Intraoperative Bleeding Control with Terlipressin in Functional Endoscopic Sinus Surgery
The Laryngoscope. 2023
OBJECTIVE To evaluate the use of terlipressin for intraoperative bleeding reduction in functional endoscopic sinus surgery (FESS). METHODS This prospective, randomized, single-center, single-blinded cohort study included 74 cases of FESS performed under general anesthesia (GA). The patients were randomized into two groups: WT (without terlipressin, n = 39) and T (with 200 μg terlipressin, n = 35). Bleeding intensity (BI) was assessed using a 6-point scale. Heart rate (HR), mean blood pressure (MBP), perfusion index (PI), and BI were recorded at 10, 30, and 60 min after surgery. A BI score ≥2 qualified as significant. RESULTS The T group had significantly higher MBP compared with the WT group, but HR values did not differ significantly. PI and BI scores were significantly reduced in the T group compared with the WT group. The risk of significant bleeding in the treatment group was 35.5 times lower (odds ratio [OR], 0.028; 95% confidence interval [CI], 0.006-0.138) at 30 min and 7.1 times lower (OR, 0.140; 95% CI, 0.049-0.402) at 60 min. The prognostic model for significant bleeding at 60 min showed that only terlipressin played a significant role in bleeding control (p < 0.05). The model predicted a 13.9-fold decrease in significant bleeding risk in the T group. CONCLUSION Low doses (200 μg) of terlipressin reduced intraoperative bleeding without decreasing blood pressure during FESS under GA. LEVEL OF EVIDENCE 2 Laryngoscope, 2023.
Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial
OBJECTIVES Rhinoplasty is one of the most common cosmetic surgeries in the world. Lack of adequate local homeostasis may lead to excessive bleeding during the operation, which increases the time of operation and recovery period, and the prevalence of complications. This study investigated the effects of nasal desmopressin on the quality of the surgical field and the volume of bleeding during rhinoplasty. MATERIALS AND METHODS This double-blind randomized clinical trial was performed on 120 patients aged 18-40 years who were candidates for rhinoplasty. Patients were randomly divided into three groups: low-dose desmopressin group and high-dose desmopressin group and placebo group. Hemodynamic changes and surgical field based on BOEZAART criteria, and the volume of bleeding were calculated. RESULTS In this study 115 women (95.8%) and 5 men (4.2%) participated. The mean age of patients was (27 ± 6.8). Bleeding volume in high dose desmopressin group was (21.7 cc ± 12.3), (27.7 cc ± 12.3) in low dose group, and (38.3 cc ± 12.3) in the placebo group, The difference in blood volume among the three groups was statistically significant with p < 0.005. Clean surgical field according to BOEZAART classification was marginally significant in both desmopressin groups. The differences in blood pressure, heart rate, blood and urine sodium, and hemoglobin before and after surgery between groups there not statistically significant. CONCLUSION Based on the results of the present study topical nasal spray desmopressin can reduce surgical field bleeding during rhinoplasty. To generalize the results to other surgeries in the ENT field it is recommended to conduct studies.
Effect of lidocaine infusion on intraoperative bleeding during functional endoscopic sinus surgery: a randomized controlled trial
Minerva anestesiologica. 2022
BACKGROUND It is crucial to reduce bleeding during functional endoscopic sinus surgery (FESS). Our primary goal was to evaluate the effect of intravenous lidocaine infusion (ILI) as an adjunct to the enhanced recovery after surgery (ERAS) protocols on intraoperative bleeding during FESS. We hypothesised that ILI could improve the surgical field. METHODS Forty-three adult patients ASA I-II, 20-50 years old, undergoing FESS under general anesthesia were randomly assigned to receive immediately after induction of anesthesia either ILI 1.5 mg/kg as a bolus followed by 1.5 mg/kg/ h until the end of surgery (Group L) or normal saline (Group NL). Intraoperative blood loss, bleeding and surgeon satisfaction scores, mean arterial pressure (MAP), heart rate (HR), extubation and eye opening times, and time to first analgesic request were recorded. RESULTS Intraoperative bleeding and bleeding scores in the first 45 min after ILI were decreased, with better surgeon satisfaction in Group L (P < 0.05). MAP and HR values were lower after ILI in Group L during surgery (P < 0.05). Extubation and eye opening times were shorter (P = 0.001) and the time to first analgesic request was prolonged (P = 0.001) in Group L than in Group NL. CONCLUSIONS ILI decreased intraoperative blood loss and improved the surgical field visibility in the first 45 min during FESS.
Efficacy of prophylactic preoperative desmopressin administration during functional endoscopic sinus surgery for chronic rhinosinusitis: a systematic review and meta-analysis of randomized placebo-controlled trials
Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 2022
AIM: To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) that examined the efficacy of prophylactic desmopressin versus placebo among patients undergoing functional endoscopic sinus surgery (FESS). METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, and Web of Science databases were screened from inception until 18-March-2022. The included studies were evaluated for risk of bias. The efficacy endpoints were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). RESULTS Five RCTs comprising 380 patients (desmopressin=191 patients and placebo=189 patients) were included. Collectively, the included RCTs had an overall low risk of bias. The pooled results showed that the mean intraoperative blood loss (n=5 RCTs, MD=-37.97 ml, 95% CI [-56.97, -18.96], p<0.001), 5-point Boezaart scores (n=2 RCTs, MD=-0.97, 95 CI [-1.21, -0.74], p<0.001), and 10-point Boezaart scores (n=2 RCTs, MD= -3.00, 95% CI [-3.61, -2.40], p<0.001) were significantly reduced in favor of the desmopressin group compared with the placebo group. Operation time did not significantly differ between both groups (n=5 RCTs, MD=-3.73 min, 95% CI [-14.65, 7.18], p=0.50). No patient in both groups developed symptomatic hyponatremia (n=3 RCTs, 194 patients) or thromboembolic events (n=2 RCTs, 150 patients) CONCLUSION Among patients undergoing FESS, prophylactic administration of desmopressin does not correlate with significant clinical benefits. Data on safety is limited. Future research may explore the synergistic antihemorrhagic efficacy and safety of tranexamic acid (TXA) plus desmopressin versus TXA alone among patients undergoing FESS.
The Effect of Desmopressin Intraoperatively on Hemorrhage During the Rhinoplasty Surgery
Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2022;74(Suppl 3):4761-4765
This clinical trial discusses the efficacy of premedication with desmopressin in the management of bleeding and clears the surgical field during rhinoplasty surgery. This study is a randomized, double-blinded placebo-control clinical trial. Seventy patients were enrolled in this study and divided into two equal intervention-control groups. Thirty minutes before surgery, the intervention group received 500 ml of normal saline containing 0.1 μg/kg desmopressin and, the control group received 500 ml of normal saline. According to the surgeon's opinion, the local distribution of bleeding was dramatically different in both groups. While DDAVP receivers had grade 1 or 2 bleeding (according to the FROMME-BOEZAART grading score), the control group had grade 3 or 4 bleeding, and this difference was statistically meaningful. It seems that intravenous DDAVP can reduce bleeding and clear the surgical field during rhinoplasty surgery, but further studies are needed to determine the exact role and dose of the DDAVP.
The Effect of the Premedication with Systemic Corticosteroids and Antibiotics on Inflammation and Intraoperative Bleeding During Sinonasal Endoscopic Surgery for Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)
The Journal of craniofacial surgery. 2022
INTRODUCTION Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease characterized by a variety of inflammatory mechanisms. Extensive genetic analyses have shown that among the molecules that are involved in its genetic base, interleukins (ILs) play a critical role in the development and progression of CRSwNP. ILs, such us IL-4 (5q31.1), IL-5 (5q31.1), IL-13 (5q31.11), and IL-25 (14q11.2) are found to be overexpressed. PURPOSE Our aim is to investigate, through a systemic review, the effect of the premedication with systemic corticosteroids and antibiotics on inflammation and intraoperative bleeding during sinonasal endoscopic surgery for CRSwNP. MATERIALS AND METHODS The search period covered January 1979 to February 2021, using the scientific databases PubMed, ScienceDirect, Scopus, Cochrane Library και Google Scholar. Search terms were "effect, premedication, systemic corticosteroids, antibiotics, intraoperative, bleeding, inflammation, sinonasal, endoscopic surgery, chronic rhinosinusitis, and nasal polypοsis." RESULTS From an initial 80 titles found in the above medline databases, the evaluations led to the final inclusion of 15 papers. Eighty titles found in the above medline databases. Eleven titles were excluded as they did not include a summary and full text in English language. Sixty-nine titles collected and duplicate references were searched. Twelve titles were excluded due to double reporting. Fifty-seven articles remained for systematic review. Fourty-two articles were excluded after systematic review and correlation with the research field. Fifteen articles were eventually included in the literature review. CONCLUSIONS The effect of corticosteroids and antibiotics on the size of nasal polyps, nasal symptoms, and systemic markers of inflammation is significant. Each of the above factors acts on different pathogenetic inflammatory mechanisms.The use of perioperative corticosteroids reduces blood loss and operation time and improves the quality of the surgical field. There are no other medications that have been shown to improve the surgical field and outcome. Whether there is an additive effect on systemic corticosteroids on top of nasal corticosteroids is unclear. The european position paper on rhinosinusitis and nasal polyps steering group advises to use (nasal) corticosteroids before endoscopic sinus surgery.However, it should be considered in future studies whether some minor differences are due to differences in the initial doses of corticosteroids or during treatment in the preoperative period. It is worth mentioning that although high doses of corticosteroids are required to control the progression of rhinosinusitis with nasal polyps, the optimal initial dosage and the total duration of the treatment have not yet been standardized in patients with CRSwNP and future studies are required to determine the 2 above parameters (optimal dosage and duration of treatment). There are, therefore, known risks from corticosteroid administration, and clinicians should consider them when evaluating each patient. Each patient should be considered as an individual case with individualized treatment.
Effect of Topical Furosemide Efficacy on Reducing Bleeding and Quality of Surgical Field During Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis
Iranian journal of otorhinolaryngology. 2022;34(124):219-224
INTRODUCTION Bleeding during endoscopic sinus surgery has an unfavorable effect on the surgical field and prolongs the time of surgery. In this study, we assessed the efficacy of topical furosemide on bleeding and the quality of the surgical field during endoscopic sinus surgery. MATERIALS AND METHODS In this clinical trial, 76 patients with chronic rhinosinusitis were selected for endoscopic sinus surgery and randomly assigned to two groups, topical furosemide (intervention) and normal saline (control). The intervention group received 20 micrograms of intranasal spray twice daily, and the control group received regular intranasal saline spray, similar to the intervention group. In addition, the quality of the surgical field (scoring by the BOEZAART grading system) and the amount of bleeding during surgeries were measured. All data were analyzed. RESULTS In the intervention and control groups, the mean surgical bleeding volume was 187.70± 24.79 and 229.21± 28.18 ml (P <0.001), the mean of Boezaart scale 2 and 3 (P <0.001) and the mean of surgical time were 106.53±14.67 and 126.63 ± 15.42 minutes (P <0.001), respectively. In patients of the intervention group with and without polyps, the mean surgery time was 99.56± 12.15 and 118.84 ±10.03 minutes (P <0.001), and the mean bleeding volume during endoscopic sinus surgery was 176.46 ± 22.58, 208.46 ±12.14 ml (P <0.001) respectively. CONCLUSIONS Our findings showed that nasal, topical furosemide spray significantly reduced the amount of bleeding during endoscopic sinus surgery and time of the surgery and improved the quality of the surgical field.
Effect of desmopressin on bleeding during endoscopic sinus surgery: A randomized clinical trial
Laryngoscope investigative otolaryngology. 2022;7(4):920-927
BACKGROUND This study aimed to evaluate the effect of local nasal desmopressin premedication on blood loss and the quality of surgical field in Functional Endoscopic Sinus Surgery (FESS). MATERIAL AND METHODS In a randomized clinical trial, patients referred for FESS to treat their bilateral chronic rhinosinusitis were recruited. The participants were adults (≥18 years). They were randomly assigned (1:1:1) to receive low-dose (20 μg) or high-dose (40 μg) intranasal desmopressin (DDAVP) or placebo 60 min before the induction of general anesthesia. Standard FESS was performed by the same surgeon. The primary outcomes were volume of intraoperative bleeding and the quality of surgical field. Clean surgical field was defined as a score ≤2 on the Boezaart grading system. RESULTS A total of 120 patients were included on an intention-to-treat basis (mean age: 41.0 years; 40 women, 80 men). There were no significant differences in primary outcomes between low-dose DDAVP and placebo. As for the volume of blood loss, however, there was a significant difference between high-dose DDAVP and placebo (mean difference: 29.6 ml; adjusted Cohen's d: -1.02; p < .001). Also, in the high-dose DDAVP, the probability of having a good surgical field over time was about two times higher than in the placebo group (RRs for first and second surgical sides: 1.89 and 2.18). The number needed to treat for the two time points was 1.6 and 1.3, respectively. CONCLUSION The present study showed that the use of desmopressin at a dose of 40 μg 1 h before surgery can reduce bleeding and improve the quality of the surgical field. Further studies are recommended to be able to generalize these findings to other ENT surgeries. LEVEL OF EVIDENCE 1b.
Intravitreal bevacizumab (IVB) versus IVB in combination with pars plana vitrectomy for vitreous hemorrhage secondary to proliferative diabetic retinopathy: a randomized clinical trial
International journal of retina and vitreous. 2021;7(1):35
BACKGROUND The main purpose of this study is to compare the vitreous hemorrhage (VH) score reduction and visual acuity outcomes in patients with VH secondary to proliferative diabetic retinopathy (PDR) treated with intravitreal injections of bevacizumab (IVB) versus IVB and pars plana vitrectomy (IVB and PPV). METHODS Patients with VH secondary to PDR were randomized into 2 groups: in Group A, patients were treated with a total of 3 IVB (1.5 mg/0.06 ml) at 8-week intervals; and in Group B, patients received a single IVB (1.5 mg/0.06 ml) and, 7 days later, underwent PPV. Patients received an ophthalmic evaluation that included best-corrected visual acuity (BCVA), indirect ophthalmoscopy, and mode B echography at weeks 8, 16 and 24. VH was classified according to the Diabetic Retinopathy Vitrectomy Study classification as grade 1, 2 or 3. Change in VH score was the primary outcome measure and change in BCVA was the secondary outcome. RESULTS Seventy-three eyes of 66 patients were randomized and 70 eyes completed the 24-week follow-up visit. Mean VH score reduction (± SEM) of 0.4571 ± 0.0283 (p = 0.0014), 1.3429 ± 0.0393 (p < 0.0001) and 1.8286 ± 0.0438 (p < 0.001) was observed in Group A at 8, 16 and 24 weeks after treatment, respectively (Table 2; Fig. 2). In Group B, the reduction of VH score (± SEM) was 2.2571 ± 0.0720 (p = 0.0014), 2.2857 ± 0.0606 (p < 0.0001) and 2.2286 ± 0.0726 (p < 0.001) at 8, 16 and 24 weeks after treatment, respectively. Group comparison revealed a significantly greater reduction in mean VH score in Group B at 8 and 16 weeks after treatment (p < 0.0001). However, at 24 weeks this difference was no longer statistically significant (p = 0.1854). In Group A, mean (± SEM) BCVA showed an improvement of 0.00285 ± 0.0004 (p = 0.971), 0.5371 ± 0.0072 (p < 0.0001), 0.8143 ± 0.0001 (p < 0.0001) and 0.8543 ± 0.0008 (p < 0.0001) compared to baseline at 1, 8, 16 and 24 weeks after treatment, respectively. In Group B, mean (± SEM) BCVA showed an improvement of 0.3657 ± 0.0507 (p = 0.0002), 0.8857 ± 0.0385 (p < 0.0001), 0.9457 ± 0.0499 (p < 0.0001) and 0.9629 ± 0477 (p < 0.0001) compared to baseline at 1, 8, 16 and 24 weeks after treatment, respectively. No significant difference in BCVA improvement was observed between groups at 24 weeks after treatment. CONCLUSION PPV with preoperative IVB is associated with more rapid clearance of VH and improvement in BCVA than IVB injections alone. However, after 24 weeks of follow-up, the reduction in VH score and BCVA were similar between both treatment strategies. Trial Registration The project is registered in Plataforma Brasil with CAAE number 927354.7.0000.5440 and was approved by the Ethics Committee of the Clinics Hospital of Ribeirao Preto Medicine School of São Paulo University-Ribeirão Preto, São Paulo, Brazil (appreciation number 3.053.397 gave the approval).
The effect of intranasal irrigation with epinephrine solution on intraoperative visualization and bleeding during FESS
European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2021
PURPOSE Bleeding during Functional endoscopic sinus surgery (FESS) can have adverse effect on surgical outcomes. This study evaluates if there is any benefit of adding epinephrine to the saline nasal irrigation in patients undergoing elective FESS for chronic rhinosinusitis. METHODS A prospective, randomized, double-blinded study was performed. Fifty ASA I or II patients undergoing FESS were randomized to have irrigation either with normal saline or (1:100,000) epinephrine in normal saline during surgery. Outcomes measure included the Boezaart grading scale to assess the intraoperative surgical field, surgeon's satisfaction with field visualization and bleeding which was evaluated in a 10 cm visual analog scale, estimated blood loss as well as hemodynamic parameters changes. RESULTS There was no statistically significant difference in the studied variables between both groups. However in patients with higher than 12 Lund-Mackay score the volume of blood loss was significantly less in the epinephrine group. All surgical procedures were completed and there were no operative complications or any reported perioperative cardiovascular events. CONCLUSIONS Intraoperative irrigation with saline-epinephrine solution at a concentration of (1:100,000) is safe and does not change heart rate or blood pressure but is unlikely to improve the setting of intraoperative surgical field except for decreasing the volume of blood loss in patients with high Lund-Mackay score.