The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery. Optimizing the surgical field in pediatric functional endoscopic sinus surgery: a new evidence-based approach. Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery. Total intravenous anaesthesia in endoscopic sinus-nasal surgery.
Bleeding during endoscopic sinus surgery (ESS) may increase complications and negatively effect the surgery and its outcome. The aim of this study was to compare the surgical field in patients in whom total intravenous anesthesia (TIVA) is used as opposed to inhalation anesthesia. A prospective randomized controlled trial was performed.
                Fifty-six patients undergoing ESS were randomly assigned to receive either inhaled sevoflurane with incremental doses of fentanyl (n = 28) or TIVA via a propofol and remifentanil infusion (n = 28) for their general anesthesia. The surgical field was graded every 15 minutes using a validated scoring system.
                The two groups were matched for surgical procedure and computed tomography scores. Patients in the TIVA group were found to have a significantly lower surgical grade score than in the sevoflurane group (p < 0.001). Surgical grade score increased with time in both groups. Mean arterial pressure and pulse were found to influence the surgical field independently (p = 0.003 and p = 0.036 respectively). Mean surgical field grade scores were higher in the patients with allergic fungal sinusitis and nasal polyposis as opposed to chronic rhinosinusitis without polyps or fungus. Lund-Mackay computed tomography scores were found to correlate positively with surgical grade (Spearman rank correlation, p = 0.001).
                In patients undergoing ESS, TIVA results in a better surgical field than inhalational anesthesia. To conduct the first prospective randomized controlled study 1) evaluating the possibility of improving the quality of the operative field and to provide a bloodless functional endoscopic sinus surgery (FESS) in children through total intravenous anesthesia (TIVA) using remifentanil combined with propofol, and 2) testing the safety and efficacy of remifentanil in propofol-TIVA in inducing controlled hypotension in children at a target mean arterial blood pressure of 50 mm Hg.
                Randomized controlled trial.
                General hospital.
                Seventy children underwent FESS under hypotensive general anesthesia with equal randomization into two groups. Group I received TIVA with remifentanil, whereas group II had balanced anesthesia (BA) with esmolol. Heart rate, blood pressure, operative time, blood loss, and quality of the surgical conditions were recorded.
                Intraoperative blood loss in the TIVA group was less than in the BA group. The quality and dryness of the surgical field in both the visual analogue scale and the six-point scale was significantly better in the TIVA group than in the BA group. Hypotension was sustained at the target mean arterial blood pressure of 50 mm Hg in the two groups, without any significant difference.
                Improving the quality of the surgical field and providing a bloodless FESS in children is attainable with TIVA. TIVA using a combination of remifentanil and propofol is superior to BA, even with the use of additional potent hypotensive agents such as esmolol. Both techniques are safe and effective in inducing controlled hypotension in children at a target mean arterial blood pressure of 50 mm Hg. Controlled hypotension is used to improve surgical conditions during microscopic and endoscopic sinus surgery. New short-acting anesthetics such as propofol and remifentanil allow exact control of intraoperative blood pressure and thus might be valuable tools to improve intraoperative conditions for the otorhinolaryngological surgeon. Intravenous anesthesia was compared with traditional balanced anesthesia by subjective assessment of surgical conditions made by two experienced otorhinolaryngological surgeons.
                Prospective, randomized, patient- and observer-blinded study.
                Ninety consecutive patients were randomly assigned to receive intravenous anesthesia with propofol 5 to 8 mg.kg-1.h-1 and remifentanil 10 to 30 microg.kg-1.h-1 or with isoflurane (0.4-1.0 vol%) and repetitive doses of 0.5 to 1 mg alfentanil. An injectable vasodilator was used in both groups to keep mean arterial pressure between 60 and 70 mm Hg (8-9.3 hecto-pascal). The attending otorhinolaryngological surgeon was unaware of the type of anesthesia administered. Immediately after the operation the surgeons rated surgical conditions (bleeding from the surgical field) on a visual analogue scale (0-10 cm) and on a verbal rating scale.
                Blood pressure was not different between the two groups, but heart rate was lower in the intravenous anesthesia group (mean heart rate in the intravenous anesthesia group, 62 beats per min [95% confidence interval, 52-72]; mean heart rate in the balanced anesthesia group, 75 beats per min [95% confidence interval, 67-83]). Surgical conditions were rated to be significantly better (P <.0001) during anesthesia with propofol-remifentanil (median rating: 2.8; 25th/75th percentile: 2.0/3.4) compared with isoflurane-alfentanil (median rating: 4.9; 25th/75th percentile: 3.6/7.6).
                Intravenous anesthesia using propofol-remifentanil provides better surgical conditions compared with a traditional balanced anesthesia technique using isoflurane-alfentanil. It is hypothesized that lower cardiac output caused by decreased heart rate during deep general anesthesia is responsible for this result. Aim of this randomized study (64 patients) was to improve the control of bleeding during functional endoscopic sinusal surgery by means of controlled hypotension achieved through either total intravenous anaesthesia using remifentanyl and propofol (27 patients), or inhaled using isoflurane and fentanyl (37 patients). The following parameters were monitored before administration of anaesthesia (T0), then after 15 (T1), and 30 minutes (T2): systolic, diastolic, and mean arterial pressure; heart rate; concentration of tele-exhaled carbon dioxide (PetCO2) and percentage of peripheral saturation of haemoglobin (SPO2); bleeding according to the Fromme-Boezaart scale at T2. Mean arterial pressure values were maintained between 60-70 mmHg throughout surgery. At T0, systolic arterial pressure, diastolic arterial pressure and mean arterial pressure values were seen to overlap in the two groups. Both types of anaesthesia were effective in reducing the pressure values of T0-T1 and T1-T2 trends (p<0.0001). Systolic arterial pressure at T1 is lower with total intravenous anaesthesia compared to isoflurane and fentanyl (p=0.02). PetCO2 and heart rate show a decreasing trend independently of the type of anaesthesia employed. In conclusion, the hypotensive effect of total intravenous anaesthesia and of isoflurane and fentanyl is equivalent, but only total intravenous anaesthesia is effective in reducing bleeding during functional endoscopic sinusal surgery.
Using propofol to achieve deliberate hypotension may improve the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and operation time. RCTs with good quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.