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