









































Texas Christian University 
“The Science Behind the Art” 
Volume 10 - No.4 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 5

Effectiveness of Total Intravenous Anesthesia in Endoscopic Sinus Surgery
Anna Busalacchi, RN, BSN, CCRN

Affiliation:
Texas Christian University 

Grant/Financial Support: 
None 

KEYWORDS: Functional endoscopic sinus surgery, anesthesia, total intravenous anesthesia

Abstract
A 58-year-old female presented for functional endoscopic sinus surgery (FESS) to treat chronic rhinosinusitis. FESS 
has been mainstay treatment for chronic rhinosinusitis, with or without nasal polyps. Goals for FESS included optimal 
visualization of anatomical structures with minimal bleeding in the surgical field.1 The anesthetic technique chosen, 
either total intravenous anesthesia (TIVA) or inhalational anesthesia (IA), has shown to affect visibility of the sinonasal 
mucosa, dictating outcome of intraoperative blood loss. Differences between anesthetic agents focused on vasodilation, 
particularly in the nasal mucosa.2,7,8 Current evidence supported TIVA as the superior anesthetic technique in FESS, as 
it has shown to successfully reduce intraoperative blood loss with superior surgical visibility. 

AEJ
Volume 10- No. 4 2022

About the Author: Anna Busalacchi is a registered intensive care unit nurse, currently enrolled in Texas Christian 
University Nurse Anesthesia program.



Texas Christian University 
“The Science Behind the Art” 
Volume 10 - No.4 2022 

Anesthesia eJournal - Online
ISSN 2333-2611 

Page 6

PowerPoint Template ©2009 Texas Christian University, Center for Instructional Services. For Educational Use Only. Content is the property of the presenter and their resources.

Introduction
• Endoscopic sinus surgery (ESS) is the mainstay treatment

currently for chronic rhinosinusitis, with or without nasal 
polyps.

• Goals for successful ESS: optimal visualization of anatomical 
structures and landmarks with minimal blood loss/bleeding in
surgical field.1

• ESS is generally conducted under general anesthesia for 
patient comfort utilizing total intravenous anesthesia (TIVA)
for optimal surgical field visualization, yet inhalational 
anesthesia (IA) is still being used in these cases.3

• The research promoting the use of TIVA stems from the 
pharmacodynamics of propofol versus inhalational agents 
such as sevoflurane and isoflurane.1,3,6

• The difference between these agents are how they produce 
vasodilation in the body and particularly the nasal mucosa.

• Anesthetic technique has shown to affect visibility of the 
sinonasal mucosa and dictate the outcomes of blood loss and
operative time.

• Highlighting the difference between TIVA and IA shines a 
light on the influence that anesthesia can have on these 
patients’ surgical course.

Discussion
Case Key Points:
• TIVA requested by surgeon as anesthetic technique
• Very minimal blood loss
• No hemodynamic abnormalities throughout entire case
Case Critiques:
• Emergence was delayed by ten minutes, due to propofol

lingering; propofol infusion should have been turned off 
sooner

• Estimated blood loss was calculated by amount in suction 
canister with amount of irrigation subtracted; many 
researchers are now recommending looking at hemoglobin
values before and after the case

Clinical Rationale:
• Surgeon must be able to identify anatomic landmarks within 

confined surgical space to complete ESS. 
• By decreasing arterial blood supply to the ethmoid bed, 

propofol leads to better visibility for the surgeon and better 
patient outcomes.2

• Those with more severe chronic rhinosinusitis have shown to
benefit even greater with TIVA in surgical outcomes.7

The Effectiveness of Total Intravenous Anesthesia in Endoscopic Sinus Surgery   
Anna Busalacchi, BSN, RN, Texas Christian University

Case Description

Pre-Anesthestic Evaluation:
• A 58-year-old female, 67 inches, 107.4 kilograms, ASA II 

presented for Endoscopic Sinus Surgery (ESS) to treat 
chronic rhinosinusitis

• Medical history: sinusitis, hyperlipidemia, obesity
• Preoperative vital signs: HR 80, BP 151/89 mmHg, RR 16,

SpO2 97%
• Preoperative Medications: clindamycin 900 mg IV, midazolam 

2 mg IV, both given in the preoperative area
Intraoperative Management:
• General anesthesia induced with lidocaine 60 mg IV, propofol 

180 mg IV, and succinylcholine 120 mg IV
• Following induction: rocuronium 40 mg IV, dexamethasone

10 mg IV, propofol infusion started at 100 mcg/kg/min
• Maintenance: propofol infusion remained on throughout 

procedure, rocuronium 10 mg given one hour into case
• At time of closure: propofol infusion turned off, ondansetron

4 mg IV, ketorolac 30 mg IV, acetaminophen 1 g IV
• No vital sign abnormalities throughout case noted
• Estimated blood loss of case: 50 mL, calculated by amount in

canister with irrigation subtracted
Postoperative Course:
• Reversed with sugammadex 200 mg IV, extubated and 

transferred to PACU with oral airway in place and dressing
under nose placed and secured by surgeon

• PACU vital signs: HR 74, BP 133/70 mmHg, RR 18, SpO2
95%

Follow Up:
• Patient dressing under nose observed with no bloody 

drainage, discharged to home within 2 hours of procedure
ending

• No nausea or pain noted by patient before discharge

References
1. Lu VM, Phan K, Oh LJ. Total intravenous versus inhalational anesthesia in endoscopic

sinus surgery: A meta-analysis. Laryngoscope. 2020;130(3):575-583. 
2. DeConde AS, Thompson CF, Wu EC, Suh JD. Systematic review and meta-analysis of total 

intravenous anesthesia and endoscopic sinus surgery. Int Forum Allergy Rhinol. 
2013;3(10):848-854. 

3. Gomez-Rivera F, Cattano D, Ramaswamy U, et al. Pilot study comparing total intravenous
anesthesia to inhalational anesthesia in endoscopic sinus surgery: Novel approach of
blood flow quantification. Ann Otol Rhinol Laryngol. 2012;121(11):725-732. 

4. Chaaban MR, Baroody FM, Gottlieb O, Naclerio RM. Blood loss during endoscopic sinus 
surgery with propofol or sevoflurane. JAMA Otolaryngol Head Neck Surg.
2013;139(5):510. 

5. Ahn HJ, Chung S-K, Dhong H-J, et al. Comparison of surgical conditions during propofol or
sevoflurane anaesthesia for endoscopic sinus surgery. Br J Anaesth. 2008;100(1):50-54.

6. Eberhart LH, Folz BJ, Wulf H, Geldner G. Intravenous anesthesia provides optimal surgical
conditions during microscopic and endoscopic sinus surgery. Laryngoscope.
2003;113(8):1369-1373. 

7. Brunner JP, Levy JM, Ada ML, et al. Total intravenous anesthesia improves intraoperative 
visualization during surgery for high-grade chronic rhinosinusitis: A double-blind 
randomized controlled trial. Int Forum Allergy Rhinol. 2018;8(10):1114-1122.

8. Kolia NR, Man L-X. Total intravenous anaesthesia versus inhaled anaesthesia for 
endoscopic sinus surgery: A meta-analysis of randomized controlled trials. Rhinology.
2019;57(6):402-410.

9. Baban MI, Mirza B, Castelnuovo P. Radiological and endoscopic findings in patients 
undergoing revision endoscopic sinus surgery. Surg. Radiol. Anat. 2020;42(9):1003-1012. 

Conclusion
• The nasal mucosa is a highly vascularized area. When 

operated on, bleeding can lead to a great deal of blood loss 
and challenging visibility for the surgeon.1

• The use of TIVA over IA has proven to lead to decreased
blood loss and a cleared surgical field, graded using the 
Wormald visibility scale in a large pool of randomized 
controlled trials and prospective studies.1

• TIVA versus IA has also proven to have no major difference in
the hemodynamic profile of these researched patients in the 
noted studies, proving its safety.1

Figure 1: Comparison of TIVA verses “balanced 
anesthesia,” meaning the use of inhalational agents, via a 

visual analog scale used by surgeons to grade the surgical 
field visibility.6

Figure 2: Radiological and endoscopic images demonstrating the progression of increased bleeding and decreased 
surgical visibility in a revision ESS.9

Propofol Vasodilation Mechanism:

- concentration-dependent vasodilatory effect7
- depresses central sympathetic tone3,7

- avoids peripheral vasodilation1
- depresses cerebral blood flow= decreased arterial supply

to the ethmoid bed2

Inhalational Agent Vasodilation Mechanism:

- concentration-dependent vasodilatory effect7
- directly acts on smooth muscle of blood vessels7,8

- leads to vasodilation of peripheral and cerebral blood
vessels7,8

- relaxes pre-capillary sphincters in the mucosa= increases
blood flow to the paranasal sinuses7,8

Key Findings from Literature
• TIVA has proven to be the superior anesthetic technique 

because it has shown to successfully reduce 
intraoperative blood loss with superior surgical visibility.7

• Propofol, with the use of a short-acting opioid, such as 
remifentanil, is currently the leading anesthetic 
technique in ESS.6

• Gaps in research have become evident including the 
need for standardized surgical visibility scoring, how 
more extensive chronic rhinosinusitis affects surgical 
outcomes regardless of anesthetic technique, and the 
quality of life of these patients following their surgery 
and anesthesia.2,5,6

Literature Review
• The overwhelmingly present theme across many studies 

supporting TIVA highlight the benefits of using propofol 
as the main anesthetic drug and how it interacts in the 
body.1,2,3,7

• Many studies used conducted research in similar 
manners of blindly assigning patients to receive TIVA or 
IA and measuring outcomes of blood loss and surgical 
visibility.

• Patients with varying degrees of chronic rhinosinusitis 
were studied.

• Hemodynamic profiles were monitored and compared
between anesthetic techniques.1,4




