Controlled Hypotension for Functional Endoscopic Sinus Surgery: Comparison of Esmolol and Nitroglycerine

Abstract

Intraoperative bleeding causing poor visibility of surgical field is of major concern during functional endoscopic sinus surgery (FESS) and impaired visibility may result in many complications. The study aimed to compare surgical conditions for FESS during controlled hypotension provided by esmolol or nitroglycerine (NTG) under general anaesthesia. 52 adult patients of both sexes requiring FESS under general anaesthesia were randomly divided to receive either esmolol (group ESM, n = 26) or NTG (group NTG, n = 26) to provide controlled hypotension. Surgical condition was assessed by surgeon using average category scale (ACS) of 0-5, a value of 2-3 being ideal. In both groups mean arterial blood pressure (MABP) was gradually reduced till ACS for assessment of surgical condition (ACS) of 2-3 or lowest targeted MABP (60 mm of Hg) was achieved. Both the drugs produced desired hypotension and improved surgical condition by reducing operative field bleeding but ideal operative conditions were achieved at mild hypotension (MABP 75-70) in ESM group while same conditions were achieved at MABP of 69-65 mm of Hg in NTG group. Mean heart rate was significantly higher in NTG group as compared to ESM group. Blood loss was significantly less in ESM group. Both NTG and esmolol can be used safely to provide controlled hypotension during FESS. Both the drugs improved visibility of surgical field by reducing capillary bleeding. But esmolol offered better operative conditions with only minimal reduction in MABP. No reflex tachycardia and less intraoperative haemorrhage were additional advantages of esmolol.

Clonidine Premedication as a Desirable Part of Hypotensive Anaesthesia for Functional Endoscopic Sinus Surgery

“…13 In our study, the placebo group required vasodilators to achieve hypotension in few cases. But none of the patients in clonidine group required vasodilators.…”

Target‑controlled infusion of propofol and remifentanil combined with dexmedetomidine reduces functional endoscopic sinus surgery bleeding

“…However, vasoactive drugs cannot reduce the FESS bleeding when MAP was controlled at level of 65-75 mmHg (17); conversely, vascular dilation caused by the drug would increase surgical bleeding and has a negative impact on the surgical field (14). Previous studies have demonstrated a significant correlation between the HR and surgical field bleeding during surgery (18)(19)(20). Compared with nitroglycerin, esmolol reduces bleeding by slowing down HR and offering an improved surgical approach with only minimal reduction in MAP (18).…”

“…Previous studies have demonstrated a significant correlation between the HR and surgical field bleeding during surgery (18)(19)(20). Compared with nitroglycerin, esmolol reduces bleeding by slowing down HR and offering an improved surgical approach with only minimal reduction in MAP (18). Therefore, FESS should be performed at a lower level of HR (20) as controlling HR is more effective on improving the surgical approach than lowering MAP.…”

A Comparison of Premedication with Metoprolol, Clonidine and Tranexamic Acid and Intravenous Nitroglycerin on Intraoperative Hemodynamics and Surgical Conditions during Functional Endoscopic Sinus Surgery (Fess).

“…But reflex tachycardia associated with NTG partially offset the advantage of induced hypotension 3,9 . Beta blockers like Metoprolol, Labetalol and Esmolol were used preoperatively to control the heart rate in view of reducing blood loss 10,11,12 . Clonidine, a centrally acting α 2 agonist is not only antihypertensive but has analgesic, sedative, anxiolytic properties.…”