| Abstract|| |
Introduction: Due to the nature of the space that endoscopic sinus surgery is performed in it, even a small amount of bleeding has a negative effect on surgeon vision. The aim of this study was to compare the effects of propofol and dexmedetomidine on controlled hypotension and bleeding during endoscopic sinus surgery. Materials and Methods: In this randomized clinical trial, 100 patients candidate for endoscopic sinus surgery entered the study. The patients were randomly divided into two groups. In the first group, Group D, 1 μg/kg dexmedetomidine was injected within 10 min as the initial dose and 0.4–0.8 μg/kg/h infusion was continued. In Group P, 50–150 μg/kg/min Propofol was infused. Hemodynamic parameters were measured from the onset of the study to 120 min after surgery, and the intraoperative bleeding was reported by surgeon. Results: Mean score of bleeding was 1.14 ± 0.70 in Group D and 1.24 ± 0.74 in Group P (P = 0.490). Wilks' group Lambda test showed a significant reduction in heart rate of both groups (F = 3.45, P = 0.002). Heart rate in Group P was significantly lower than Group D (Greenhouse-Geisser test, F = 2.70, P = 0.015). There was no statistical difference in mean arterial pressure and O2saturation. The average time of patients recovery was 32.52 ± 7.9 min in Group D and 29.90 ± 10.6 min in Group P (P = 0.166). Conclusion: Propofol could reduce heart rate significantly more than dexmedetomidine. However, about reduction of bleeding and obtaining an appropriate surgical field which were the main outcomes of the study, there was no significant difference between groups.
Keywords: Blood loss, controlled hypotension, dexmedetomidine, endoscopic sinus surgery, propofol
|How to cite this article:|
Moshiri E, Modir H, Yazdi B, Susanabadi A, Salehjafari N. Comparison of the effects of propofol and dexmedetomidine on controlled hypotension and bleeding during endoscopic sinus surgery. Ann Trop Med Public Health 2017;10:721-5
|How to cite this URL:|
Moshiri E, Modir H, Yazdi B, Susanabadi A, Salehjafari N. Comparison of the effects of propofol and dexmedetomidine on controlled hypotension and bleeding during endoscopic sinus surgery. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Dec 16];10:721-5. Available from: http://www.atmph.org/text.asp?2017/10/3/721/213152
| Introduction|| |
Endoscopic sinus surgery has been proposed as selected treatment method, and it is used widely in patients with chronic sinusitis that has not responded to medical therapy. Due to the nature of location that endoscopic sinus surgery is done, even a small amount of bleeding can leave a negative effect on vision of surgeon. Increased bleeding leads to many problems in establishing a proper surgical field, making surgery harder and longer. There are numerous methods such as holding up the head during surgery, injection of epinephrine in the lining of the nose, creation of bradycardia during the surgery, lower blood pressure by prescribing fast-acting beta-blocker or magnesium sulfate, or using alpha-receptor agonists before surgery to reduce bleeding inside the nose. Among the different methods, using anesthetics can affect amount of bleeding and surgery situation by hypotension or vasodilatory effect  that systolic blood pressure should be between 80 and 90 or mean of arterial blood pressure should be kept between 50 and 60 so that no disruption to occur in perfusion of tissues. Ideally, antihypertensive agents should have features including ease of prescribing, the quick starting and ending effect, lack of producing toxic intermediates, slight effect on vital organs, and predictable dose-dependent effects. Propofol is one of the most common drugs used in general anesthesia, which reduces systemic blood pressure by dilating blood vessels. In the maintenance of anesthesia, propofol infusion reduces pressure by 20%–30% compared to before that. Many studies have shown that propofol reduces the amount of bleeding in different surgeries, and this drug decreases bleeding during endoscopic sinus surgery., As mentioned before, using alpha-receptor agonists can reduce the bleeding during the surgery by lowering the blood pressure. Dexmedetomidine that is selected alpha-2 receptor agonist has a retentive, sedative, analgesia, and sympatholytic property in anesthesia. Central and peripheral sympatholytic performance of dexmedetomidine depends on alpha-2 receptor manifested by reduced arterial blood pressure, heart rate, cardiac output, and reduced release of norepinephrine. Various studies have proven the effect of this drug in lowering blood pressure to reduce the bleeding in various surgeries.,, Therefore, the aim of this study was to compare the effects of propofol and dexmedetomidine in reducing the blood pressure and amount of bleeding in the surgical field during endoscopic sinus surgery.
| Materials and Methods|| |
In this double-blind clinical trial, 100 patients undergoing endoscopic sinus surgery in Arak AmirKabir Hospital were included after obtaining written consent, and according to inclusion and exclusion criteria, including patients aged 18–60 years and American Sociological Association I–II patients who were a candidate for nonemergency endoscopic sinus surgery. In addition, those patients who had coagulation disorders, a history of cardiovascular disease, lack of proper control blood pressure, pregnancy, addiction to opiates, and body mass index >35 were excluded from the study. Ethics Committee of Arak University of Medical Sciences approved this study with the code of IR.ARAKMU.REC.1394.228. The study was also registered with the code of IRCT2015101814056N5 in Iran's clinical trials site. Based on mean arterial blood pressure during surgery (71 ± 4 and 474 ± 6) and alpha error of 5% and beta error of 20%, sample in each group was considered fifty patients.
All patients were hospitalized 1 day before surgery, and they were fasting for 8 h. After recording demographic data, on arrival to the operating room, two intravenous lines were placed in different locations, one of them for injection of dexmedetomidine or propofol and another one for injection of intravenous fluids or other drugs. Before induction, heart rate, mean arterial blood pressure (using noninvasive measurement method), and arterial oxygen saturation were measured. In the starting of induction, 5 mg/kg crystalloid fluid was injected and 100% oxygen was given to patients through a mask in the first 3 min. Anesthesia was induced with 1 μg/kg fentanyl and 5 mg/kg thiopental, and intubation was performed with 0.5 mg/kg atracurium. Then, patient was mechanically ventilated up to 30–35 mmHg concentration of exhaled carbon dioxide and 95% arterial oxygen saturation. Then, patients were randomly divided into two groups. In Group D, 1 μg/kg dexmedetomidine was infused for 10 min as initial dose followed by 0.4–0.8 μg/kg/h to maintain dose. In Group P, the propofol was infused with a dose of 50–150 μg/kg/min. Infusion rate to maintain mean arterial blood pressure between 65 and 75 mmHg was regulated in both groups. General anesthesia was also maintained with isoflurane (0.5%–2%). Heart rate, mean arterial blood pressure, and arterial oxygen saturation were measured and recorded after the induction, during the hypotension stage (every 15–120 min), and at the end of surgery. The surgeon who was blind on classifications of the study and had no information on anesthesia drug investigated the status of the surgery area in terms of bleeding and he rated it based on 0–6 scoring. The scores of this ratings include 0 (area without blood), 1 (very mild bleeding that can be considered dry), 2 (mild bleeding that does not distort the cut area), 3 (moderate bleeding that affects cut area), 4 (much bleeding which can be controlled but destroys the cut area), and 5 (so much bleeding that cannot be controlled). In this rating, Score 2 and lower reflect the desired state of operated area in terms of bleeding. Five minutes before the end of surgery, anesthesia and propofol and dexmedetomidine infusion were cut. Extubation was performed when respiratory volume was proper and based on back of reflexes of the airway and recovery time based on Aldrete Table  (obtaining a score of 9 or more), and it was recorded in the patient form when patient scored 9 or higher, he was transferred to ward. Finally, complications such as low blood pressure during surgery (<65 mmHg) and bradycardia (heart rate <50/min) and postoperative complications such as nausea and vomiting, muscle stiffness and shivering, and a dose of consumed drugs (dexmedetomidine and propofol) were recorded. In the case of using other blood pressure-lowering drugs, they were recorded in the assessment form of patient. The data collected in this study were analyzed using statistical IBM SPSS Statistics V20.0.0 (IBM Co., Armonk, NY, USA) For qualitative data, Chi-square test was used, and independent t-test was used for quantitative data. To evaluate quantitative data changes in time sequences, variance analysis test, repeated observations, and Wilks's Lambda test were used. P < 0.05 in this study was considered statistically significant.
Ultimately, 100 patients who were a candidate for endoscopic sinus surgery were included in the study. In Group D, 22 female patients (44%) were included, and in Group P, 21 female patients (42%) were included, and the rest of patients (P = 0.840) were male [Table 1]. The mean age of patients in Group D was 35.16 ± 8.2 years and the mean age of patients in Group P was 36.90 ± 8.2 (P = 0.294). During surgery, the amount of patients' bleeding was scored based on 6-point score explained in the procedure of study. Accordingly, mean score of bleeding in Group D was 1.14 ± 0.70, and in the Group P, it was 1.24 ± 0.74 that was not a significant difference between the two groups in terms of bleeding score (P = 0.490).
|Table 1: Amounts of demographic variables and variables related to surgery in two groups|
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To assess changes in hemodynamic parameters, variance analysis with repeated observations was used. During induction of anesthesia, heart rate of patients in Group D was 91.68 ± 14.5 and it was 88.14 ± 6.3 in Group P (P = 0.116). Intergroup Wilks' Lambda test with the amount of F = 3.45 and a significant level of P = 0.002 represents a significant decrease in heart rate in both groups. Intergroup analysis with the Greenhouse-Geisser test also showed that the heart rate was significantly lower in Group P (F = 2.70, P = 0.015) [Figure 1].
|Figure 1: The mean heart rate of patients within 120 min after induction of anesthesia|
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The mean arterial blood pressure of patients at the beginning of the study in Group D was 82.9 ± 9.4 mmHg and it was 81.59 ± 10.9 mmHg in Group P (P = 0.512). Intergroup Wilks' Lambda test with F = 2.43 and a significant level of P = 0.020 represents a significant decrease in mean arterial blood pressure in both groups. Intergroup analysis with the Greenhouse-Geisser test also showed that there is no difference between the two groups in terms of mean arterial blood pressure (P = 0.546; F = 0.848) [Figure 2].
|Figure 2: Mean values of arterial blood pressure of patients within 120 min after induction of anesthesia|
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In terms of arterial oxygen saturation at the beginning of the study, the difference between the two groups was not significant (P = 0.185). Intergroup analysis with the Greenhouse-Geisser test showed that there is no significant difference between two groups in terms of mean arterial oxygen saturation (P = 0.197; F = 1.64) [Figure 3].
|Figure 3: Mean values of arterial oxygen saturation at 120 min after induction of anesthesia|
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The mean time to extubation in Group D was 87.64 ± 22.1 min and it was 81.44 ± 13.5 min in Group P, which there was not significant between two groups (P = 0.094). Mean of recovery time of patients in Group D was 32.52 ± 7.9 min and it was 29.90 ± 10.6 min in Group P (P = 0.166). Mean of Aldert's score was also 9.56 ± 0.50 in Group D patients, whereas it was 9.54±0.50 in Group P (P = 0.843).
| Discussion|| |
The results of this study showed that propofol could reduce heart rate significantly compared to patients receiving dexmedetomidine. Both groups could cause a controlled hypotension, but they had no significant advantage over each other. The bleeding was not significantly different in the two groups, and surgeon had relatively high satisfaction with both drugs. The mean time to extubation and recovery time for patients was not significantly different between the two groups. Since good visibility in the surgical field is directly associated with postoperative outcomes, reduced bleeding during surgery is the largest concern of ear, nose, and throat specialists and anesthetists. Recent studies have proven that better visibility in the surgical field is directly related to heart rate., Hence, controlled hypotension is one of the requirements to create a good vision in surgery. This could lead to better surgical field and reduced surgery time and complications. Propofol is the most common drug used in general anesthesia. Through vasodilatation, this drug creates the greatest reduction in systemic blood pressure. Propofol is an intravenous anesthetic drug leading to reduced mean arterial blood pressure by reduced cardiac output and systemic vascular resistance. One feature of this drug is that when heart rate increases due to blood pressure drop, reduces it through baroreceptor reflex suppression. In addition, when propofol is infused continuously, it may cause a decrease in cerebral perfusion pressure that leading to brain blood flow regulation. Ethmoid, sphenoid, and frontal sinuses are perfused by branches of the internal carotid artery (ethmoidal and supraorbital arteries). Internal carotid artery is a branch of the blood circulation of the brain. Thus, Due to reduced blood flow around the paranasal sinuses, bleeding is reduced. In a study conducted by Marzban et al., propofol compared to isoflurane could provide a better view for the surgeon and reduce the amount of bleeding. In another study conducted by Pavlin et al., propofol compared to isoflurane could create better hypotension during endoscopic sinus surgery. In a study conducted by Hasani, difference between propofol/remifentanil and isoflurane/remifentanil was not significant in reducing bleeding. In a study conducted by Chaaban et al., the difference between propofol and inhalation anesthetics was not significant in reducing bleeding during nasal endoscopic surgery. As propofol, studies have shown that dexmedetomidine also has positive effects in creating an appropriate vision in endoscopic sinus surgical field. This improvement may be due to the vasoconstrictor effect of alpha-2 agonists. However, in studies related to endoscopic sinus surgery, patients in the placebo group had a heart rate much higher than dexmedetomidine group. Vasoconstrictor effects of dexmedetomidine have been widely confirmed in animal studies., Moreover, experimental studies have published evidence suggesting that venous dexmedetomidine has vasoconstrictor effect on arterial and venous system of human. Although there is no evidence to show dexmedetomidine contracts peripheral vascular directly and reduces bleeding during surgery, it seems dexmedetomidine reduces bleeding during endoscopic sinus surgery, resulting in better visibility for surgery. Basar et al. examined the effect of dexmedetomidine with a single dose of 0.5 μg/kg 10 min before induction of anesthesia, and they stated that the drug could significantly decrease the mean arterial pressure and heart rate. Dexmedetomidine impact on establishing better surgical conditions and less bleeding during controlled hypotension in tympanoplasty, septoplasty, and maxillofacial surgeries has been reported.,, Results of a study conducted by Bayram et al. showed that dexmedetomidine compared with magnesium sulfate could create controlled hypotension effectively leading to better view in the surgical field. In the study conducted by Shams et al., dexmedetomidine with a dose of 1 μg/kg and infusion of 0.4–0.8 μg/kg/h (the dose used in this study) was safe to create controlled hypotension and create the ideal surgical field in endoscopic sinus surgery. Another study that examined the effects of dexmedetomidine at a dose of 1 μg/kg and infusion of 0.7 μg/kg/h, it was stated that this drug could reduce bleeding at the surgical site, improve the surgeon vision, and reduce the need for fentanyl during surgery. In the study conducted by Snidvongs, similar results were obtained reflecting the advantages of dexmedetomidine drug in endoscopic surgery of the nose.
| Conclusion|| |
Studies have proven that desired surgical field is made possible by reducing the heart rate rather than through vasoconstriction. In our study, propofol could reduce the heart rate significantly more than dexmedetomidine. However, in the main result of the study, reducing the bleeding and establishing the appropriate surgical field showed no difference between two groups.
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] [Full text]
Snidvongs K, Tingthanathikul W, Aeumjaturapat S, Chusakul S. Dexmedetomidine improves the quality of the operative field for functional endoscopic sinus surgery: Systematic review. J Laryngol Otol 2015;129 Suppl 3:S8-13.
Department of Anesthesiology, Arak University of Medical Sciences, Arak
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]