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Warner BK, Munhall CC, Nguyen SA, Schlosser RJ, Guldan GJ, Meyer TA. Dexmedetomidine and surgical field visibility in nasal surgery: A systematic review and meta-analysis. J Perioper Pract 2024:17504589241252107. [PMID: 38831613 DOI: 10.1177/17504589241252107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
INTRODUCTION Nasal and sinus surgery, especially using endoscopy, relies upon adequate haemostasis to be safe and effective. Often other haemostatic methods, such as cautery are not viable, and other methods must be employed. This study examines the effectiveness of dexmedetomidine in controlled hypotension and for surgical field visibility in endoscopic sinus surgery and other nasal surgeries. REVIEW METHODS A literature search was conducted in PubMed, Scopus, CINAHL and Central for randomised controlled trials using dexmedetomidine for controlled hypotension in adult patients undergoing endoscopic sinus surgery or other nasal surgery. Meta-analysis of mean differences and single means were performed. RESULTS Of 935 identified studies, 31 met the inclusion criteria. A statistically significant difference in Fromme-Boezaart surgical field visibility scores was found comparing dexmedetomidine to placebo (p < 0.00001) and propofol (p < 0.0001), but not other agents. A significant difference in intraoperative blood loss volume was found compared with placebo (51.5mL, p < 0.00001) and propofol (13.6mL, p < 0.0001), but not other agents. CONCLUSION Dexmedetomidine demonstrated significantly improved surgical field visibility and blood loss volume compared with placebo and propofol, but not other agents. Dexmedetomidine is viable and useful for controlled hypotension in nasal surgery. Choice of controlled hypotension agent should follow patient and procedure-specific considerations.
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Affiliation(s)
- Brendon K Warner
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - C Cooper Munhall
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - George J Guldan
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery. J Craniofac Surg 2023; 34:83-91. [PMID: 35968948 DOI: 10.1097/scs.0000000000008893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/04/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery. METHODS The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed. RESULTS The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population. CONCLUSION Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.
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Xu N, Chen L, Liu L, Rong W. Dexmedetomidine versus remifentanil for controlled hypotension under general anesthesia: A systematic review and meta-analysis. PLoS One 2023; 18:e0278846. [PMID: 36649357 PMCID: PMC9844847 DOI: 10.1371/journal.pone.0278846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/04/2022] [Indexed: 01/18/2023] Open
Abstract
This meta-analysis aimed to analyze and compare the efficacy and safety of remifentanil and dexmedetomidine applied respectively for controlled hypotension under general anesthesia. We searched the Cochrane Library, PubMed, EMBASE, Web of Science, CNKI, SinoMed, Wanfang, and VIP databases, as well as dissertations and conference papers, to obtain randomized controlled trials comparing remifentanil and dexmedetomidine applied respectively for controlled hypotension before August 23, 2021. The primary outcomes included hemodynamic profiles, surgical field score, and blood loss. Extubation time, sedation and pain score at the PACU, and perioperative adverse events were the secondary outcomes. Nine randomized controlled trials with 543 patients (272 in the dexmedetomidine group and 271 in the remifentanil group) were eventually included. This meta-analysis indicated no significant difference between dexmedetomidine and remifentanil in terms of surgical field score, blood loss, minimum values of mean arterial pressure (MD 0.24 with 95% CI [-1.65, 2.13], P = 0.80, I2 = 66%) and heart rate (MD 0.42 [-1.33, 2.17], P = 0.64, I2 = 40%), sedation scores at the PACU (MD -0.09 [-0.69, 0.50], P = 0.76, I2 = 92%), and incidence of bradycardia (OR 2.24 [0.70, 7.15], P = 0.17, I2 = 0%). Compared with remifentanil, dexmedetomidine as the controlled hypotensive agent showed a lower visual analogue score at the PACU (MD -1.01 [-1.25, -0.77], P<0.00001, I2 = 0%) and incidence of shivering (OR 0.22 [0.08, 0.60], P = 0.003, I2 = 0%), nausea, and vomiting (OR 0.34 [0.13, 0.89], P = 0.03, I2 = 0%). However, extubation time was shorter in the remifentanil group (MD 3.34 [0.75, 5.93], P = 0.01, I2 = 90%). In conclusion, dexmedetomidine and remifentanil are both effective in providing satisfactory controlled hypotension and surgical conditions. Dexmedetomidine is better in easing postoperative pain at the PACU and reducing the occurrence of shivering, nausea, and vomiting. Meanwhile, remifentanil is a fast-track anesthesia with a shorter extubation time. Given the limitations of this meta-analysis, further studies are needed for a more definitive comparison of the efficacy and safety of dexmedetomidine and remifentanil.
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Affiliation(s)
- Ning Xu
- Department of Anesthesiology, Weihai Central Hospital affiliated to Qingdao University, Wendeng, Weihai, Shandong, People’s Republic of China
| | - Linmu Chen
- Department of Pain Medicine, Weihai Central Hospital affiliated to Qingdao University, Wendeng, Weihai, Shandong, People’s Republic of China
| | - Lulu Liu
- Department of Respiratory and Critical Care Medicine, Weihai Central Hospital affiliated to Qingdao University, Wendeng District, Weihai, Shandong, People’s Republic of China
| | - Wei Rong
- Department of Anesthesiology, Weihai Central Hospital affiliated to Qingdao University, Wendeng, Weihai, Shandong, People’s Republic of China
- * E-mail:
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Muacevic A, Adler JR. Controlled Hypotension for Functional Endoscopic Sinus Surgery With Two Different Doses of Fentanyl. Cureus 2023; 15:e33859. [PMID: 36819423 PMCID: PMC9932825 DOI: 10.7759/cureus.33859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
Background and Objectives Functional endoscopic sinus surgery (FESS) is a type of minimally invasive surgery done for acute and chronic sinus diseases or paranasal illnesses. The idea of FESS is to preserve the normal anatomy, which is non-obstructing and mucous membrane while removing tissue obstructing OMC (osteo metal complex) and facilitating drainage. The critical structures, including the brain, orbit, and carotid veins, the lack of adequate operating room, and bleeding that obscures endoscopic vision throughout the procedure may increase the likelihood of unfavorable surgical results. This study seeks to examine the hemodynamic effects of intubation and extubation as well as the impact of fentanyl infusion on lowering blood pressure during FESS procedures. Materials and Methods Sixty-eight patients from the American Society of Anesthesiologists classes 1 and 2 who were planned for functional endoscopic sinus operations were randomly split into two groups for this randomized prospective trial. Group 1 patient belonging to the fentanyl 2 mcg per kg bolus 30 minutes before induction followed by 2 mcg per kg per hr infusion for 90 minutes of surgery, and Group 2 patient belonging to fentanyl 1 mcg per kg bolus 30 minutes before induction followed by 1 mcg per kg per hr infusion for 90 minutes of surgery. The significance of the difference in quantitative measures was measured using the student-t test, and the Chi-square test was used to measure up the difference in proportion. Statistically significant was set at P<0.05. Results Mean systolic blood pressure was higher in members of Group 2 than in Group 1. In contrast to Group 2, Group 1 had considerably better surgical field conditions, surgeon satisfaction on the AONO'S scale, post-operative nausea and vomiting, and a post-operative VAS Score during the first 24 hours. Conclusion Pre-induction Fentanyl with infusion can effectively control hypotension during functional endoscopic sinus surgery.
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Bafna U, Sharma P, Singhal RK, Gurjar SS, Bhargava SK. Comparison of hypotensive properties of dexmedetomidine versus clonidine for induced hypotension during functional endoscopic sinus surgery: A randomised, double-blind interventional study. Indian J Anaesth 2021; 65:579-585. [PMID: 34584280 PMCID: PMC8445218 DOI: 10.4103/ija.ija_57_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/06/2021] [Accepted: 08/02/2021] [Indexed: 02/05/2023] Open
Abstract
Background and Aims Excessive bleeding is a major concern in functional endoscopic sinus surgery (FESS) under general anaesthesia; this can be decreased by various hypotensive agents. This study was conducted to compare the hypotensive effectiveness and haemodynamic stability of dexmedetomidine and clonidine in patients undergoing elective FESS. Methods In this prospective double-blinded interventional study, 70 adult patients of either sex, 20-50 years of age, posted for elective FESS were randomly assigned to two groups. Group A received a loading dose of intravenous (IV) dexmedetomidine 1 μg/kg, followed by infusion of 1 μg/kg/h, and group B received a loading dose of IV clonidine 2 μg/kg, followed by 1 μg/kg/h infusion. Surgical field quality, emergence time, sedation score, visual analogue score, recovery profile and haemodynamic parameters were recorded. Statistical analysis was done by Student's unpaired t-test to evaluate the significance of normally distributed variables, whereas Mann-Whitney test and Chi-square test were used for ordinal data and categorical variables and proportions, respectively. Results In both the groups, target mean arterial pressure (MAP) of 65-70 mmHg and improved surgical field quality were achieved. MAP and heart rate (HR) were statistically significantly lower in the dexmedetomidine group with a longer duration of post-operative analgesia (P = 0.001). None of the groups showed any statistically significant adverse effects. Conclusions Both dexmedetomidine and clonidine can be used for controlled hypotension to improve surgical field quality in FESS. Dexmedetomidine provides more haemodynamic stability and an additional benefit of post-operative analgesia and conscious sedation.
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Affiliation(s)
- Usha Bafna
- Department of Anaesthesiology, SMS Medical College, Jaipur, Rajasthan, India
| | - Priya Sharma
- Department of Anaesthesiology, SMS Medical College, Jaipur, Rajasthan, India
| | - Rajneesh K Singhal
- Department of Anaesthesiology, SMS Medical College, Jaipur, Rajasthan, India
| | - Satveer S Gurjar
- Department of Anaesthesiology, SMS Medical College, Jaipur, Rajasthan, India
| | - Suresh K Bhargava
- Department of Anaesthesiology, Shalby Multispeciality Hospital, Jaipur, Rajasthan, India
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Yang Y, Li Y, Zhang H, Xu Y, Wang B. The efficacy of computer-assisted cognitive behavioral therapy (cCBT) on psychobiological responses and perioperative outcomes in patients undergoing functional endoscopic sinus surgery: a randomized controlled trial. Perioper Med (Lond) 2021; 10:28. [PMID: 34407884 PMCID: PMC8375045 DOI: 10.1186/s13741-021-00195-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 05/31/2021] [Indexed: 01/06/2023] Open
Abstract
Background Functional endoscopic sinus surgery (FESS) is required to minimize bleeding to maintain a clear operative field during surgery, so it is important to preoperative anti-anxiety and stable hemodynamics. Initial evidence suggests cognitive behavioral therapy (CBT) is effective to minimize surgery-related stress and to speed up recovery. The study aimed to evaluate the efficacy of a newly developed computer-assisted CBT (cCBT) program on surgery-related psychobiological responses in patients undergoing FESS. Methods Participants were allocated to a CCBT group (cCBT; n = 50) or a UC group (usual care; n = 50) by random number table. The State Anxiety Inventory (SAI), Patients Health Questionnaire-9 (PHQ-9), Athens Insomnia Scale (AIS), systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were assessed before intervention (T1), at 1 h before operation (T2), at postoperative 48 h (T3), and 96 h (T4: after intervention completed) respectively. The stress hormone was assayed at T1 and T2. The duration of surgery, anesthesia, and post-anesthesia care unit (PACU) were recorded. A satisfaction survey about nursing services was completed by participants before discharge. Results Compared to the UC group, the SAI scores at T2 and the AIS scores at T3 were lower in the CCBT group (p < 0.01 and p = 0.002). The positive rate of participants who were moderate and severe anxiety (SAI score > 37) at T2 were lower (72% vs. 88%, p = 0.04); the cortisol levels, SBP, DBP, and HR at T2 in the CCBT group were lower (p = 0.019 and all p < 0.01); the duration of anesthesia and PACU was shorter (p = 0.001 and p < 0.01); the CCBT group showed higher satisfaction scores. Conclusion The newly developed cCBT program was an effective non-pharmacological adjunctive treatment for improving the surgery-related psychosomatic responses and perioperative outcomes. Trial registration The study was registered with the Chinese Clinical Trial Registry (ChiCTR1900025994) on 17 September 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00195-3.
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Affiliation(s)
- Yang Yang
- Nursing College, Shanxi Medical University, Taiyuan, People's Republic of China.,Nursing Department, The First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China
| | - Yuling Li
- Nursing Department, The First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China
| | - Haibin Zhang
- Department of Anesthesia, The First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China
| | - Yong Xu
- Department of Psychiatry, The First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China. .,Shanxi Key Laboratory of Artificial Intelligence Assisted Diagnosis and Treatment for Mental Disorder, The First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China.
| | - Binquan Wang
- Department of Otorhinolaryngology Head and Neck Surgery, The First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China. .,Shanxi Key Laboratory of Otorhinolaryngology Head and Neck Cancer, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China.
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Lee YL, Thangavelautham S, Harikrishnan S, Karthekeyan R, Kothandan H. Is hypotensive anaesthesia guided by invasive intraarterial monitoring required for orthognathic surgery? - A retrospective review of anaesthetic practice and intraoperative blood loss in orthognathic surgery in a tertiary hospital. Indian J Anaesth 2021; 65:525-532. [PMID: 34321683 PMCID: PMC8312394 DOI: 10.4103/ija.ija_201_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/22/2021] [Accepted: 07/01/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Aims: Orthognathic surgeries for maxillofacial deformities are commonly performed globally and are associated with significant blood loss. This can distort the surgical field and necessitate blood transfusion with its concomitant risks. We aimed to review if invasive intraarterial (IA) line monitoring and/or hypotensive anaesthesia is required for orthognathic surgeries, and their effects on intraoperative blood loss and transfusion requirements. Methods: This was a retrospective observational study conducted in patients admitted for orthognathic surgeries in a public tertiary hospital. Anaesthetic techniques and intraoperative haemodynamics were studied for their effects on intraoperative blood loss. Results: The data from 269 patients who underwent orthognathic–bimaxillary surgeries was analysed. Inhalational anaesthetic combined with remifentanil was administered for 86.6%, total intravenous anesthesia to 11.2% patients, while the rest received inhalational anaesthesia. Hypotensive anaesthesia was achieved in 48 subjects (17.8%) and associated with shorter duration of surgery (349 vs 378 min, P = 0.02) and a trend towards lower blood loss (874 mL vs 1000 mL, P = 0.058) but higher transfusion requirement (81.3% vs 58.8%, P = 0.004). An IA line was used in 119 patients (44.2%) and was not associated with a higher probability of achieving hypotensive anaesthesia (19.3% vs 16.7%, P = 0.06). However, less blood loss (911 vs 1029 mL, P = 0.05) occurred compared to noninvasive blood pressure monitoring. Conclusion: Invasive blood pressure monitoring is as effective as noninvasive methods to achieve hypotensive anaesthesia. It does not aid in achieving lower target blood pressure. There is a lack of association between a reduction in blood loss and higher blood transfusion during hypotensive anaesthesiaand thiswill require further evaluation.
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Affiliation(s)
- Yi Lin Lee
- Department of Surgical Intensive Care, Singapore General Hospital, Chennai, Tamil Nadu, India
| | | | - Sudha Harikrishnan
- Department of Anaesthesiology, Singapore General Hospital, Tamil Nadu, India
| | - Ranjith Karthekeyan
- Department of Anaesthesiology and Critical Care Medicine, Singapore, Sri Ramachandra Medical Centre Porur, Chennai, Tamil Nadu, India
| | - Harikrishnan Kothandan
- Department of Anaesthesiology and Critical Care Medicine, Singapore, Sri Ramachandra Medical Centre Porur, Chennai, Tamil Nadu, India
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Abdelraheem TM, Elkeblawy AM. Remifentanil versus labetalol for deliberate hypotensive anesthesia in children undergoing cochlear implantation: A randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1935125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Taysser M. Abdelraheem
- Anesthesiology, Surgical Intensive Care and Pain Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amira M. Elkeblawy
- Anesthesiology, Surgical Intensive Care and Pain Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Sahu BP, Nayak LK, Mohapatra PS, Mishra K. Induced Hypotension in Functional Endoscopic Sinus Surgery: A Comparative Study of Dexmedetomidine and Esmolol. Cureus 2021; 13:e15069. [PMID: 34150405 PMCID: PMC8207487 DOI: 10.7759/cureus.15069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Functional endoscopic sinus surgery (FESS) is one of the common surgical procedures requiring hypotensive anesthesia; many agents have been tried to reduce the amount of blood loss. This study aims at comparing the efficacy of two agents for providing deliberate hypotension. Objectives The aim of this study was to evaluate the efficacy of esmolol and of dexmedetomidine and compare which one of the two is a better agent to produce induced hypotension during FESS. Materials and methods This was a comparative study conducted in a tertiary care hospital in Odisha, India. There were two study groups with 30 participants each who were given either esmolol or dexmedetomidine (group E and group DEX, respectively). Results Esmolol is an anti-hypertensive agent with better hemodynamic stability. The amount of drug and dose requirement was low in group DEX. The emergence time, sedation score, and time to first analgesic request were found to be highly statistically significant in group DEX. Conclusion Dexmedetomidine was found to be a better agent at controlling intra-operative blood pressure than esmolol and had beneficial effects on recovery from anesthesia and analgesia.
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Affiliation(s)
- Baladev P Sahu
- Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Laba K Nayak
- Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Partha S Mohapatra
- Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Krishna Mishra
- Department of Community Medicine, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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