Skip to main content
The Egyptian Journal of Otolaryngology
Download PDF

Does tranexamic acid, deliberate hypotension, and anti-Trendelenburg position improve the quality and outcome for functional endoscopic sinus surgery

The Egyptian Journal of Otolaryngology volume 29, pages 71–75 (2013)Cite this article

En

Abstract

Objectives

To improve the control of bleeding during functional endoscopic sinus surgery (FESS) by means of positional changes, controlled hypotensive anesthesia, and an intraoperative (IO) intravenous injection of tranexamic acid.

Patients and methods

The study included 45 patients assigned to undergo FESS. Patients were divided randomly into three equal groups: group A received an IO injection of tranexamic acid 10 mg/kg as a bolus injection after induction of anesthesia. Group B included patients placed on a table inclined by ∼30π in the anti-Trendelenburg position and received an IO injection of tranexamic acid 10 mg/kg after induction of anesthesia. Group C included patients maintained supine who did not receive an IO injection of tranexamic acid. All patients received a maintenance anesthetic regimen that used combined intravenous/inhalational anesthesia. Operative field visibility was evaluated using the Fromme scale. The total amount of bleeding as judged by the amount evacuated was recorded.

Results

The anesthetic maneuver used reduced blood pressure and heart rate significantly at the end of surgery compared with the measures estimated at the time of induction of anesthesia. Groups A and C showed significantly higher blood pressure and heart rate estimated at the end of surgery compared with group B. All surgeries were conducted completely without IO complications. No extensive bleeding was recorded and no patient had a visibility score of 0 or 5. Four patients had a visibility score of 1, nine patients had a visibility score of 2, 15 patients had a visibility score of 3, and 17 patients had a visibility score of 4. The frequency of patients who had higher field visibility was significantly higher in group B compared with groups A and C, with a significantly higher frequency in group A compared with group C. Manipulations applied for group B significantly reduced the amount of IO bleeding, with a subsequent significant improvement in the mean field visibility score compared with groups A and C. Tranexamic acid significantly reduced the amount of bleeding and improved field visibility in group A compared with group C.

Conclusion

A combination of maintaining patients in the anti-Trendelenburg position, anesthetic manipulation using combined intravenous and inhalational anesthesia, and an IO intravenous injection of tranexamic acid could minimize bleeding and improve field visibility during FESS and this combination of manipulations could be recommended as strategy for this type of surgery.

References

  1. Eisenberg G, Pérez C, Hernando M, Taha M, González R, Montojo J, et al. Nasosinusal endoscopic surgery as major out-patient surgery. Acta Otorrinolaringol Esp. 2008; 59: 57–61.

    Article  PubMed  Google Scholar 

  2. Bradley DT, Kountakis SE. Correlation between computed tomography scores and symptomatic improvement after endoscopic sinus surgery. Laryngoscope. 2005; 115: 466–469.

    Article  PubMed  Google Scholar 

  3. Huang H-M, Cheng J-J, Liu C-M, Lin K-N. Mucosal healing and mucociliary transport change after endoscopic sinus surgery in children with chronic maxillary sinusitis. Int J Pediatr Otorhinolaryngol. 2006; 70: 1361–1367.

    Article  PubMed  Google Scholar 

  4. Mohseni M, Ebneshahidi A. The effect of oral clonidine premedication on blood loss and the quality of the surgical field during endoscopic sinus surgery: a placebo-controlled clinical trial. J Anesth. 2011; 25: 614–617.

    Article  PubMed  Google Scholar 

  5. Shen P-H, Weitzel EK, Lai J-T, Wormald P-J, Ho C-S. Intravenous esmolol infusion improves surgical fields during sevoflurane-anesthetized endoscopic sinus surgery: a double-blind, randomized, placebo-controlled trial. Am J Rhinol Allergy. 2011; 25: e208–e211.

    Article  PubMed  Google Scholar 

  6. Panda N, Verma RK, Panda NK. Efficacy and safety of high-concentration adrenaline wicks during functional endoscopic sinus surgery. J Otolaryngol Head Neck Surg. 2012; 41: 131–137.

    PubMed  Google Scholar 

  7. Kennedy DW. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope. 1992;102(12 II):1–18.

    CAS  PubMed  Google Scholar 

  8. Fromme GA, MacKenzie RA, Gould AB Jr, Lund BA, Offord KP. Controlled hypotension for orthognathic surgery. Anesth Analg. 1986; 65: 683–686.

    Article  CAS  PubMed  Google Scholar 

  9. Boezaart AP, Van Der Merwe J, Coetzee A. Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional endoscopic sinus surgery. Can J Anaesth. 1995;42(5 I):373–376.

    Article  CAS  PubMed  Google Scholar 

  10. Lee JM, Chiu AG. Role of maximal endoscopic sinus surgery techniques in chronic rhinosinusitis. Otolaryngol Clin N Amer. 2010; 43: 579–589.

    Article  CAS  Google Scholar 

  11. Cohen-Kerem R, Brown S, Villaseñor LV, Witterick I. Epinephrine/lidocaine injection vs. saline during endoscopic sinus surgery. Laryngoscope. 2008; 118: 1275–1281.

    Article  CAS  PubMed  Google Scholar 

  12. Sieśkiewicz A, Drozdowski A, Rogowski M. The assessment of correlation between mean arterial pressure and intraoperative bleeding during endoscopic sinus surgery in patients with low heart rate. Otolaryngol Pol. 2010; 64: 225–228.

    Article  PubMed  Google Scholar 

  13. Degoute C-S, Ray M-J, Manchon M, Dubreuil C, Banssillon V. Remifentanil and controlled hypotension; comparison with nitroprusside or esmolol during tympanoplasty. Can J Anesth. 2001; 48: 20–27.

    Article  CAS  PubMed  Google Scholar 

  14. Ko M-T, Chuang K-C, Su C-Y. Multiple analyses of factors related to intraoperative blood loss and the role of reverse Trendelenburg position in endoscopic sinus surgery. Laryngoscope. 2008; 118: 1687–1691.

    Article  PubMed  Google Scholar 

  15. Moumoulidis I, Del Pero MM, Brennan L, Jani P. Heamostasis in head and neck surgical procedures: Valsalva manoeuvre versus Trendelenburg tilt. Ann R Coll Surg Engl. 2010; 92: 292–294.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  16. Ipema HJ, Tanzi MG. Use of topical tranexamic acid or aminocaproic acid to prevent bleeding after major surgical procedures. Ann Pharmacother. 2012; 46: 97–107.

    Article  CAS  PubMed  Google Scholar 

  17. McConnell JS, Shewale S, Munro NA, Shah K, Deakin AH, Kinninmonth AWG. Reduction of blood loss in primary hip arthroplasty with tranexamic acid or fibrin spray: a randomized controlled trial. Acta Orthop. 2011; 82: 660–663.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Greiff G, Stenseth R, Wahba A, Videm V, Lydersen S, Irgens W, et al. Tranexamic acid reduces blood transfusions in elderly patients undergoing combined aortic valve and coronary artery bypass graft surgery: a randomized controlled trial. J Cardiothorac Vasc Anesth. 2012; 26: 232–238.

    Article  CAS  PubMed  Google Scholar 

  19. George A, Kumar R, Kumar S, Shetty S. A randomized control trial to verify the efficacy of pre-operative intravenous tranexamic acid in the control of tonsillectomy bleeding. Indian J Otolaryngol Head Neck Surg. 2011; 63: 20–26.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Alimian M, Mohseni M. The effect of intravenous tranexamic acid on blood loss and surgical field quality during endoscopic sinus surgery: a placebo-controlled clinical trial. J Clin Anesth. 2011; 23: 611–615.

    Article  CAS  PubMed  Google Scholar 

  21. Abrams J. Local use of tranexamic acid in ENT surgery. HNO. 2012; 60: 1014–1018.

    Article  CAS  PubMed  Google Scholar 

  22. Choi WS, Irwin MG, Samman N. The effect of tranexamic acid on blood loss during orthognathic surgery: a randomized controlled trial. J Oral Maxillofac Surg. 2009; 67: 125–133.

    Article  PubMed  Google Scholar 

  23. Kaewpradub P, Apipan B, Rummasak D. Does tranexamic acid in an irrigating fluid reduce intraoperative blood loss in orthognathic surgery? A double-blind, randomized clinical trial. J Oral Maxillofac Surg. 2011; 69: e186–e189.

    Article  PubMed  Google Scholar 

  24. Sankar D, Krishnan R, Veerabahu M, Vikraman B. Evaluation of the efficacy of tranexamic acid on blood loss in orthognathic surgery. A prospective, randomized clinical study. Int J Oral Maxillofac Surg. 2012; 41: 713–717.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Departments of Otolaryngology - HNS & Anaesthesia, Ain Shams University Hospital, Cairo, Egypt, 11371

    Ahmed H. Khafagy FRCS & Sameh M. Osman

Authors
  1. Ahmed H. Khafagy FRCS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sameh M. Osman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ahmed H. Khafagy FRCS.

Additional information

Conflicts of interest

There are no conflicts of interest.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Khafagy, A.H., Osman, S.M. Does tranexamic acid, deliberate hypotension, and anti-Trendelenburg position improve the quality and outcome for functional endoscopic sinus surgery. Egypt J Otolaryngol 29, 71–75 (2013). https://doi.org/10.7123/01.EJO.0000426359.69695.7c

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.7123/01.EJO.0000426359.69695.7c

Keywords