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

Abstract

Transnasal transsphenoidal (TNTS) pituitary surgery is associated with short-lived but intense nociceptive stimuli which cause substantial hemodynamic perturbations that may increase blood loss and impair visualization of the surgical field. This systematic review aimed to critically appraise the clinical evidence for the efficacy and safety of various 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 pituitary surgery. Relevant randomized clinical trials and observational studies were identified in a systematic literature search; 16 studies (13 randomized clinical trials, 3 observational studies) enrolling a total of 907 patients were identified for inclusion in this review. Propofol provided more potent hemodynamic control compared with volatile anesthetics with a sparing effect on the need for additional drugs to blunt hemodynamic responses. Recovery profiles between propofol and sevoflurane were either equivalent or favored sevoflurane, but both agents were superior to isoflurane. Regarding intraoperative analgesia, remifentanil was associated with superior hemodynamic control and recovery profiles than fentanyl. Dexmedetomidine had beneficial effects on hemodynamics, surgical field quality, recovery characteristics, and nociceptive properties compared with placebo. Although there was no clear-cut superiority of other adjunct pharmacological modalities on hemodynamic responses during surgery, regional blocks were associated with beneficial impacts on both primary and secondary outcomes. In summary, short-acting anesthetics, analgesics and dexmedetomidine seem to improve intraoperative hemodynamics, blood loss, and recovery qualities during TNTS pituitary surgery. However, definitive conclusions cannot be drawn because of methodological heterogeneity in the identified studies.

Effects of Low versus Intermediate Doses of Dexmedetomidine Infusion on Blood Loss, Hemodynamics, and Operative Time in Transsphenoidal Pituitary Tumor Removal: A Prospective Randomized Study

“…Clinicians should be aware of the potential harmful effects of intraoperative bradycardia and hypotension. 14,16 In contrast to our results, other studies 3,5,17 showed that dexmedetomidine achieved better control of hemodynamics than placebo or oral clonidine.…”

Anesthetic management during transsphenoidal pituitary surgery

“…A randomized, double-blind controlled trial showed statistically significant reduction in opioid consumption in TSR patients receiving scheduled intravenous acetaminophen and ibuprofen (26.3 ± 28.7 mg oral morphine equivalents (OME) in multimodal group vs. 62.5 ± 63.8 mg OME in control group, P < 0.0001) [34]. Tsaoui et al' s systematic review of various medications used in TSR did not indicate an increased risk of PONV with the use of remifentanil or fentanyl and found that dexmedetomidine has been shown to have significant benefits in regard to hemodynamic profile, analgesia, and PONV prevention [35 ▪▪ ]. Several studies have shown that dexmedetomidine as an intravenous analgesic adjunct may reduce intraoperative opioid requirements, improve surgical field visualization, provide hemodynamic stability, and reduce postoperative pain scores and PONV in patients undergoing TSR [35 ▪▪ ,36,37].…”

“…Tsaoui et al' s systematic review of various medications used in TSR did not indicate an increased risk of PONV with the use of remifentanil or fentanyl and found that dexmedetomidine has been shown to have significant benefits in regard to hemodynamic profile, analgesia, and PONV prevention [35 ▪▪ ]. Several studies have shown that dexmedetomidine as an intravenous analgesic adjunct may reduce intraoperative opioid requirements, improve surgical field visualization, provide hemodynamic stability, and reduce postoperative pain scores and PONV in patients undergoing TSR [35 ▪▪ ,36,37].…”