ANESTHETIC MANIPULATIONS TO MINIMIZE BLEEDING AND … Elsaeid...chronic pediatric sinusitis, the...
Transcript of ANESTHETIC MANIPULATIONS TO MINIMIZE BLEEDING AND … Elsaeid...chronic pediatric sinusitis, the...
Benha' M. J. ^^
Vol. 26 No 2 May 2009
ANESTHETIC MANIPULATIONS TOMINIMIZE BLEEDING AND IMPROVE OUTCOMEOF FUNCTIONAL ENDOSCOPIC SINUS SURGERY
Ahmed El-Emshati MD & Ahmed Al-Arfaj MD*Departments of Anesthesia & Otorhinoktryngofopi/*, Faculty of Medicine,
Benha & King Saud Universities*, Egypt
AbstractObjectives: The present study was designed as a trial to improve field
visibility during functional endoscopic sinus surgery (FESS) by means ofpositional changes and the use of controlled hypotension achievedthrough maintenance of anesthesia using remifentanH and either ofpro-pofol infusion (Total Intravenous: TI) or isqflurane inhalation (CombinedIntravenous/Ihhalational; C1I).
Patients & Methods: The study included 32 patients; 23 males and9 females, with mean age of 39.28.4 years and assigned to undergo
FESS. Patients were divided randomly into two equal groups accordingmaintenance anesthetic regimen Group TI and Group CH. Each group
was subdivided according to patients' position during surgery into supineand anti-Trendelenburg by 30. Anesthesia was maintained in bothgroups by infusion of 0.5 pg/kg/min of remifentanil in addition to 10 pg/kg/min propofol infusion in Group TI or isoflurane 2% in Group CII. Patients were monitored non-invasively; before induction of anesthesia (TO)and 20 (T20), 40 (T40) and 60 min (T60) after induction of anesthesia, formean arterial pressure (MAP) and heart rate (HR). The approachfor FESSwas conducted totally endonasal The visibility of the operative field during FESS was evaluated using &points Fromme scale and total amountof bleeding as fudged by the amount evacuated was also recorded.
Results: Both anesthetic modalities reduced blood pressure significantly and decreased heart rate throughout times of observation compared to preoperative levels with significantly lower MAP measures inanti-Trendelenburg compared to supine position. All surgeries were con
ducted completely without intraoperative complications and no extensivebleeding was recorded. There was a significant increase in the frequency
83
84
Chronic sinusitis not respond
ing to medical treatment and nasal polyposis are two main classi
cal indications for performing
endoscopic sinus surgery. With
FESS, the advantage of good illumination and clear vision with
minimally invasive surgery, it is
possible to achieve consistently
good results, provided the surgeryis done accurately and with care,
(Bradley & Kountakis, 2005).
Huang et al., (2006) reported that
after endoscopic sinus surgery forchronic pediatric sinusitis, the an-
tral mucosa recovered and muco-
Introduction
Functional endoscopic sinus
surgery is a useful and wide
spread technique that allows the
treatment of a large number of na
sal pathologies aiming at main
taining physiological function andanatomical structure. The extent
of the operation is adapted according to each case. It is focused on
the ostiomeatal complex in the
middle meatus and the ethmoid
cells. FESS enables re
establishing sinus drainage andmucosal recovery, (Eisenberg et
al., 2008).
ofgoodjield visibility with TI compared to CII anesthesia with significantly improved field, visibility in patients maintained in anti-Trendelenburgposition compared to supine position. Estimated mean blood loss was sig
nificantly less and the recorded field visibility scores were significantlyhigher in TI group compared to CH group. There was a negative significant correlation between the field visibility score and mean MAP andmean amount of bleeding. Using regression analysis, the use of hypoten-
sive anesthesia was found to be a significant independent factor for improving filed visibility, and the use ofTl anesthesia was found to be significant determinant independent factor for induction of hypotensiveanesthesia. The receiver operating characteristic (ROC) carve analysisjudged by the area under the curve (AUC) defined the superiority of use ofTI over CII anesthesia as independent determinant for field visibility.
Conclusion: It could be concluded that maintaining patients in anti-Trendelenburg position and anesthetic manipulation using total intrave
nous anesthesia could minimize bleeding and improve field visibility during FESS and thus this combination of manipulations could be appropriate strategy for such type of surgery.
Ahmed El-Emshati & Ahmed Al-Arfaj
85
bleeding is an important task for
an anesthetist during a FESS. Inthe case of the expanded process,
still more numerous interventions
are performed with general anes
thesia, (Cincikas & Ivaskevicius,
2003).
To improve the control of bleeding during FESS, induced hypotension was tried. The state of "hy
potension" . was achieved by
reducing the peripheral blood vessel resistance, reducing the heart
rate per minute and by inter-
coordinating these two effects, (Ja-
cobi et al., 2000). Most frequentlyperipheral vasodilators, beta-
blockers, volatile anesthetics are
used to cause induced hypotension, (Praveen et al., 2001).
The present study was de
signed as a trial to improve thecontrol of bleeding during FESSby means of positional changes
and the use of controlled hypoten
sion achieved through maintenance of anesthesia using remi-
fentanil and either of propofolinfusion (Total Intravenous) or iso-
flurane inhalation (Combined In-travenous/Inhalational).•
Vol. 26 No 2 May 2009
ciliary clearance improved for bothtypes of antral mucosa, with im
proved ventilation and drainage.
Moretz & Kountakis. (2006) reported a significant decrease ofthe mean overall headache and
sino-nasal outcomes test scores
from 28.7 preoperatively to 6.7
postoperatively.
Intraoperative bleeding, which
reduces visibility in the operativefield, is one of the major problemsof such interventions, (Eberhart et
al., 2003). Complicated anatomicstructure, its unique variations,
vicinity of delicate cranial base,
brain, eyes, blood vessels and
nerves requires for the surgeon to
know anatomy in detail and to
precisely identify structures, thus
abundant bleeding during surger
ies undoubtedly is among the factors able to cause complications.
Upon reduced visibility the time ofintervention extends. Increased
bleeding sometimes causes finish
ing surgeries before the due time,
when targets raised at the begin
ning are given up in order to avoid
possible complications, (Zeng etal., 2003). Improvement of intra
operative visibility while reducing
Benha M. J.
86
duced by a bolus of remifentanil
(1 pg//kg), propofol (2 mg/kg) androcuronium (0.5 mg/kg). Two minutes later, trachea was intubated
and a posterior pharyngeal packwas placed to limit the risk of aspiration of blood and lungs wereventilated with 100% oxygen. Ven-
tilatory parameters were adjusted
so as to maintain end-tidal CO2around 32 mmHg. Anesthesia was
maintained in both groups by infusion of 0.5 gg/kg/min of remifentanil in addition to 10pg/kg/
min propofol infusion in Group TI
group or isoflurane 2% in GroupCII. Propofol infusion rate and
MAC of isoflurane were adapted
according to hemodynamic responses, in order to maintain MAP
values in the range of 60-70mmHg.
Immediately after tracheal intu
bation, all patients underwent
packing of the nasal cavity withadrenaline soaked pledgets
(1:100,000) to obtain maximumvasoconstriction of the mucosa
and thus better visuali^ation of
the main features of the cavity.
Prior to insertion in the cavity, liq
uid is removed from the pledgets
and then, under endoscopic guidance, carefully applied on the mu-
Patients and MethodsThis prospective comparative
study was conducted at Day-
Surgery Unit, Al-Habib MedicalGroup, Riyadh, KSA and included
32 patients; aged 21-53 years andassigned to undergo FESS. Afterobtaining patients' fully informed
written consents, they were divid
ed randomly into two equal main
groups (n=16) according maintenance anesthetic regimen used ei
ther total intravenous (Group TI),or combined Intravenous/Inhala-
tional (Group CII). Each main
group was further subdividedequally according to patient's posi
tion during surgery either supine
or inclined by approximately 30in anti-Trendelenburg. Patients
with the cardiovascular pathology,heart failure, hypertension, as
well as patients with bleeding di
athesis and those administering
aspirin or other medications affecting coagulation system and
patients with kidney or liver dysfunctions, as well as anemia
(Hb<10g/dl) were excluded off thestudy.
All patients were pre-medicatedwith midazolam (0.05 mg/kg), 2min thereafter, anesthesia was in
Ahmed El-Emshati & Ahmed Al-Arfaj
87
nate process was removed by
cutting around the site of attachment with a sickle knife or shaver
starting adjacent to the anterior
attachment of the middle turbinate. Shaver and ethmoid forceps
were used to remove nasal polyps
and to open the ethmoid air cell;then any retained secretions were
suctioned.
The visibility of the operative
field during FESS was evaluated
using Fromme et al., (1986) scale
adapted by Boezaart et al., (1995)
was used: 5= no bleeding, 4=slightbleeding and blood evacuation not
necessary, 3=slight bleeding andsometimes blood has to be evacu
ated, 2= low bleeding, blood has to
be often evacuated and operative
field is visible for some secondsafter evacuation, l=average bleed
ing, blood has to be often evacuat
ed and operative field is visibleonly after evacuation and O=high
bleeding and constant blood evac
uation is needed but sometimesbleeding exceeds evacuation and
surgery is hardly possible or impossible at all. The total amount
of bleeding as judged by theamount evacuated was also re
corded
Vol. 26 No 2 May 2009
cosa. The middle meatus, hiatus
semilunarls and the sphenoeth-
moldal recess were packed as pos
sible with cotton pads which wereintroduced using small auricularforceps, and after 5 minutes, the
pledgets were removed. Xylocalne
1% with adrenaline (1:100,000),1-1.5 ml, was injected under the
mucosa of the uncinate pro
cess, at the level of the head of
the middle turblnate and the inferior part of the bulla. Local anes
thetic was given at the point of in
sertion of the middle turbinate, so
as to block the vessels and thenerve fibers which come from the
artery and the anterior ethmoidal
nerve.
Patients were monitored non-
invasively; before induction of an
esthesia (TO) and 20 (T20), 40(T40) and 60 mm (T60) after induction of anesthesia, for systolic
arterial pressure (SAP), diastolic
arterial pressure (DAP) and MAP;
HR, SPO2 and Et CO2.
The approach for FESS wasconducted totally endonasal. The
maxillary ostium was identified by
locating the inferior posterior edge
of the uncinate process. The unci
Benha M. J.
88
tients underwent anterior and
posterior ethmoidectomy withopening of the middle lamina ofthe turbinate and/or sphenoidoto-
my and 7 patients underwent an
terior ethmoidectomy, opening of
the middle lamina of the turbinate
and/or opening of the frontal recess. There was a non-significant
difference between patients en
rolled in both groups as regardsage, sex, ASA grade distribution or
procedure performed, (Table 1).
Both anesthetic modalities reduced blood pressure significantly
(p<0.05) at the three times ofmeasurements compared to pres
sure levels determined preopera-
tively. Moreover, blood pressure
parameters showed progressive
significant (p<0.05) decrease at
T40 and T60 compared to meas
ures determined at T20 in both
groups with non-signiflcantly lower pressure measures with propof-
ol compared to isoflurane, (Fig. 1).
Mean HR showed progressive sig
nificant (p<0.05) decrease in bothgroups compared to their preoper-
ative rates with a non-significant
difference between mean HR re
ported in both groups, (Table 2,Fig. 2). However, irrespective of
Statistical analysisObtained data were presented
as mean+SD, ranges, numbers
and ratios. Data were analyzed us
ing Wilcoxon Z-test for unrelated
data and possible relationshipswere investigated using Pearson
linear regression. Regression anal
ysis (Enter Method) was used todefine independent factors for pro
viding proper field visibility andspecificity of these factors wereevaluated using the receiver oper
ating characteristic (ROC) curveanalysis judged by the area under
the curve (AUC). Statistical analysis was conducted using the SPSS
(Version 10, 2002) for Windowsstatistical package. P value <0.05
was considered statistically significant.
ResultsThe study included 32 patients;
23 males and 9 females withmean age of 39.28.4; range: 21-
53 years. According to American
Society of Anesthesiologists (ASA),
there were 25 ASA grade I and 7ASA grade II. Sixteen patients underwent anterior ethmoidectomy
(resection of the uncinate process
and opening of the bulla) and/ormiddle hiatal antrostomy; 9 pa
Ahmed El-Emshati & Ahmed Al-Arfaj
89
Mean blood loss estimated inpatients received If anesthesia
was 157.344.9; range 105-270
ml and was significantly (Z=3.184,p=0.001) less compared to those
received CII anesthesia: 23949.5;range: 135-355 ml, (Fig. 6). More
over, recorded field visibility scorewas 3.33+0.6; range 2-4 in TI
group and was significantly higher(Z=2.266, p=0.023) compared toscore recorded in patients received
CII group; 2.470.99; range 1-4,
(Table 4, Fig. 7).
There was a negative significantcon^lation between the field visi
bility score and mean MAP, (r=-
0.486, p=0.006) and mean
amount of bleeding, (r=-0.366,
p=0.047), (Fig. 8). Using regres
sion analysis to determine theindependent factor for improving
the field visibility, the use of hypo-tensive anesthesia was found to
be a significant independent factor
for improving filed visibility(0=0.370, t=2.222. p=0.035), and
the use of TI anesthesia was found
to be significant determinant inde
pendent factor for induction of hy-potensive anesthesia, ((1=0.242,t=2.500, p=0.015). Using ROCcurve to define the specific inde-
VoL26 No 2 May 2009anesthetic modality used, anti-
Trendelenburg position induced asignificantly lower (Z=2.484,p=0.013) mean arterial pressure
compared to those maintained in
supine position, (Fig.3).
All surgeries were conducted
completely without intraoperativecomplications. No extensive bleed
ing was recorded and no patient
had visibility score of 0 and only 3
patients in group CII (20%) had
visibility score of 1, 7 patients; 2
in TI (12.5%) and 5 in CH group
(31.2%) had visibility score of 2.
Fourteen patients; 8 in TI (50%)and 6 in CII group (37.5%) had
visibility score of 3 and 8 patients;
6 in TI (37.5%) and 2 in CII
(12.5%) had visibility score of 4.
There was a significant increase
(X2=5.544, p<0.05) in the frequency of good field visibility with TIcompared to CII anesthesia, (Fig.
4). Moreover, Patient's position
during surgery significantly in
fluenced surgical field visibility.Patient's positioning in anti-
Trendelenburg position significantly (X2=9.164, p<0.01) improved field visibility compared
to supine position, (Table 3, Fig.5).
Benha M J.
90
-0.0232.266
2.4710.99(1-4)3.3310.6 (2-4)Visibility score
=0.0013.184
239149.5 (135-355)157.3144.9(105-270)
Amount (ml)
DZGroup CR (n-16)Group TI (n-16)Group
Table (4): Mean collective amount of bleeding and field visibility score reported at 60minutes after induction of anesthesia in both groups
7 (43.7%)8 (50%)1 (6.3%)
0
Anti-Trendelenburg(n-16)
1 (6.3%)6 (37.5%)6 (37.5%)3(18.7%)
Supine(n-16)
Position
2(12.5%)6 (37.5%)5(31.2%)3(18.7%)
Group CII(n-16)
6(37.5%)8 (50%)
2 (12.5%)0
Group TI(n-16)
Anesthetic Modality
4321Visibility score
Table (3): Patients' distribution according to the Held visibility score reported in bothgroups categorized according to anesthetic modality and position during surgery
*: significant versus ToData are presented as meanSD66.23.3*t70.63.9*t
7513.8*82.813
67.53.3*t69.1l5.2"t73.314.5*81.812.9
HR (beat/min)
67.6l3.2*t7213. l*t74.213.9*89.914.4
68.53.5*t68.413.S*f67.7112.9*
92.816 9MAP (mmHg).
60.24.2*t65.12.9*t
68.114*76.515
63.U4.6*t64.214*t66.715.5*78.315.9
DAP (mmHg)
82.513.2*t83.114.1*t
86.415*116.715.279.47*t
76.77.6*t83.216.2*121.819.6
SAP (mmHB)
TwT,TmTnToTn,•pTn
(n-16)Group CII
(n-16)Group TI
Table (2): Mean blood pressure and heart rate changes reported in both groups at T3o, T40and Tso after induction of anesthesia in comparison to preoperative measures
Data are presented as meaniSD, numbers & ratios; ranges & percentages in parenthesis
7(21.9%)9(28.1%)
16 (50%)26:623:9
39-28.4(21-53)
Total (n-32)
349
13:311:5
40.218(23-51)
Group CH(n-16)
457
13:312:4
38.38.8(21-53)
Group TI(n-16)
Ant ethmoidectomy, opening of middlelamina of turbinate & frontal recess
Ant & Post ethmoidectomy^Anterior ethmoideclomv
perfumedProcedureASA trade 1:11Sex; M:F
Age (years)
Table (1): Patients' distribution in both studied groups according to patients' character andprocedure performed
thesia as independent determi
nant for field visibility,(AUC=0.778 vs 0.630, respective
ly), (Fig. 9).
Ahmed El-Emshati & Ahmed Al-Arfaj
pendent factor defined the su
periority of use of total intravenous anesthesia over combined
intravenous / inhalational anes
91
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Vol. 26 No 2 May 2009
Benha M J
92
Fig. (9): HOC curve analysis of mode of anesthetic maintenance as a specific independent predictor forimproving field visibility
-SO.751.00
1ii
i
FleW\*s*S(y scoreReHtrisfcifty scoreFig. (8): Correlation between field visibility and mean MAP and mean amount of intraoperative bleedingreported in studied patients
a. (7): Maul (SD) fluid visibility aeor* raoordac
im
_JBM̂^T o Group Tl OGranpcn
Ahmed El-Emshati & Ahmed Al-Arfaj
93
and heart rate measures through
out observation period compared
to preoperative measures with
progressive significant decrease atT4o and T60 compared to meas
ures determined at T20 in bothgroups, but with non-significantdifference between both groups.
These results agreed with Tirelli et
al., (2004) who reported progressive reduction of blood pressure
with both TIVA and inhalational
anesthesia during endoscopic si
nus nasal surgery and with Rath-
jen et al., (2006) who reported thatTTVA allows the reduction of themean arterial blood pressure to 60
mmHg and concluded that forgeneral anesthesia in endonasal
sinus surgery sodium nitroprus-
side is no longer recommended
and instead a TIVA using propofoland remifentanil should be used.
The reported significant hypotension showed non-significant
difference between both groups
and this could be attributed to themaintenance of anesthesia using
remifentanil infusion. In support
of this explanation, Manola et al.,
(2005) compared three types of
general anesthesia for FESS withcontrolled hypotension and report-
Benha M. J.
Vol. 26 No 2 May 2009
Discussion
FESS is most successful in patients who have recurrent acute or
chronic infective sinusitis. Pa
tients in whom the predominant
symptoms are facial pain and nasal blockage usually respond well.The sense of smell often improves
after this type of surgery. In pa
tients with nasal polyposis that isnot controlled with topical cortl-
costeroids, FESS permits the ac
curate removal of polyps, (Bugtenetal., 2008).
A number of previous studies
have tried to assess the effects of
various hypotension-inducing
drugs on the surgical field during
FESS to minimize bleeding so as
to improve the operative field visi
bility in FESS, (Nair et al., 2004).The present study was designed
as a trial to improve the control of
bleeding during FESS by means of
positional changes and the use of
controlled hypotension achieved
through maintenance of anesthe
sia using remifentanil and either
of propofol infusion or isofluraneinhalation.
Both anesthetic modalities sig
nificantly reduced blood pressure
94
with significantly improved quality
of visibility of the surgical fieldand concluded that TWA is effective in reducing bleeding duringFESS.
The obtained results support
that obtained by Sivaci et al.,
(2004) who found general anesthesia based on propofol Infusion
have the advantage of significantly
decreased bleeding compared withconventional inhalation agents
and therefore, making endoscopic
surgery technically easier and saf
er by improving endoscopic visualization of the surgical field and
with Manola et al., (2005) and
Wormald et al., (2005) who reported significant reduction of bleed
ing and higher field visibility with
propofol and remifentanil infusion
as opposed to inhalation anesthesia using sevoflurane.
Statistical analysis to define ifthese effects could be attributed to
induced decreased MAP or to the
use of TI anesthesia showed that
TI anesthesia was found to be a
significant independent factor for
determination of field visibilityand showed wider area under
ROC curve as specific determi-
ed proper blood pressure adjustment using either TWA or inhala-
tional anesthesia with a significant difference in favor of
remifentanil / propofol comparedto either of sufentanil / sevoflu-
rane or fentanyl / isoflurane.
Noseir et al., (2003) tried to explore the possible mechanisms ofhypotension during the adminis
tration of remifentanil in young
ASA I volunteers and reported direct effects of remifentanil on re
gional vascular tone that may play
a role in promoting hypotension.Also, Jones, (2003) concluded that
reductions in sympathetic outflow
with remifentanil would implicate
central effects of this anestheticon sympathetic control.
Mean blood loss estimated inpatients received TI anesthesia
was significantly less with significantly higher field visibility score
in TI group compared to CII group.
These results agreed with Tirelli etal., (2004) and Sun et al., (2003);
both studies reported that the
mean estimated blood loss for pa
tients received TWA was significantly reduced compared to thosereceived inhalatlonal anesthesia
Ahmed El-Emshati & Ahmed Al-Arfaj
95
ry to that reported by Beule et al.,(2007) who compared the effect ofpropofol versus sevoflurane anes
thesia on bleeding and field visibility during FESS and reported that
total blood loss, blood loss per
minute, and endoscopic visionshowed no group difference and
platelet function was significantly
impaired 45 minutes after onset of
surgery in both groups, but morepronounced after propofol anesthesia. On contrary to Beule et al.,
(2007) and in support of the re
sults of the current study. Aim etal., (2008) reported that in thehigh-Lund-Mackay score patients,
propofol/remifentanil anesthesia
results in less blood loss and abetter surgical conditions for
FESS than sevoflurane/remifenta-nil anesthesia.
Furthermore, patients' position
during surgery showed additional
impact on the reported beneficialeffects of hypotensive anesthesia,
irrespective of the type of anesthetic used manifested as significantly decreased MAP in patients
maintained in antt-Trendelenburg
position with significantly unproved field visibility in compari
son to those maintained in supine
Benha M. J.
Vol. 26 No 2 May 2009
nant. These findings could be attributed to the fact that in clinically relevant concentrations propofoldid not influence the surface ex
pression density of fibrinogen receptors, P-selectin molecules, and
the percentage of leukocyte-
platelet aggregates ex vivo; thusdid not allow interruption of eitherof platelet or coagulation func
tions, (Scheinicherf et al., 2002).Also, Dordoni et al., (2004) report
ed that propofol, in comparison to
other anesthetics, had no effect on
platelet function both ex vivo and
in vitro and propofol might be considered hemostatically safer.
As an explanation for the effectof propofol on platelet function,
Fourcade et al., (2004) experimentally reported that propofol doesnot significantly alter intracellular
calcium increases caused by re
ceptor activation and its inhibitionof platelet aggregation appears to
act distal to platelet receptors, in-
ositol phosphate 3, and phospholi-pase C.
The obtained results and the
previous experimental studiedconcerning effect of propofol on
platelet function were contradicto-
96
(2007) : Propofol versus sevoflurane: bleeding in endoscopic sinus
surgery. Otolaryngol Head Neck
Surg.; 136(l):45-50.
Boezaait A. P., Merwe J. and
Coetzee A. (1995) : Comparisonof sodium nitrbprusside and es-
molol induced controlled hypotension for functional endoscopic si
nus surgery. Can J Anaesth.; 42:
373-6.
Bradley D. T. and Kountakis
S. E. (2005) : Correlation between
computed tomography scores andsymptomatic improvement after
endoscopic sinus surgery. Laryn
goscope; 115(3): 466-9.
Bugten V., Nordgard S. and
Steinsvag S. (2008) : Long-termeffects of postoperative measures
after sinus surgery. Eur Arch
Otorhinolaryngol.; 265: 531-7.
Cincikas D. and Ivaskevicius
J. (2003) : Application of con
trolled arterial hypotension in en
doscopic rhinosurgery. Medicina
(Kaunas), 39(9): 852-9.
Dordoni P. L., Frassanlto L.,
Bruno M. F., Proietti R., de Cris-
position during surgery. Thesefindings go in hand with Ko et al.,(2008) who evaluated the factorsrelated to the volume of intraoper-
ative blood loss during endoscopicsinus surgery and reported thatreverse Trendelenburg position
may reduce intraoperative blood
loss.
It could be concluded thatmaintaining patients in anti-
Trendelenburg position and anes
thetic manipulation using total intravenous anesthesia could mini
mize bleeding and improve field
visibility during FESS and thusthis combination of manipulationscould be appropriate strategy forsuch type of surgery.
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