The Hemostatic and Hemodynamic Effects of Epinephrine During Endoscopic Sinus Surgery

Background Intranasal injection of epinephrine and placement of topical epinephrine pledgets are methods to improve visualization during endoscopic sinonasal surgery. Studies comparing the hemodynamic effects of these vasoconstrictors using intraoperative arterial line monitoring are lacking. Methods Twenty‐eight patients undergoing endoscopic skull‐base surgery were enrolled in a prospective, randomized study. Patients were randomized to have either 2 mL of 1:100,000 or 2 mL of 1:200,000 epinephrine injected intranasally. Hemodynamic parameters, including pulse, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), were collected using intraoperative arterial line monitoring for 5 minutes. Afterward, 1:1000 topical epinephrine‐soaked pledgets were placed in both groups, and the same parameters were collected for another 5 minutes. Results There was no statistical difference in change in pulse, SBP, DBP, and MAP between the 1:100,000 and 1:200,000 epinephrine groups. However, epinephrine injections did cause an increase in all hemodynamic parameters when compared with baseline (p < 0.05). Topical epinephrine pledgets placed after injection of epinephrine did not have any significant hemodynamic effects, except for 2 of 28 patients who had a >75‐mmHg increase in SBP. No preoperative characteristics were identified that predicted sensitivity to epinephrine. Conclusion There is no statistical difference in changes in hemodynamic parameters between injecting epinephrine 1:100,000 compared with 1:200,000 during endoscopic sinonasal surgery. In a subset of patients, placement of topical 1:1000 epinephrine pledgets had significant hemodynamic elevation requiring intervention and thus should be used judiciously depending on patient comorbidities.

Section: Discussioncontrasting

confidence: 58%

Real‐time hemodynamic effects of 1:100,000 and 1:200,000 injectable epinephrine and placement of topical 1:1000 epinephrine pledgets in patients undergoing endoscopic sinus and skull‐base surgery: a randomized, prospective study

Ahmed

Choi

et al. 2019

“…10,[12][13][14][15] Although these effects are of significant concern, they are largely the result of intravascular injection and there is limited literature on the safety of topical CE use or the optimal dose. 11,[16][17][18][19] One study concluded that topical CE use was safe in sinus surgery when combined with avoidance in patients with comorbid cardiac disease. 20 An additional practical concern with the use of CE arises from the potential for the masking of arterial bleeding, which may manifest postoperatively after the vasoconstriction has resolved.…”

mentioning

confidence: 99%

Safety and efficacy of concentrated topical epinephrine use in endoscopic endonasal surgery

Korkmaz

Yao

Korkmaz

et al. 2015

“…Zhao et al. also found significant increase in heart rate and significant decrease in blood pressure 1.5 minutes after infiltration of lidocaine with epinephrine . There are several additional reports in the literature on the adverse effects following intranasal preparation for ESS, including several recorded events of significant cardiac morbidity .…”

Section: Discussionmentioning

confidence: 92%

“…Zhao et al also found significant increase in heart rate and significant decrease in blood pressure 1.5 minutes after infiltration of lidocaine with epinephrine. [13][14][15][16] There are several additional reports in the literature on the adverse effects following intranasal preparation for ESS, including several recorded events of significant cardiac morbidity. [17][18][19][20][21] Furthermore, a randomized study by Javer et al called into question the therapeutic value of infiltrated epinephrine, as there was no difference in blood loss during ESS between patients receiving infiltrated 0.25% bupivacaine with 1:200,000 epinephrine and those receiving saline control injections.…”

Section: Discussionmentioning

confidence: 99%

The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: a double‐blind randomized controlled study

Tangbumrungtham

Hwang

Maul

et al. 2019

Background The objective of this study is to determine whether the infiltration of 1% lidocaine with 1:100,000 epinephrine in addition to topical application of 1:1000 epinephrine significantly improves surgical field grading scale score over topical 1:1000 epinephrine alone. Methods A prospective, double‐blind, randomized, controlled study was performed of 40 patients undergoing bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Patients were enrolled and randomly assigned to receive infiltration with 1% lidocaine with 1:100,000 epinephrine on 1 side of the nasal cavity vs plain saline on the other side in preparation for ESS. Both groups received topical application of 1:1000 epinephrine. Surgical videos were recorded and Wormald surgical field grading scale was assigned by 2 blinded reviewers. The number of extra 1:1000 epinephrine pledgets used during the surgery, estimated blood loss, and surgical duration were also recorded. Results There were no statistically significant differences in Wormald surgical field grading scale, number of extra pledgets used, or estimated blood loss between the nasal cavity side infiltrated with 1% lidocaine with 1:100,000 epinephrine in comparison to infiltration with saline. The side infiltrated with 1% lidocaine with 1:100,000 epinephrine had a reduced operative time compared to the side infiltrated with saline (p = 0.002). There were no differences in postoperative bleeding from questionnaire completed by patient at the first postoperative visit. Conclusion Addition of infiltration of 1% lidocaine with epinephrine 1:100,000 to topical application of epinephrine 1:1000 for preparation of ESS does not significantly improve surgical field of view compared to topical epinephrine alone.