Evaluating the Role of Anesthesia on Intraoperative Blood Loss and Visibility during Endoscopic Sinus Surgery: A Meta-analysis

Abstract

Background Previous studies and meta analyses have led to incongruent and incomplete results respectively when total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) are compared in endoscopic sinus surgeries in regards to intraoperative bleeding and visibility. Objective To perform a more comprehensive meta-analysis on randomized controlled trial (RCTs) comparing TIVA with IA in endoscopic sinus surgery to evaluate their effects on intraoperative bleeding and visibility. Methods A systematic review and meta-analysis of studies comparing TIVA and IA in endoscopic sinus surgery for chronic rhinosinusitis was completed in May 2020. Utilizing databases, articles were systematically screened for analysis and 19 studies met our inclusion criteria. The primary outcome included intraoperative visibility scores combining Boezaart, Wormald and Visual Analogue Scale (VAS). Secondary outcomes included rate of blood loss (mL/kg/min), estimated total blood loss (mL), Boezaart, Wormald scores, VAS, heart rate, and mean arterial pressure (MAP). Results 19 RCTs with 1,010 patients were analyzed. TIVA had a significantly lower intraoperative bleeding score indicating better endoscopic visibility (Boezaart, VAS, and Wormald) than IA (−0.514, p = 0.020). IA had a significantly higher average rate of blood loss than TIVA by 0.563 mL/kg/min (p = 0.016). Estimated total blood loss was significantly lower in TIVA than IA (−0.853 mL, p = 0.002). There were no significant differences between TIVA and IA in the mean heart rate (−0.225, p = 0.63) and MAP values (−0.126, p = 0.634). The subgroup analyses revealed no significant difference between TIVA and IA when remifentanil was not utilized and whenever desflurane was the IA agent. Conclusion TIVA seemed to have superior intraoperative visibility scores and blood loss during endoscopic sinus surgery when compared to IA. However, the results are not consistent when stratifying the results based on the use of remifentanil and different inhaled anesthetics. Therefore, the conclusion cannot be made that one approach is superior to the other.

Inhalational Anesthesia is Noninferior to Total Intravenous Anesthesia in Terms of Surgical Field Visibility in Endoscopic Sinus Surgery: A Randomized, Double-Blind Study

“…However, in clinical practice, multiple clinical trials and meta-analyses have found that IA and TIVA showed no significant differences in MAP or HR. 14,15 In our study, the MAP and HR of the IA and TIVA groups were similar.…”

“…Additionally, a recent meta-analysis showed no significant difference in BS between patients receiving IA and those with TIVA. 15 Chaaban et al stated that even with further studies, a significant difference in blood loss between patients with TIVA and those with IA during ESS was unlikely to be seen. 9 We found that the majority of studies obtaining positive results compared TIVA with propofol to IA with isoflurane [17][18][19]23 or desflurane 5 but not sevoflurane, and one meta-analysis confirmed our hypothesis.…”

“…Therefore, remifentanil may play a key role in closing the gap in surgical field visibility during ESS between IA and TIVA. 15 In some previous studies, TIVA was superior to IA, although most IA groups were not given remifentanil for anesthesia maintenance. 24 In other words, when remifentanil is infused during anesthesia maintenance, the choice of different methods for anesthesia maintenance-inhaled anesthetic, propofol, or their combination-may not be important.…”

“…First, after a detailed search of the relevant literature, we found that the maximum sample size from previous studies was ninety cases (TIVA group plus IA group); 17 in contrast, the sample size calculation in our study was more rigorous, with 110 patients included (with the TIVA and IA groups each containing 55 patients). Second, the bleeding rate may be a better variable than the estimated amount of 15 Some studies only compared total blood loss and did not calculate the bleeding rate. 15 We compared not only the total blood loss between IA and TIVA but also the bleeding rates of the two groups.…”

The Cutting Edge of Rhinology Research

“…Finally, optimizing surgical outcomes is paramount for our patients, and this issue of AJRA explores critical questions to aid surgeons in this goal. Moffatt et al 13 perform a meta-analysis of the role of anesthesia on intraoperative blood loss and surgical field visibility; they determine that total intravenous anesthesia may improve these metrics relative to inhalational agents, but the results are inconsistent when accounting for the use of specific agents like remifentanil and desflurane. Swords et al 14 perform a meta-analysis of the use of postoperative antibiotics following ESS, and although there was significant heterogeneity of the included studies, they did not identify high-level evidence to support their use.…”