Manipulations To Minimize Bleeding And Improve Outcome Of Functional Endoscopic Sinus Surgery
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Objectives: The present study was designed as a trial to improoe field visibility during functional endoscopic sinus surgery (FESS) by means of positional changes and the use of controlled hypotension achieved through maintenance of anesthesia usmg remifentanil and either of propofol infusion (Total Intravenous; Tl) or isofhtrane inhalation (Combined Intravenousflnhalational; CU). Patients & Methods : The study included 32 patients; 23 males and 9 females, with mean age of3928.i years and assigned to undergo FESS. Patients were divided randomly into two equal groups according maintenance anesthetic regimen: Group 77 and Group CU. Each group was subdivided according to patients' position during surgery into supine and anti-Trendelenburg by 30. Anesthesia was maintained in both groups by slow infusion of 2 mg of remifentanil in 40 cc of physiological saline in addition toSOcc of propofol infusion in Group Tl group or isoflurane 1-2% in Group CU. Patients were monitored non-invasivety, before induction of anesthesia (To) and 20 (Tat), 40 (Tad and 60 min (Tea) after induction of anesthesia, for mean arterial pressure (MAP) and heart rate (HR). The approach for FESS was conducted totally endonastd after Kennedy procedure. The visibility of the operative field during FESS was evaluated using 6-points Fromme scale and total amount of bleeding as judged by the amount evacuated was also recorded. Results: Both anesthetic modalities reduced blood pressure significantly and decreased heart rate throughout times of observation compared to preopera^ve levels with significantly lower MAP measures in anti- Trendelenburg compared to supine position. All surgeries were conducted completely without intraoperative complications and no extensive Weeding was recorded. There was a significant increase in the frequency of good field viability with Tl compared to CU anesthesia with significantly improved field visibility in patients maintained in anti-Trendelenburg position compared to supine position. Estimated mean Wood loss was significantly less and the recorded field visibility scores were significantly higher in Tl group compared to CU group. There was a negative significant correlation between the field visMity score and mean MAP and mean amount of bleeding. Using regression analysis, the use ofhypotensive anesthesia was found to be a significant independent factor for improving filed visibility, and the use of Tl anesthesia was found to be significant determinant independent factor for induction of hypotensive anesthesia. Using ROC curve defined the superiority of use ofTl ever CU anesthesia as independent determinant for field visibility^ Conclusion : It could be concluded that maintaining patients in anti-Trendelenburg position and anesthetic manipulation using total intravenous anesthesia could minimize bleeding and improoe field visibility during FESS and thus this combination of manipulations could be appropriate strategy for such type of surgery.