Quality Of Surgical Field Research Articles

The Effect of Topical Tranexamic Acid on Bleeding Reduction during Functional Endoscopic Sinus Surgery.

Bleeding is a common concern during functional endoscopic sinus surgery (FESS) that can increase the risk of damage to adjacent vital elements by reducing the surgeon's field of view. This study aimed to explore the efficacy of topical tranexamic acid in reducing intraoperative bleeding. This double-blind, randomized clinical trial was conducted in 60 patients with chronic rhinosinusitis with polyposis (CRSwP) who underwent FESS. Patients were randomly divided into two groups; tranexamic or saline treatment. During surgery, normal saline (400 mL) or tranexamic acid (2 g) in normal saline with a total volume of 400 mL were used in the saline and tranexamic groups, respectively, for irrigation and suctioning. The surgeons' assessment of field of view during surgery and intraoperative blood loss were recorded. Mean blood loss was 254.13 mL in the saline group and 235.6 mL in the tranexamic group (P=0.31). No statistically significant differences between the two groups were found in terms of other investigated variables, such as surgical field quality based on Boezzart's scale (P=0.30), surgeon satisfaction based on a Likert scale (P=0.54), or duration of surgery (P=0.22). Use of tranexamic acid (2 g in 400 mL normal saline) through washing of the nasal mucosa during FESS did not significantly reduce blood loss or improve the surgical field of view. Further studies with larger sample sizes and higher drug concentrations, and using other methods of administration, such as spraying or applying pledgets soaked in tranexamic acid, are recommended.

Dexmedetomidine versus Magnesium Sulfate in Anesthesia for Cochlear Implantation Surgery in Pediatric Patients.

Context:Cochlear implantation surgery represents a great advance in ENT surgeries. Special anesthetic managements were required to provide bloodless surgical field and monitoring of the facial nerve.Aims:We aimed to compare both dexmedetomidine and magnesium sulfate as regards their efficacy in inducing deliberate hypotension and providing better quality of the surgical field during cochlear implantation in pediatrics.Settings and Design:Prospective, randomized double-blinded study.Subjects and Methods:Forty-six pediatric patients aging 1.5–2.5 years of either sex with American Society of Anesthesiologists physical status classes I and II were randomized into dexmedetomidine (D) group (n = 23) and magnesium sulfate (M) group (n = 23). In the D group, after induction of anesthesia but before the surgery, a bolus dose of 0.4 μg/kg slowly infused over 10 min, then continuous infusion by a rate of 0.4 μg/kg/h until the end of surgery. In M group, after induction of anesthesia but before the surgery, magnesium sulfate 10% (50 mg/kg) was given slowly, then continuous infusion by a rate of 10 mg/kg/h during the whole surgery. Intraoperative hemodynamics, quality of surgical field, fentanyl consumption, blood loss, operative time, FLACC pain scores, and adverse effects were compared in both groups.Statistical Analysis Used:Data were presented as mean ± standard deviation, ranges, numbers, and percentages as appropriate. Comparison of demographic data and time of surgery was done by Student's t-test. Two-way analysis of variance with correction for repeated measurements was used for heart rate and blood pressure comparison. Mann–Whitney U-test was used for nonparametric measurements.Results:Surgical field score and blood loss were better in D group than M group. Fentanyl consumption was less in D group than M group. Heart rate and mean atrial blood pressure were lower in D group except in the initial times than M group.Conclusions:In our study, both drugs were effective in achieving hypotensive anesthesia in pediatrics; however, dexmedetomidine proved to have superior effect on the surgical field and blood loss compared to magnesium sulfate with no intra- and post-operative complications for cochlear implantation surgery.

A Study to Compare the Quality of Surgical Field Using Total Intravenous Anesthesia (with Propofol) versus Inhalational Anesthesia (with Isoflurane) for Functional Endoscopic Sinus Surgeries.

Background and Objectives:Functional endoscopic sinus surgery (FESS) being a delicate technique, intraoperative bleeding is one of the major challenges. Even a little bleeding can adversely affect the surgeon's ability to visualize the region to be operated. General anesthesia is preferred over topical anesthesia in FESS. This study was conducted to compare the surgical field using total intravenous anesthesia (TIVA) with propofol and inhalational anesthesia with isoflurane for FESS. Secondary outcomes such as intraoperative blood loss and the incidence of perioperative complications were also recorded.Subjects and Methods:A total of sixty patients in the age group of 16–60 years with physical status American Society of Anesthesiologists Classes I and II, undergoing FESS were randomly divided into two groups of thirty each after taking informed consent and approval from the Hospital Ethics Committee. Thirty patients in Group I: received isoflurane-based inhalational anesthesia and other Thirty patients in Group II: were administered TIVA with propofol. Various parameters were recorded and statistically analyzed.Results:There was improved quality of surgical field at the end of surgery in the Group II as compared to Group I. Total blood loss during surgery and incidence of intraoperative complications were less in Group II as compared to Group I.Conclusion:This study concludes that in FESS, using TIVA with propofol decreases blood loss and the incidence of complications during surgery in addition to providing good quality of surgical field.

Hypotensive anesthesia for the correction of scoliosis under total intravenous anesthesia: comparison between dexmedetomidine and magnesium sulfate

Context This study was designed to compare dexmedetomidine with magnesium sulfate as an adjunctive to total intravenous anesthesia (TIVA) as regards the efficacy and safety as hypotensive agents in scoliosis correction surgery. Patients and methods This prospective randomized double-blinded study included 40 patients of American Society of Anesthesiology II who were scheduled for the correction of scoliosis under TIVA and divided into two groups of 20 patients each. The first group was the Dex group, which was administered dexmedetomidine infusion at a rate of 0.5 μg/kg/h, and the second group was the Mg group, which was administered magnesium sulfate infusion at a rate of 15 mg/kg/h. The target mean arterial pressure (MAP) was 60–70 mmHg. The two groups were compared as regards MAP, heart rate (HR), intraoperative blood loss, blood transfusion, quality of surgical field, need for vasodilators and analgesics, time to extubation, time to recover the hypotension, time to recover the full conscious level, and perioperative serum levels of calcium and magnesium. Results Both groups could achieve the target MAP before skin incision. The Dex group showed more HR stability, less intraoperative blood loss, and less intraoperative blood transfusion with better surgical field quality. Moreover, the need for vasodilators was lesser in this group. However, the Mg group showed faster extubation time, faster reversibility of hypotension, and faster recovery of full conscious level. Need for intraoperative analgesia was comparable between the two groups. Intraoperative and postoperative serum magnesium were higher in the Mg group and intraoperative and postoperative serum calcium levels showed gradual drop in the Mg group compared with the Dex group and the preoperative level in the Mg group. Both electrolytes showed recovery to normal preoperative level 24 h postoperatively without interference. Conclusion TIVA with both dexmedetomidine and magnesium sulfate could achieve the target MAP for hypotensive anesthesia. Dexmedetomidine can control MAP with lesser need for vasodilators and with better control of HR. It provided lesser blood loss and better quality of surgical field. Magnesium sulfate showed faster extubation and recovery of conscious level with faster reversibility of hypotensive state but with the risk for perioperative hypocalcemia.

The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial.

To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P≤0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0-4.0) days. Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. I.

Anesthetic techniques and haemodynamic control for Endoscopic Sinus Surgery: A retrospective analysis and review of literature

IntroductionBleeding from mucosal edges is known to decrease surgical visibility and increase the risk of complications in Endoscopic sinus surgery (ESS). A variety of strategies, including modifying anesthetic techniques have been proposed to create a bloodless field. A recent survey in anesthesiologist revealed that a vast majority neither use controlled hypotension nor believe that modifying the anesthetic techniques will improve the outcome of ESS. This study investigates the different anesthetic techniques used for ESS and their effect on the haemodynamic variables achieved intra-operatively.MethodsData were retrospectively collected from an electronic anesthesia database on 233 consecutive adult patients who underwent endoscopic sinus surgery in a tertiary hospital in Singapore from January 2014 to August 2015 and statistical analysis was performed using SPSS.ResultsInhaled anesthetics (IA) were used for 93% (49% with morphine or fentanyl, 42% with remifentanil) and total intravenous anesthesia (TIVA) for 7% of the cases respectively. The airway was secured with endotracheal tube in 94.6% and the rest were having LMA. Average Mean Arterial Pressure (MAP) lower than 70 mmHg was achieved in 74.4%. Antihypertensive drugs were used only in 5 cases (2.3%). Distribution of intra operative MAP and Heart rate (HR) were similar among different anesthetic techniques. Lowest MAP and HR achieved were significantly lower in IA with remifentanil use.ConclusionInhaled anesthesia is the preferred maintenance technique used for ESS. The desired MAP range was achieved in about 75% of the cases without needing anti hypertensives. Use of remifentanil reduces the MAP and HR further which might potentially improve the quality of surgical field and the outcome.

Role of corticosteroids in Functional Endoscopic Sinus Surgery - a systematic review and meta-analysis

The aim of our study is to systematically review the existing evidence on the role of corticosteroids in patients undergoing functional endoscopic sinus surgery (FESS). Systematic search of MEDLINE (1950- 2014), EMBASE (1980-2014), metaRegister, Cochrane Library and ISI conference proceedings was carried out. Eighteen randomised controlled trials with 1309 patients were included. Use of local and/or systemic corticosteroids with FESS was reported in four categories; operative, anaesthesia related, post-operative outcomes and risk of recurrence. Meta-analysis for operative outcomes demonstrated that, mean operative time (MD -10.70 minutes; 95% CI -15.86, -5.55; P <0.0001) and mean estimated blood loss (MD -28.32 mls; 95% CI -40.93, -15.72; P <0.0001) was significantly lower; and surgical field quality (MD -0.81; 95% CI -1.32, -0.30; P = 0.002) was significantly better in corticosteroid group. Meta-analysis showed that post-operative endoscopic scores (SMD -0.39; 95% CI -0.60, -0.17; P = 0.0004) were significantly better in corticosteroid group compared to no corticosteroid group. There was no increase in risk of sinusitis (RR 0.64; 95% CI 0.32, 1.30; P = 0.22) between use of corticosteroids and no corticosteroids; There was no significant difference in recurrence risk of chronic rhinosinusitis (CRS) in mixed population studies (RR 0.77; 95% CI 0.35, 1.70; P = 0.52) between the two groups but analysis of studies reporting on chronic rhinosinusitis with nasal polyps (CRSwNP) (RR 0.64;95% CI 0.45,0.91;P=0.01) showed significant difference in favour of the corticosteroid group. Pre-operative use of local and/or systemic corticosteroids in FESS, results in significantly reduced blood loss, shorter operative time and improved surgical field quality. Studies are limited on the intra-operative use of corticosteroids to reduce postoperative pain. Postoperative corticosteroids improve postoperative endoscopic scores in CRS and recurrence rates in cases of CRSwNP.

Deliberate hypotension with propofol under anaesthesia for functional endoscopic sinus surgery (FESS).

Functional endoscopic sinus surgery (FESS) is a minimally invasive technique that is used to treat chronic sinusitis. Small bleeding areas can reduce operative visibility and result in destruction of surrounding structures. Deliberate hypotension (lowering the mean arterial blood pressure to between 50 and 65 mm Hg in normotensive patients) using a range of pharmacological agents during general anaesthesia reduces blood loss in many operations. This review was originally published in 2013 and updated in February 2016. We aimed to compare the use of propofol versus other techniques for achieving deliberate intraoperative hypotension during FESS procedures with regard to blood loss and operative conditions. We searched the following databases in the updated review: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (1950 to February 2016), Embase (1980 to February 2016), LILACS (1982 to February 2016), and ISI Web of Science (1946 to February 2016). We also searched the reference lists of relevant articles and conference proceedings and contacted the authors of included trials. We sought all randomized controlled trials comparing propofol with other techniques for deliberate hypotension during FESS with regard to blood loss and operative conditions in both adults and children. Our primary outcome was total blood loss (TBL). Other outcomes included surgical field quality, operation time, mortality within 24 hours, complications, and failure to reach target blood pressure. We used standard methodological procedures expected by Cochrane. Two review authors independently extracted details of trial methodology and outcome data from the reports of all trials considered eligible for inclusion. We made all analyses on an intention-to-treat basis where possible. When I2 was less than 40% and the P value from the Chi2 test was higher than 0.10, we pooled data using the fixed-effect model. Otherwise, we pooled data using the random-effects model. We found no new studies. This updated review therefore includes four studies with 278 participants. Most analyses were based on data from few participants and low-quality evidence, so our results should be interpreted with caution. Deliberate hypotension with propofol did not decrease TBL (millilitres) when compared with inhalation anaesthetics in either children (1 study; 70 participants; very low-quality evidence), or adults (1 study; 88 participants; moderate-quality evidence). Propofol improved the quality of the surgical field by less than one category on a scale from 0 (no bleeding) to 5 (severe bleeding) (mean difference -0.64, 95% CI -0.91 to -0.37; 4 studies; 277 participants; low-quality evidence), but no difference in operation time was reported (3 studies; 214 participants; low-quality evidence). Failure to lower blood pressure to target was less common in the propofol group (risk ratio of failure with propofol 0.24, 95% CI 0.09 to 0.66; 1 study; 88 participants; moderate-quality evidence). Using propofol to achieve deliberate hypotension probably improves the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and the operation time. However, due to the very low quality of the evidence, this conclusion is not definitive. Randomized controlled trials with good-quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.

Preoperative clonidine use in trans-sphenoidal pituitary adenoma surgeries – a randomized controlled trial

Background: Pituitary masses are common lesions accounting for about 15–20% of all brain tumours. Oozing blood is an annoyance in microscopic sublabial trans-sphenoidal approach for these masses. There have been many ways of reducing the ooze, having their own pros and cons.Objective: To find out the efficacy and safety of clonidine in reducing blood loss in pituitary adenoma surgery through a randomized masked trial.Methods: It was a prospective randomized controlled trial done. Total 50 patients of pituitary adenomas were randomized into two groups. Group A (25 patients) was given 200 μg clonidine orally, while Group B (25 patients) was given placebo. Surgeon, anaesthesiologist and patient were blinded for the trial. Sublabial trans-septal trans-sphenoidal approach to sella and excision of mass was performed in each patient. Patients were studied for pre-, intra- and post-operative blood pressure and heart rate, pre- and post-operative imaging findings, intra-operative blood loss, bleeding grading by surgeon, surgeon’s satisfaction about condition of specific part and quality of surgical field, operative time and extent of resection.Results: Blood loss during the surgery, operative time and bleeding grading by the surgeon were found significantly less in the clonidine group, while quality of surgical field, condition of the specific part and extent of resection were found significantly better in the clonidine group (p value <.05). There was no untoward adverse effect of the drug in the test group.Conclusion: Clonidine is a safe and effective drug to reduce bleeding in trans-sphenoidal microscopic pituitary adenoma surgeries.

Optimizing surgical field during cochlear implant surgery in children: Dexmedetomidine versus Esmolol

BackgroundThe field of cochlear implantation has been expanding rapidly and it has been hailed as one of the greatest advances in otology. The technique of anesthesia plays a crucial role in success of cochlear implant surgery as the anesthesiologist has to produce conditions which facilitate surgery by inducing bloodless operative field.Study objectiveTo determine the efficacy of dexmedetomidine versus esmolol usage as an adjunct to induce controlled hypotension in children undergoing cochlear implant surgery.DesignClinical trial study.SettingOperating room in a university hospital.Patients70 children aged 2–4 years scheduled for cochlear implant surgery under general anesthesia. Patients were randomly allocated according to drugs used into two equal groups (35 patients in each group). Interventions: Group (D): The patients in this group received a bolus dose of dexmedetomidine 0.5 ug/kg over 10 min followed by continuous infusion 0.2–0.5 ug/kg/h after induction of anesthesia but before surgery. Group (E): The patients in this group received a bolus dose of esmolol 0.5 mg/kg over 10 min followed by continuous infusion 100–300 ug/kg/min after induction of anesthesia but before surgery.MeasurementsHeart rate, Mean Arterial blood Pressure, Quality of surgical field, operative time, adverse events.Main resultsThe quality of surgical field was comparable between both groups in all times of measurements. The time to first analgesic request was statistically significant longer in group (D) than in group (E) and the total tramadol consumption was statistically significant less in group (D) than in group (E).ConclusionsIn our study both dexmedetomidine and esmolol were effective in reducing MABP, and lowering the heart rate providing dry surgical field and ensured good surgical condition during cochlear implant surgery in pediatric patients.

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

Magnesium sulfate or diltiazem as adjuvants to total intravenous anesthesia to reduce blood loss in functional endoscopic sinus surgery

Study objectiveThis study was designed to know whether addition of magnesium sulfate (MgSO4) or diltiazem to total intravenous anesthesia (TIVA) (propofol) aided reduction in blood loss during functional endoscopic sinus surgery (FESS). The secondary outcomes measured were surgeon's assessment of the surgical field and hemodynamics. DesignRandomized, double-blinded, placebo-controlled trial. SettingOperating room. PatientsForty-five American Society of Anesthesiologists I and II adult patients (18-60years) undergoing FESS. InterventionsAll groups received propofol-fentanyl TIVA. Patients were randomly allocated to 1 of the 3 groups (MgSO4 group, n=15; diltiazem group, n=15; saline group, n=15). MeasurementsIntraoperative bleeding was quantified, and quality of surgical field was graded. Hemodynamic parameters were recorded. Main resultsAddition of both MgSO4 and diltiazem significantly reduced blood loss (240 and 350mL) in comparison to control group (415mL) (P=.003). The surgical field was significantly better in the MgSO4 group compared with the diltiazem (P=.028) and saline groups (P=.0001). ConclusionIt was concluded that the addition of both MgSO4 and diltiazem to TIVA propofol results in significant reduction in blood loss and significant improvement in the quality of surgical field during FESS without causing any adverse effects on the hemodynamics or on the recovery from anesthesia. The surgical field in the MgSO4 group was significantly better than that in the diltiazem group (P=.04).

The efficacy of intravenous clonidine premedication to reduce surgical area bleeding in posterior lumbar spine fusion surgery

Background: A posterior lumbar spine fusion surgery always associated with significant amount of blood loss and requires blood transfusion. The purpose of this study is to evaluate the efficacy of intravenous clonidine premedication to achieve bloodless surgical field and decrease the need for blood transfusion by controlled hypotension. Methods: Sixty patients scheduled for posterior lumbar fusion surgery were included in this randomized placebo controlled trail. Patients were classified into two groups: Group 1 received intravenous clonidine 3 µg/kg by infusion over 15 minutes before surgery and Group 2 received placebo as same. Hemodynamic variables, quality of surgical field by bleeding severity score, estimated amount of blood loss, duration of surgery and any blood transfusion were analyzed. Results: Heart rate and mean arterial pressure found less in clonidine group than placebo but not significant. The estimated blood loss (390.8±99.99 mL vs 741.13±79.90 mL; P = 0.001*) and duration of surgery (160.67±16.91 vs 205.9±16.72 min, P=0.001*) were significantly less in clonidine group compared to placebo. The quality of surgical field was better in clonidine group than placebo at all times. No cases of severe bradycardia or clinically significant hypotension were observed in clonidine group. Conclusion: Premedication with intravenous clonidine 3 µg/kg found clinically safe & effective drug in controlling blood loss and improves quality of surgical field in posterior lumbar fusion surgeries as a sole agent.

Role of corticosteroids in Functional Endoscopic Sinus Surgery--a systematic review and meta-analysis.

The aim of our study is to systematically review the existing evidence on the role of corticosteroids in patients undergoing functional endoscopic sinus surgery (FESS). Systematic search of MEDLINE (1950- 2014), EMBASE (1980-2014), metaRegister, Cochrane Library and ISI conference proceedings was carried out. Eighteen randomised controlled trials with 1309 patients were included. Use of local and/or systemic corticosteroids with FESS was reported in four categories; operative, anaesthesia related, post-operative outcomes and risk of recurrence. Meta-analysis for operative outcomes demonstrated that, mean operative time (MD -10.70 minutes; 95% CI -15.86, -5.55; P <0.0001) and mean estimated blood loss (MD -28.32 mls; 95% CI -40.93, -15.72; P <0.0001) was significantly lower; and surgical field quality (MD -0.81; 95% CI -1.32, -0.30; P = 0.002) was significantly better in corticosteroid group. Meta-analysis showed that post-operative endoscopic scores (SMD -0.39; 95% CI -0.60, -0.17; P = 0.0004) were significantly better in corticosteroid group compared to no corticosteroid group. There was no increase in risk of sinusitis (RR 0.64; 95% CI 0.32, 1.30; P = 0.22) between use of corticosteroids and no corticosteroids; There was no significant difference in recurrence risk of chronic rhinosinusitis (CRS) in mixed population studies (RR 0.77; 95% CI 0.35, 1.70; P = 0.52) between the two groups but analysis of studies reporting on chronic rhinosinusitis with nasal polyps (CRSwNP) (RR 0.64;95% CI 0.45,0.91;P=0.01) showed significant difference in favour of the corticosteroid group. Pre-operative use of local and/or systemic corticosteroids in FESS, results in significantly reduced blood loss, shorter operative time and improved surgical field quality. Studies are limited on the intra-operative use of corticosteroids to reduce postoperative pain. Postoperative corticosteroids improve postoperative endoscopic scores in CRS and recurrence rates in cases of CRSwNP.

Deliberate hypotensive anesthesia during maxillofacial surgery: A comparative study between dexmedetomidine and sodium nitroprusside

Background The aim of the present study was to evaluate the anesthetic properties such as the onset of required hypotension, the quality of the surgical field, the percentage of inhaled anesthesia, intraoperative consumption of fentanyl, time to recovery, and adverse events of dexmedetomidine (DEX) as a hypotensive agent in comparison with sodium nitroprusside (SNP) in maxillofacial surgery. Patients and methods A total of 70 ASA I or II patients, aged 20-60 years, scheduled for maxillofacial surgery were randomly assigned to receive either DEX 1 mg/kg before induction of anesthesia for over 10 min followed by 0.2-0.5 mg/kg/h infusion during maintenance (DEX group; n = 35 patients) or SNP 0.25 mg/kg/min infusion after induction of anesthesia (SNP group; n = 35 patients) to maintain mean arterial blood pressure (MAP) between 50 and 65 mmHg. Hemodynamic variables and end-tidal isoflurane concentration were recorded, quality of surgical field was assessed by the same surgeon who was blinded of the selected hypotensive agent, and intraoperative fentanyl consumption and recovery time were recorded. Results Heart rate was significantly lower ( P Conclusion We concluded that DEX is an effective and safe agent with anesthetic benefits for controlled hypotension, and that compared with SNP DEX offers the advantage of better quality of the surgical field and decreased anesthetic and fentanyl requirements intraoperatively. However, DEX was associated with significantly longer time to reach the target MAP and delayed recovery from anesthesia compared with SNP.

Controlled Hypotensive Anesthesia in Children Undergoing Nasal Surgery

Background: The nasal surgery in pediatric patient’s caries a major challenge to both anesthesiologist and surgeon. The surgeon faces small nostrils and narrow nasal passages. The anesthesiologist has to produce condition which facilitate the surgery, decrease the operative time by minimize the intraoperative bleeding to allow better visualization this can be achieved by controlled hypotensive anesthesia which is the key issue in the success of nasal surgery in pediatric age group. Patient and methods: Seventy pediatric patients aged 8-12 years scheduled for elective nasal surgery under general anesthesia. Patients were classified into two equal groups (35 patients per group) according to study drugs used. Group (D): The patients in this group received dexmedetomidine 0.5 μg/kg as loading dose over 10 minutes followed by 0.2-0.5 μg/kg/h as maintenance infusion after induction of anesthesia but before surgery. Group (E): The patients in this group received esmolol 0.5 mg/kg as loading dose over 10 minutes followed by 100-300 μg/kg/min as maintenance infusion after induction of anesthesia but before surgery. Measurements: Heart rate, Mean Arterial blood Pressure, Quality of surgical field, duration of surgery, duration of anesthesia, Aspartate aminotransferase (AST), alanine aminotransferase (ALT), blood urea, serum creatinine, adverse events and postoperative analgesia. Results: There were no significant differences between groups as regards to demographic data, duration of surgery, and duration of anesthesia. The MABP and HR were significantly decreased after infusion of study drugs till the end of surgery with no differences between both groups in all times of measurements. The quality of surgical field was comparable between both groups in all times of measurements. There were no changes in blood urea, serum creatinine, AST, and ALT. Conclusion: Our study demonstrated that both dexmedetomidine and esmolol are safe and effective agents for inducing controlled hypotension in pediatric patients undergoing nasal surgery with no reported complications.

Comparison of quality of the surgical field after controlled hypotension using esmolol and magnesium sulfate during endoscopic sinus surgery.

Background and Aims:Most vital aspect of Endoscopic Sinus Surgery (ESS) is an optimal visibility in the surgical field. This invariably requires controlled hypotension to facilitate surgical dissection and to decrease operative time. We used esmolol and magnesium sulfate to achieve controlled hypotension and assessed the quality of the surgical field in ESS.Material and Methods:A total of 30 patients undergoing ESS, were enrolled in three parallel groups of 10 patients each in a prospective randomized double-blind study. “Magnesium Sulfate group” received magnesium sulfate 40 mg/kg intravenously (i.v.) as a bolus over 10 min before induction of anesthesia, followed by 15-30 mg/kg/h through infusion. “Esmolol group” received 0.5 mg/kg i.v. bolus over 10 min after induction followed by 150-300 μg/kg/min infusion and “control group” received normal saline in same volume schedule. The primary aim was to assess the quality of surgical field, using Fromme scale. Category Scale values of all the three groups were compared using Kruskal-Wallis analysis of variance (ANOVA) test. Hemodynamic data was compared using ANOVA test.Results:Quality of the surgical field was better in both magnesium sulfate and esmolol groups as compared to the control group. Durations of anesthesia and surgery were significantly lower in esmolol group as compared to the control group. Blood loss was comparable in all the three groups.Conclusion:Quality of the surgical field was better in esmolol and magnesium sulfate groups as compared to control group. Duration of surgery was significantly less in esmolol group as compared to other two groups.

Comparison of dexmedetomidine with nitroglycerinefor hypotensive anaesthesia in functional endoscopic sinus surgery

Aim: The aim of the study is to compare Dexmedetomidine with Nitroglycerine for hypotensive anaesthesia for Functional Endoscopic Sinus Surgeries (FESS) with respect to quality of the surgical field, hemodynamics, amount of blood loss, intraoperative opioid requirement, time to first analgesic request and recovery profile. Methods: After approval by institutional Ethics Committee, 60 patients were randomly allocated by sealed envelope technique into two drug groups: Nitroglycerine (Group N) and Dexmedetomidine (Group D). After induction of anesthesia, Nitroglycerine infusion at 0.5-10 µg/kg/min was started for patients in group N and Dexmedetomidine was given as loading dose of 1 µg/kg over 10 min followed by maintenance infusion rate of 0.2- 0.7 µg/kg/hr for patients in group D. The infusion rates were then titrated to maintain MAP between 50-60 mm of Hg or 30% reduction of baseline MAP, whichever is higher. Parameters observed include heart rate, mean arterial pressure, blood loss (Average Category Scale), emergence time, time to first rescue analgesic and post-operative recovery (Modified Alderete Score). Results: In our study, statistically significant reduction in heart rate (58/min vs 69/min) was observed in patients in group D, while Systolic, diastolic and mean arterial pressure were comparable. The quality of surgical field as assessed by ACS was better in group D (p

A comparative study of propofol and isoflurane for the maintenance of anesthesia in spine surgery using the bispectral index monitor: a randomized control study

Background Early awakening is required in spine surgery to perform neurological examination in the early postoperative period. Bispectral index (BIS) monitoring allows reduction in the total amount of anesthetic drugs and decreases the time for emergence and recovery. Thus, BIS monitor helps in reducing the incidence of awareness. Kinetics of propofol allows both induction and continuous intravenous maintenance of anesthesia with rapid recovery of consciousness that aids in performing neurological examination in the early postoperative period. This study was conducted to compare propofol and isoflurane in the maintenance of anesthesia during spine surgery using the BIS monitor. Patients and methods A total of 50 patients (American Society of Anesthesiologists grades I and II) scheduled for spine surgeries were divided into two groups (25 each). Group A received an infusion of propofol 5 mg/kg/h and group B received isoflurane 1% vol. for maintenance to keep the BIS value between 40 and 60. The groups were compared as regards pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure, surgeons’ satisfaction, time to recovery, extubation time, and side effects. Results Both groups were well matched for their demographic data and preoperative vital data. There was no significant difference in hemodynamic parameter between the two groups. The mean recovery time was significantly different (P 0.05). Incidence of postoperative nausea and vomiting was 35% lower in group A compared with group B. The quality of surgical field was acceptable in both groups but slightly better in the propofol group. No other major complications were noted in our study. Conclusion Propofol-based anesthesia provides early and better recovery with clear headedness for early neurological assessment for spine surgery.

Oral nifedipine as a premedication for induced hypotension in functional endoscopic sinus surgery (FESS)

ObjectiveTo evaluate the effects of oral nifedipine as pretreatment, quality of surgical field and amount of hypotensive agent during functional endoscopic sinus surgery (FESS) under general anesthesia.MethodsSixty patients ASA I or II scheduled for FESS were randomly allocated into two equal groups. Oral nifedipine 20 mg was given one hour before induction of anesthesia (nifedipine) group and placebo. In the other group (control), all the patients received standard anesthesia and monitoring. Nitroglycerin (GTN) was administrated in a dose of 2 μg/kg/min after induction of anesthesia till it achieved a target mean arterial blood pressure (MAP) of 50–60 mmHg, followed by a continuous i.v. infusion (1 μg/kg/min) intraoperative when needed. Hemodynamic variables were recorded at baseline preoperatively, intraoperatively and till the end of operation. The surgical field score was assessed by average category scale (ACS) and intraoperative blood loss and amount of GTN was estimated. Emergence time and total recovery from anesthesia (Aldrete score ⩾9) were recorded.ResultsThere were no statistically significant differences between two groups with respect to the amount of blood loss and scores for a bloodless surgical field. Emergence time and time needed to achieve 9 of modified Aldrete score were significantly shorter in Control group than nifedipine group (4.46 ± 1.25 min and 7.46 ± 2 min versus 8 ± 1.62 min and 9.5 ± 2.41 min, respectively) (P < 0.01). MAP during hypotensive period showed no statistically significant difference (p > 0.05) but at 5 and 10 min after stoppage of hypotensive anesthesia, at the end of surgery and after recovery, MAP was significantly lower in nifedipine group than Control group (p < 0.01). Heart rate (HR) during hypotensive period showed no statistically significant difference (p > 0.05). At 5 and 10 min after stoppage of hypotensive anesthesia, at end of surgery and after recovery, HR was significantly lower in nifedipine group than Control group (p < 0.001). The amount of GTN used in nifedipine group was significantly lower than Control group (p < 0.001).ConclusionAdministration of a single preoperative dose of nifedipine (20 mg) can significantly reduce the blood loss during FESS and improves the visualization of the operative field and it also lowers the amount of GTN needed to achieve target hypotension.