A Prospective Randomized Trial Comparing Topical Intranasal Lidocaine and Levobupivacaine in Patients Undergoing Endoscopic Binostril Transnasal Transsphenoidal Resection of Pituitary Tumors

Abstract

Introduction: Local anesthetic intranasal packing is used in transnasal surgery to reduce hemodynamic fluctuations. We hypothesized that the long acting local anesthetic levobupivacaine would provide superior hemodynamic stability and postoperative analgesia compared with lidocaine in endoscopic transnasal transsphenoidal (TNTS) surgery. Materials and Methods: In this prospective, randomized, double-blind trial, 48 patients undergoing TNTS surgery were allocated to the 2 groups to receive preoperative intranasal packing with 15 mL of 1.5% lidocaine or 0.5% levobupivacaine each mixed with 60 mg ephedrine. Heart rate and mean arterial blood pressure were recorded immediately before induction of anesthesia, at various time points throughout surgery, and at tracheal extubation. Bleeding in the surgical field, time to extubation, and postoperative pain were also assessed. Results: There was no significant difference in heart rate between the lidocaine and levobupivacaine groups at any point. Mean arterial pressure was also similar between the 2 groups during surgery, whereas at extubation blood pressure was lower in the lidocaine compared with levobupivacaine group (85±10 vs. 96±16 mm Hg; P=0.0010). There were no differences between the 2 groups in the other outcome variables. Conclusions: Preoperative intranasal packing with 1.5% lidocaine or 0.5% levobupivacaine provide similar hemodynamic stability throughout TNTS. Lidocaine packing may be more advantageous for hemodynamic stability during extubation.

Control of Hemodynamic Responses and Perioperative Outcomes in Transsphenoidal Pituitary Surgery: A Qualitative Systematic Review of the Available Evidence

“…8 However, the hemodynamic responses to nasal infiltration with local anesthetics and vasoconstrictive drugs could vary between hypertension due to sympathetic system activation to mild hypotension induced by β2-mediated vasodilatation caused by low plasma concentrations of adrenaline. 16…”

“…31 However, the use nasal packs soaked in 1.5% lidocaine provided equivalent clinical effects to 0.5% levobupivacaine soaked packs, with similar requirement for vasoactive drugs to maintain hemodynamic stability. 16 Interestingly, the application of preincision regional nerve blocks, such as bilateral sphenopalatine ganglion block alone 29 or in combination with maxillary nerve block, 30 provided better control of MAP fluctuations at nasal mucosa infiltration, nasal dissection, and speculum insertion compared with patients who did not receive a nerve block. 30 Moreover, sphenopalatine ganglion block minimized the need for anesthetic or adjunct drugs to maintain predefined hemodynamic targets without leading to any notable adverse cardiovascular effects.…”

“…17,28 Infiltration of the nasal cavity with solutions containing both local anesthetic and vasoconstrictive drugs is commonly used to enhance analgesic potency and mitigate bleeding from the nasal mucosa. 35 Lidocaine soaked intranasal packs provided equivalent clinical effects compared with levobupivacaine soaked packs, 16 although no obvious clinical benefit has been reported with the systematic use of local anesthetics. 31 Sphenopalatine ganglion block has also been suggested as an adjuvant to general anesthesia as part of a multimodal approach to managing hemodynamic responses during TNTS surgery.…”

“…The primary measures of interest were the effect of the applied anesthetic technique or intervention on intraoperative systemic hemodynamics assessed by alterations in heart rate (HR) and mean arterial blood pressure (MAP) at various intraoperative time-points, as well as use of adjunct medications to maintain stable hemodynamics. Other end-points included the impact of the implemented practice on the quality of the surgical field as assessed by neurosurgeons using preestablished scores, estimated intraoperative blood loss, recovery profiles, including emergence and extubation times, quality of recovery (measured by modified Aldrete Score 19 or Danish Society of Anesthesiology and Intensive Care Medicine score), 16 analgesia (evaluated by the visual analogue scale in the postoperative care unit), and occurrence of adverse events including sedation, postoperative nausea and vomiting (PONV), pruritus, shivering, or respiratory depression.…”

“…3,4,[8][9][10][11][12] Notably, various adjuncts focusing predominantly on nonopioid agents have been suggested as attractive options to counter hemodynamic responses to noxious stimuli during TNTS, while mitigating the risk of prolonged emergence or postoperative respiratory compromise anesthetic or opioid overdosing. [12][13][14][15][16][17] This systematic review aimed to critically appraise the clinical evidence for the efficacy and safety of different anesthetic techniques, other pharmacological modalities and supplementary interventions by assessing intraoperative systemic hemodynamics, use of adjunct medications, quality of the surgical field, intraoperative blood loss, and recovery profiles in patients undergoing TNTS surgery for resection of pituitary lesion.…”