pterygopalatine fossa injection via greater palatine canal with xylocaine and adrenaline on intra-operative surgical field bleeding and overall blood loss during FESS.MethodsWe are doing this randomized blinded study on 60 patients who underwent FESS. Infiltration with 2 ml of xylocaine 2% with 1:100,000 adrenaline was slowly injected on one side and the surgeon was asked to assess the surgical field using a Boezaart scale.ResultsOperative time is significantly less in injected cases than the other cases with a P value < 0.001. blood loss in injected side was significantly less than Non-injected side with a P value < 0.001.ConclusionThere was a significant decrease in blood loss, duration of surgery, and improvement in visual field using Boezaart score in injection group (cases) who underwent pterygopalatine fossa injection of xylocaine/adrenaline compared to the other non-injected group.

Carpal tunnel release under wide awake local anesthesia with no tourniquet in hemodialysis patients with arteriovenous shunt

IntroductionLong-term hemodialysis patients experience many hand diseases caused by dialysis-related amyloidosis (DRA), with carpal tunnel syndrome (CTS) being the most common. For the patients with arteriovenous (AV) shunt, surgical decompression remains challenging because of the contraindications of a tourniquet. A technique called wide-awake local anesthesia with no tourniquet (WALANT), in which epinephrine provides hemostasis instead of the tourniquet, can be a good option for hemodialysis patients. The purpose of this study was to assess the prevalence of CTS and related factors in hemodialysis patients, and to establish the efficacy and safety of WALANT on hemodialysis patients with AV shunt. Materials and methodsThis prospective study included 275 hemodialysis patients between March 2013 and July 2019. 43 patients were diagnosed with CTS, involving surgical treatment on 70 wrists. We performed mini-open carpal tunnel release using WALANT on the AV shunt arm (defined as the WALANT group), while using lidocaine and a tourniquet on the arm without an AV shunt (defined as the tourniquet group). The operative time, surgical field bleeding (blood loss and hemostasis score), surgical pain (injection pain and tourniquet pain), outcomes, complications, and satisfaction were compared between the two groups. ResultsThe incidence of CTS in hemodialysis patients was 15.6%. Longer dialysis durations were related to higher proportions of patients with CTS. There was no significant difference in blood loss (p=0.184) and hemostasis score (p=0.165) between the two groups. Clinical symptoms improved in all patients, and there were no severe complications. The WALANT group had a significantly longer preparation time of approximately 20minutes, but they had low injection pain and no tourniquet pain. There was also no significant difference in terms of satisfaction levels (p=0.212). DiscussionCTS is a very common disease among hemodialysis patients. WALANT provided sufficient hemostasis without a tourniquet, despite the patients’ high bleeding tendency. The technique also had the advantages of low injection pain, no tourniquet pain, and no major complications. In this respect, WALANT can be a good choice for hemodialysis patients with AV shunt. Level of evidenceII.

Immediate Higher-Dose Prothrombin Complex Concentrate Without Fresh Frozen Plasma or Fibrinogen Concentrate for Significant Coagulopathic Cardiac Surgical Field Bleeding

Treatment of significant coagulopathic cardiac surgical field bleeding with immediate higher-dose prothrombin complex concentrate (PCC) without fresh frozen plasma (FFP) or fibrinogen concentrate is unexplored. To study characteristics, chest drainage, and clinical outcomes of patients with significant coagulopathic surgical field bleeding treated with immediate higher-dose (defined at >15 IU/kg based on factor IX) PCC without FFP or fibrinogen concentrate. We screened sequential cardiac surgery patients. We reviewed electronic blood bank data, Australian Society of Cardiothoracic Surgery database information and anaesthetic, intensive care unit (ICU), ward and radiological charts and electronic data. We identified patients deemed by the operating surgeon to require treatment for significant coagulopathic surgical field bleeding who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. Among 168 patients, we identified 30 who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. Median age was 68 years, 23 were male, 17 underwent coronary artery bypass surgery and three underwent complex surgery (David procedure, redo mitral valve surgery, and redo thoraco-abdominal aneurysm repair). Median dose of PCC was 2,500 IU. In addition, 27% underwent platelets and one underwent cryoprecipitate. Chest drainage at 24 hours was 505 ml. Survival to hospital discharge was 100%. There were no cases of pulmonary embolism, stroke, or other thrombotic events. Stage 1 AKI occurred in one patient. In a pilot cohort of patients with significant coagulopathic surgical field bleeding, immediate higher-dose PCC without FFP or fibrinogen concentrate was feasible and had an acceptable efficacy and safety profile, which justifies future controlled studies.

Effect of low molecular weight heparin on bleeding after radical gastrectomy: A retrospective study from a high-volume center in China

BackgroundAlthough low molecular weight heparin (LMWH) is recommended to prevent venous thromboembolism (VTE) in patients with gastric cancer, it's difficult for surgeons to choose appropriate time to start anti-coagulation because of the risk of surgical field bleeding after radical gastrectomy. We compared the risk of VTE and bleeding between patients receiving LMWH within and beyond 48 ​h after surgery. MethodsThe medical records of consecutive cases receiving radical gastrectomy from November 1st, 2017 to October 31st, 2018 in Zhongshan Hospital Gastric Cancer Center were carefully reviewed. Patients receiving LMWH within and beyond 48 ​h after surgery were regarded as Early Group (EG) and Delayed Group (DG), respectively. Incidence of VTE and bleeding complications were compared and risk factors of bleeding were evaluated. ResultsSix hundred and sixty-five cases were enrolled, including 465 in EG and 200 in DG. No significant differences of clinicopathological or operative features were observed except for fewer combined resection (DG: 5.0%, EG: 1.9%, P ​= ​0.030) and shorter surgery duration (DG: 194min, EG: 168min, P ​< ​0.001). No patients suffered from deep venous thrombosis or pulmonary embolism in our study. However, postoperative bleeding rate was higher in EG (DG: 1.5%, EG: 7.5%, P ​= ​0.002). Multivariate analysis suggested that EG was the independent risk factor of bleeding (OR: 3.744, 1.13–12.36, P ​= ​0.030). ConclusionUse of LMWH 48 ​h after radical gastrectomy maybe a good choice for clinical surgeons to reduce postoperative bleeding rate without increasing VTE risk in gastric cancer patients.

Er:YAG laser brainsurgerywithvascularspecificcoagulation.

Erbium:yttrium-aluminum-garnet (Er:YAG) laser ablation can effectively resect water-bearing tissues. Application of Er:YAG resection in neurosurgery is complicated by unpredictable bleeding in surgical field. Recently, an integrated theranostic system combining a dual-wavelength laser surgery system using a thulium (Tm) fiber-laser for coagulation and Er:YAG for resection, combined with optical coherence tomography (OCT) guidance was demonstrated for the in vivo resection of tumor tissue. However, lateral thermal spread in the range of 100s of micrometers is common due to lack of vascular specificity using a Tm fiber-laser for coagulation. In this study, a vascular specific ytterbium (Yb) fiber-laser is utilized for enhanced photocoagulation during in vivo neurosurgery improving the precision of Er:YAG tissue resection with minimal lateral thermal spread. Mice underwent stereotactic laser surgery with the proposed Yb/Er:YAG dual wavelength vascular specific neurosurgery in vivo. AnOCTsystem (wavelength range 1310 ± 70 nm) and OCT derived angiography images were used to record cortical images to confirm the coagulation of blood vessels and guide subsequent Er:YAG resection steps. After the laser surgery, mice were killed, and histological analysis was carried out using hematoxylin and eosin staining and Nissl staining to compare the lateral thermal spread with our previously reported Tm/Er:YAG neurosurgery where a continuous wave Tm fiber-laser was used for coagulation. Coagulation scheme using a Yb fiber-laser allowed stoppage of blood flow in disparately sized blood vessels encountered in the mice brain. Histological analysis of murine brain slices post Yb/Er:YAG laser surgery yielded lower thermal spread compared withTm/Er:YAG laser surgery, maximizing the efficiency in both hemostasis (blood flow stoppage) and maximizing tissue ablation efficiency with minimal residual thermal damage zone. In this study, a vascular specific coagulation scheme with Yb/Er:YAG dual-wavelength surgery is presented for neurosurgery. Additionally, Yb/Er:YAG study results are compared with that of a tissue coagulation approach in Tm/Er:YAG surgery previously reported to highlight improved coagulation, reduced nonspecific thermal damage and limited lateral thermal spread. Experimental results suggest that the developed dual-wavelength laser system can effectively resect neural tissues with high localization, minimal lateral thermal spread at the micrometer level while maintaining a bloodless surgical field.

The Effect of the Method of Airway Management During Endoscopic Sinus Surgery Procedures on the Intraoperative Bleeding

The objective: to conduct a comparative assessment of the severity of intraoperative bleeding with different methods of airway management (using a laryngeal mask and endotracheal tube) during endoscopic rhinosinussurgical procedures.Subjects and Methods. A prospective randomized cohort single-center study of 160 cases of endoscopic rhinosinussurgical procedures under general anesthesia was conducted.Tracheal intubation (TI) was used in 79 cases (Group 1), a laryngeal mask (LM) – in 81 (Group 2). The evaluation criteria in the groups included the bleeding intensity (BI) by 6-point scale of average categories (Fromme-Boezaart Score), indicators characterizing the state of blood circulation during surgery: HR, BPsys., BPdiast., MAP, and perfusion index.Results. Significantly lower BI values were observed in Group 2 at all time points of the study (at the 10th, 30th and 60th minute of surgery). This was due both to using a laryngeal mask, and to lower HR, BPsys., BPdiast, and MAP.Conclusion. The use of a laryngeal mask for airway management during general anesthesia in endoscopic rhinosinussurgical procedures helps to reduce the intensity of surgical field bleeding.

Comparison of surgical field bleeding during endoscopic sinus surgery between GTN-Esmolol and Remifentanil as hypotensive anesthesia techniques: Randomized control trial single center institution

Comparison of surgical field bleeding during endoscopic sinus surgery between GTN-Esmolol and Remifentanil as hypotensive anesthesia techniques: Randomized control trial single center institution

The effect of low central venous pressure on hepatic surgical field bleeding and serum lactate in patients undergoing partial hepatectomy: a prospective randomized controlled trial

BackgroundThis prospective randomized controlled study was designed to evaluate the effect of fluid restriction alone versus fluid restriction + low central venous pressure (CVP) on hepatic surgical field bleeding, intraoperative blood loss, and the serum lactate concentration in patients undergoing partial hepatectomy.MethodsOne hundred forty patients undergoing partial hepatectomy with intraoperative portal triad clamping were randomized into a fluid restriction group (Group F) or fluid restriction + low CVP group (Group L). Both groups received limited fluid infusion before the liver lesions were removed. Ephedrine was administered if the systolic blood pressure (SBP) decreased to <90 mmHg for 1 min. When the urine output was <20 ml/h or the SBP was <90 mmHg for 1 min more than three times, an additional 200 ml of crystalline solution was quickly infused within 10 min. In addition to fluid restriction, patients in Group L received continuous nitroglycerin and esmolol infusion to maintain a low CVP. The duration of portal triad clamping, frequency of additional fluid infusion, frequency of ephedrine administration, intraoperative blood loss, extent of liver resection, and bleeding score of the hepatic surgical field were recorded. Arterial blood gas analysis was performed before anesthesia (T1), after liver dissection and immediately before liver resection (T2), 10 min after removal of the liver lesion (T3), and before the patient was discharged from the postanesthesia care unit (T4).ResultsBeing in the fluid restriction Group (Group F) (odds ratio = 5.04) and cirrhosis (odds ratio = 3.28) were risk factors for hepatic surgical field bleeding. Factors contributing to intraoperative blood loss were the operation time, duration of portal triad clamping, and extent of resection. No significant between-group difference was observed for blood loss or blood transfusion. The serum lactate concentration peaked at T3 in both groups.ConclusionsMaintaining a lower CVP during hepatectomy provides an optimal surgical field but has no significant effect on intraoperative blood loss. Moreover, lower CVP does not increase the serum lactate concentration.Trial registration“A comparative study of the effect fluid restriction and low CVP pressure on the oozing of blood in liver wounds and blood lactate in patients undergoing partial hepatectomy” was prospectively registered as a trial (registration number: ChiCTR-INR-17014172, date of registration: 27 December 2017).

Randomized Controlled Trial of Intravenous Dexmedetomidine for Control of Hemodynamics, Surgical Bleeding, and Recovery Profile during Transsphenoidal Pituitary Surgery

Abstract Background Microscopic transsphenoidal excision of pituitary gland, though considered safe from neurosurgical point of view, produces marked cardiovascular and stress responses despite adequate depth of anesthesia. The aim of this study was to evaluate the effect of dexmedetomidine bolus and infusion in microscopic transsphenoidal pituitary surgery on hemodynamics, bleeding in surgical field, and recovery parameters. Materials and Methods A prospective randomized double-blind study was conducted in 40 American Society of Anesthesiologists (ASA) I-II patients between 18 and 65 years, who underwent elective transsphenoidal excision of pituitary tumor. Two groups were constituted: one group received dexmedetomidine 1 μg/kg loading dose followed by 0.5 μg/kg/h infusion, the other received placebo bolus and infusion. A standard anesthesia protocol including isoflurane and fentanyl was used in both groups. The hemodynamic profile, intraoperative bleeding, and recovery profile were studied. Results The heart rate (HR) did not vary significantly from the baseline during surgery and recovery in the dexmedetomidine group. The systolic, diastolic, and mean blood pressures decreased significantly with dexmedetomidine in statistical terms, though they were within the clinically acceptable range and did not require intervention. On comparing the groups, dexmedetomidine group had better perioperative blood pressure profile and decreased isoflurane requirement. Bleeding scores during surgery and recovery were similar in both groups. Conclusions Intraoperative use of dexmedetomidine in transsphenoidal pituitary surgery provided stable perioperative hemodynamics comprising reduced cardiovascular response to intubation and surgical noxious stimuli along with a similar recovery compared with the control group. Therefore, dexmedetomidine appears as a useful adjunct to control hemodynamics in neurosurgical patients undergoing transsphenoidal surgery.

The efficacy of esmolol, remifentanil and nitroglycerin in controlled hypotension for functional endoscopic sinus surgery

IntroductionControlled hypotension is a reversible procedure in which the patient’s baseline mean arterial blood pressure is reduced by 30% and sustained at 60–70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures. ObjectivesThe purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency. MethodsThe research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon’s satisfaction. ResultsBetween May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15–51), 43.0 mL (21–105) and 40.0 mL (26–97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon’s satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001). ConclusionLess volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients’ characteristics and advantages/disadvantages of the drugs.

Comparison of Operating Conditions, Postoperative Pain and Recovery, and Overall Satisfaction of Surgeons with Deep vs. No Neuromuscular Blockade for Spinal Surgery under General Anesthesia: A Prospective Randomized Controlled Trial.

We aimed to investigate operating conditions, postoperative pain, and overall satisfaction of surgeons using deep neuromuscular blockade (NMB) vs. no NMB in patients undergoing lumbar spinal surgery under general anesthesia. Eighty-three patients undergoing lumbar fusion were randomly assigned to receive deep NMB (n = 43) or no NMB (n = 40). In the deep-NMB group, rocuronium was administered to maintain deep NMB (train-of-four count 0, post-tetanic count 1–2) until the end of surgery. In the no-NMB group, sugammadex 4 mg/kg at train-of-four (TOF) count 0–1 or sugammadex 2 mg/kg at TOF count ≥2 was administered to reverse the NMB 10 min after placing the patient prone. Peak inspiratory airway pressure, plateau airway pressure, lumbar retractor pressure significantly were lower in the deep-NMB group. Degree of surgical field bleeding (0–5), muscle tone (1–3), and satisfaction (1–10) rated by the surgeon were all superior in the deep-NMB group. Pain scores, rescue fentanyl consumption in post-anesthesia care unit (PACU), and postoperative patient-controlled analgesia consumption were significantly lower in the deep-NMB group, and this group had a shorter length of stay in PACU. Compared to no NMB, deep NMB provides better operating conditions, reduced postoperative pain and higher overall satisfaction in lumbar spinal surgery.

Is Pterygopalatine Fossa Injection with Adrenaline an Effective Technique for Better Surgical Field in Fess?

Functional endoscopic sinus surgery (FESS) is one of most common surgeries in otorhinolaryngology practice. It is done in the narrow confines of the nasal cavity. Bleeding into the surgical field is a major problem faced by endoscopic surgeons. To assess the effectiveness of pterygopalatine fossa infiltration with lignocaine and adrenaline in controlling surgical field bleeding during endoscopic sinus surgery. A randomized blinded study was done among 68 patients who underwent FESS. Infiltration with 2% lignocaine with 1:80,000 adrenaline was given only on one side and the surgeon was blinded as to which side was infiltrated and he was asked to assess the surgical field using a standard scale. There was statistical significant improvement in surgical field on the infiltrated side (p=0.001) with almost 25-30% improvement in surgical field on the infiltrated side. The surgical field bleeding also varied with the blood pressure with a positive correlation. There were no complications associated with the procedure. Pterygopalatine fossa infiltration with lignocaine and adrenaline is an effective technique in reducing surgical field bleeding during FESS. It can be combined with nasal decongestion or hypotensive anaesthesia for an optimum surgical field.

Arnica Montana and Blood Loss, Surgical Field Bleeding and Operative Time in Endoscopic Sinus Surgery: A Randomized-Controlled Trial

OBJECTIVE: To determine the association of Arnica montana and blood loss, surgical field bleeding and operative time in endoscopic sinus surgery among adults with chronic rhinosinusitis with nasal polyposis.&#x0D; METHODS:&#x0D; STUDY DESIGN: Single-blinded Randomized Controlled Trial&#x0D; SETTING: Tertiary government hospital&#x0D; PARTICIPANTS: Forty-one (41) adults aged 19-76 years old with chronic rhinosinusitis with nasal polyposis and meeting inclusion criteria were randomly divided into two groups, Arnica and control. The former took 5 sublingual Boiron® Arnica montana 30C pellets, 12 hours then 1 hour prior to surgery; the latter did not. Both groups had routine oxymetazoline and lidocaine-epinephrine decongestion. Intraoperative blood loss, surgical field bleeding quality and operative time were assessed by blinded surgeons and anesthesiologists.&#x0D; RESULTS: Mean estimated blood loss was 187ml (SD 100.14) for controls versus 72ml (SD 12.59) for the Arnica group; (p &lt; 0.05). Mean operative time was 3.55 hours (SD 1.25) for controls and 3.44 hours (SD 1.57) for the Arnica group; (p=0.9). Surgical field bleeding was graded slight with 75% needing occasional suctioning (grade 2) and 25% needing frequent suctioning (grade 3) in the Arnica group, versus moderate bleeding with more frequent suctioning (grade 4) in 71% and slight bleeding but needing frequent suctioning (grade 3) in 29% of controls.&#x0D; CONCLUSION: In this randomized clinical trial, Arnica montana was associated with less blood loss and less surgical field bleeding compared to controls, but there was no difference in mean operative times. Arnica montana may be effective in reducing blood loss and improving surgical field quality during endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis.&#x0D; KEYWORDS: Arnica montana, hemostasis, surgical

Generation of efficacy data to support routine clinical practice: use of clonidine as adjunctive to anesthesia to reduce surgical field bleeding in endoscopic naso-sinusal Surgery

Generation of efficacy data to support routine clinical practice: use of clonidine as adjunctive to anesthesia to reduce surgical field bleeding in endoscopic naso-sinusal Surgery