Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 598-605

The effects of adding lidocaine hydrochloride nasal spray (10%) to xylometazoline nasal drops (0.1%) in functional endoscopic sinus surgery: a comparative study


Department of Anesthesia, Critical Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission04-Jan-2016
Date of Acceptance16-Apr-2016
Date of Web Publication12-Jan-2017

Correspondence Address:
Ghada M Samir
Department of Anesthesia, Critical Care and Pain Management, Faculty of Medicine, Ain Shams University, Embassies Area, Symphony Tower, Cairo 11471
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.198262

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  Abstract 

Background
The aim of this study was to assess the effectiveness of adding lidocaine hydrochloride nasal spray (10%) to xylometazoline nasal drops (0.1%) as an anesthetic approach in patients undergoing functional endoscopic sinus surgery.
Patients and methods
A total of 52 patients of American Society of Anesthesiologist physical status I were included in the study and divided into two groups: the first group (group X) received xylometazoline hydrochloride nasal drops (0.1%) and lidocaine hydrochloride nasal spray (10%), whereas the second group (group S) received xylometazoline hydrochloride nasal drops (0.1%) only. The total blood loss (TBL) during surgery, the hemodynamic changes up to 30 min following incision of the nasal mucous membrane (m.m.) and in the immediate postoperative period, the need to add propranolol and the dose of propranolol given, as well as the duration of surgery and the quality of the surgical field were recorded.
Results
TBL and the duration of surgery were statistically significantly lower in group X than in group S. On comparing the grades given by the surgeon for the surgical field assessment, we found the results to be statistically highly significant for each group in favor of a better surgical field in group X than in group S. As for the hemodynamic parameters, the systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate in group S were higher than the values at baseline after induction of anesthesia, after incision of the nasal m.m., and during the 30 min after incision of the nasal m.m., and were also higher than those recorded in group X at the same time periods and this was statistically and clinically significant as propranolol was given to patients in group S after induction of anesthesia.
Conclusion
Better intraoperative hemodynamic control ensuring patient safety with decreased intraoperative TBL and duration of surgery, with better grades for the quality of the surgical field during functional endoscopic sinus surgery, can be achieved with the use of lidocaine hydrochloride nasal spray (10%) with xylometazoline nasal drops (0.1%).

Keywords: functional endoscopic sinus surgery, hypotensive anesthesia, lidocaine hydrochloride nasal spray, surgical field quality


How to cite this article:
Samir GM, Gerges-Fahmy N, Labib HA. The effects of adding lidocaine hydrochloride nasal spray (10%) to xylometazoline nasal drops (0.1%) in functional endoscopic sinus surgery: a comparative study. Ain-Shams J Anaesthesiol 2016;9:598-605

How to cite this URL:
Samir GM, Gerges-Fahmy N, Labib HA. The effects of adding lidocaine hydrochloride nasal spray (10%) to xylometazoline nasal drops (0.1%) in functional endoscopic sinus surgery: a comparative study. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Sep 23];9:598-605. Available from: http://www.asja.eg.net/text.asp?2016/9/4/598/198262


  Introduction Top


Functional endoscopic sinus surgery (FESS) is a widely accepted, increasingly popular, minimally invasive surgical procedure in otorhinolaryngology. It is adopted for symptomatic improvement of medically refractory chronic rhinosinusitis and chronic polypus rhinosinusitis [1], with a high success rate (∼90%). Small bleeding areas can reduce operative visibility, making recognition of the anatomical landmarks difficult, and results in risk of destruction of the surrounding structures (vascular, orbital, and intracranial) as well as increasing the duration of the operation and procedural failure. Minimizing bleeding in the surgical field during FESS is key to the success of this surgery. Bleeding may be difficult to control surgically because of the extensive vascular supply in the sinus region and pathophysiological changes in the patient [2]. Capillary bleeding is the most serious problem; fortunately, it can be greatly reduced by decreasing the patient’s mean blood pressure (MBP) and by local vasoconstriction [3],[4]. Lowering the blood pressure carries its own risks, such as permanent brain damage, delayed awakening, cerebral thrombosis, cerebral ischemia, and death [4],[5]. Also, submucosal injection of lidocaine–epinephrine results in hemodynamic fluctuations. Therefore, proper anesthetic management is essential to optimize the surgical field and make the surgical dissection as easy as possible [6],[7]. For the anesthetist, it provides an interesting challenge to use the drugs and techniques available in order to allow an optimal operating field while decreasing the risk of surgery [8],[9]. This study was designed to assess the effects of adding lidocaine hydrochloride nasal spray (10%) to xylometazoline nasal drops (0.1%) on the total blood loss (TBL), quality of the surgical field, operative duration, and hemodynamic stability, with decreased need for the use of intraoperative β-blockers and better patient safety.


  Patients and methods Top


After taking approval from the Ethical Committee of Ain Shams University and obtaining informed consent from each patient, this randomized controlled study was conducted at Ain Shams University hospitals on 52 patients scheduled to undergo FESS by the same otorhinolaryngology surgeon. Preoperative evaluation included a detailed history, physical examination, and investigations, which included hemoglobin level, platelet count, random blood glucose, prothrombin time, international normalized ratio, partial thromboplastin time, and ECG.

Inclusion criteria

Patients who have chronic rhinosinusitis refractory to medical treatment were included in the study.

Exclusion criteria

Patients with nasal polyposis (as polyps may bleed more aggressively on dissection), hypertension, or ischemic heart disease, those allergic to the used drugs, those taking medications known to alter the parameters under investigation, such as calcium channel blockers, β-blockers, or vasodilators, and patients with bronchial asthma (contraindication to take propranolol), anemia (hemoglobin level<10 g/dl), thrombocytopenia (platelets count<100 000/µl), or coagulation defects (international normalized ratio>1.5 or partial thromboplastin time>40 s) were excluded from the study.

Preoperative preparation of the patient by the surgeons

Preoperative antibiotics were prescribed to patients with sinusitis who have an infective complication requiring surgery, as inflammation increases tissue vascularity [10].

Patients were divided by means of a sealed envelope into two groups:

Group X (25 patients): These patients received six drops of xylometazoline hydrochloride (Otrivin adult nasal drops 0.1%, 10 ml of 1 mg/ml; Novartis Consumer Health, UK Ltd, 980 Great West Road, Brentford, Middlesex, TW8 9GS, UK) in each nostril in the induction room and four puffs of lidocaine hydrochloride (Xylocaine 10% spray, 100 mg/ml; AstraZeneca, London, UK) in each nostril after induction of anesthesia.

Group S (27 patients): These patients received six drops of xylometazoline hydrochloride (Otrivin adult nasal drops 0.1%, 10 ml of 1 mg/ml; Novartis Consumer Health, UK Ltd, 980 Great West Road, Brentford, Middlesex, TW8 9GS, UK) in each nostril in the induction room only.

Anesthetic technique

In the induction room, the 52 patients had an intravenous cannula inserted in the dorsum of the left hand. All patients were then premedicated with intravenous 0.05 mg/kg midazolam hydrochloride (Dormicum, 5 mg/ml; Roche, Basel, Switzerland) and 1 mcg/kg fentanyl (Sunny Pharmaceutical, Industrial Zone, Badr City, Egypt, under license of Hamelin Pharmaceuticals, Hameln, Niedersachsen, 31789Germany) followed by application of six drops of xylometazoline hydrochloride (Otrivin adult nasal drops 0.1%, 10 ml of 1 mg/ml; Novartis Consumer Health, UK Ltd, 980 Great West Road, Brentford, Middlesex, TW8 9GS, UK) in each nostril as it is generally well tolerated in sedated patients [11]. On arrival at the operating room, three-lead ECG, noninvasive blood pressure monitoring, and pulse oximetry were started using General Electric-Dash 5000 monitor (GE Medical Systems Information Technologies Inc., Milwaukee, Wisconsin, USA). Capnogram was then applied after induction of anesthesia. Thereafter, a temperature probe was inserted into the oropharynx after oral endotracheal intubation as maintenance of normothermia is vital for the function of platelets and coagulation factors essential in hemostasis [12],[13].

Induction of anesthesia was done with intravenous 2 mg/kg propofol (propofol 1%; Fresenius Kabi Bad Homburg, Germany), 0.15 mg/kg Nimbex [cisatracurium besylate, 10 mg cisatracurium (bis-cation) in 5 ml; GlaxoSmithKline Manufacturing S. Brentford, London), and 0.01 mg/kg morphine (morphine sulfate, 10 mg/ml; Misr Co, For pharmaceuticals, Alexandria, Egypt). Four puffs in each nostril of lidocaine hydrochloride (Xylocaine 10% spray, 100 mg/ml; AstraZeneca, London, UK) were administered to patients in group X after induction of anesthesia owing to the bitter taste of lidocaine hydrochloride 10% nasal spray when trickling from the nose in awake patients. After 3 min of manual ventilation using oxygen (8 l of 100% O2) and 1.2% isoflurane (Forane, isoflurane, USP, liquid for inhalation, 250 ml; Baxter Healthcare Corporation, Deerfield, IIIinois, USA) by means of a bag and mask, intubation was done using a Macintosh laryngoscope blade and a cuffed endotracheal tube of appropriate size inserted orally and to the left. A small oropharyngeal pack lubricated with K-Y lubricating jelly (42 g; Johnson and Johnson, New Brunswick, New Jersey, United States) was inserted using a pair of Magill forceps. Eye ointment (Maxitrol sterile ophthalmic ointment, 3.5 g; Alcon Couvreur, Rijksweg 14, 2870 Puurs, Belgium) was applied in the lower fornixes.

Maintenance of anesthesia was done with oxygen (3 l of 60% O2) and total intravenous anesthesia (TIVA) using a propofol multistep infusion regimen in the form of 10 mg/kg/h for 10 min followed by 8 mg/kg/h for the next 10 min and then 6 mg/kg/h for the remaining duration of the surgery. Further neuromuscular blockade was maintained with intermittent boluses of 0.03 mg/kg cisatracurium besylate given intravenously at 30-min intervals. One gram paracetamol (Perfalgan vial, 100 ml of 10 mg/ml; Bristol-Myers Squibb , New York City, New York, United States) was infused over 20 min. Patients received intravenous fluids in the form of Ringer lactate solution 4 ml/kg/h. Mayestrotense : propranolol HCl 1 mg/ml was prepared in a 10-ml syringe with normal saline and the dose was titrated slowly, intravenous, for patients in group S if needed. Patients were mechanically ventilated using the Datex-Ohmeda Inc. (3030 Ohmeda Drive Madison WI 53707-7550 USA) anesthesia machine attached to the closed circuit system fitted with a circle absorber to maintain normocarbia guided by end tidal carbon dioxide readings between 35 and 40 mmHg while adjusting the intermittent positive pressure ventilation such that the airway pressures were kept to a minimum with tidal volume at 6 ml/kg and respiratory rate of 10–12 breaths/min with no positive end expiratory pressure applied to prevent high intrathoracic pressure [14]. Patients were positioned with their heads raised by 15° just before starting the procedure as every 2.5 cm elevation above the heart correlates to a decrease of 2 mmHg in arterial blood pressure [15].

After completion of surgery, the residual neuromuscular blockade was antagonized with the mixture of intravenous injection of neostigmine 0.05 mg/kg and atropine 0.02 mg/kg. The trachea was extubated once the patient regained consciousness and the patient was transferred to the postanesthesia care unit (PACU).

Primary outcome

TBL (ml) and blood loss during surgery, measured as blood collected in the suction apparatus, were the primary outcomes.

Secondary outcomes

  1. Hemodynamics [heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and MBP] recorded before induction of anesthesia as baseline values, then after induction of anesthesia, after incision of the nasal mucous membrane (m.m.), every 5 min for 30 min after incision of the nasal m.m., and finally in the immediate postoperative period.
  2. Need to add propranolol HCl (Mayestrotense : propranolol HCl 1 mg/ml; Alex. Co. for Egypharma, Alexandria, Egypt).
  3. Dose of propranolol given with a maximum dose of 2 mg.
  4. Duration of surgery assessed in minutes.
  5. Surgical field quality on a five-point scale as assessed by the surgeon [6]:
    1. Grade 1: Cadaveric conditions with minimal suction required.
    2. Grade 2: Minimal bleeding with infrequent suction required.
    3. Grade 3: Brisk bleeding with frequent suction required.
    4. Grade 4: Bleeding covers the surgical field after removal of suction before surgical maneuvers can be performed.
    5. Grade 5: Uncontrolled bleeding. Bleeding out of the nostril on removal of suction.


Statistical analysis

Using PASS 11 program, Dr. Jerry L. Hintze Kaysville, Utah 84037, USA. For sample size calculation, it was calculated that a sample size of 23 patients per group will achieve 80% power to detect a difference of 500 ml blood loss with a significance level (α) of 0.05 using a two-sided two-sample t-test. Twenty-seven patients per group were included to replace any dropouts. In group X two patients were excluded as one patient refused to be administered the xylometazoline hydrochloride nasal drops while still awake and the other patient was discovered to have fungal sinusitis intraoperatively. The statistical analysis was performed using a standard SPSS software package (version 17; SPSS Inc., Chicago, Illinois, USA). Normally distributed numerical data are presented as mean±SD. Repeated measures were compared using ANOVA test and categorical variables were analyzed using the χ2-test and are presented as number of patients. P-values less than 0.05 were considered statistically significant and P-values less than 0.001 were considered statistically highly significant.


  Results Top


The two groups were comparable as regards the demographic data (age, sex, and weight) (P=0.63, 1, and 0.955, respectively; [Table 1]). The duration of surgery and the TBL were statistically significantly lower in group X than in group S (P=0.04 and <0.001, respectively; [Table 2]). The grades given by the surgeon for the surgical field assessment by applying the grading scale initially described by Fromme et al. [16] and adapted by Boezaart et al. [6] revealed highly statistically significant results (P<0.001), as 20 patients in group X and only three patients in group S had a score of 2, which is minimal bleeding with infrequent suction, and 14 patients in group S and no patient in group X had a score of 4, which is bleeding covering the surgical field after removal of suction and before surgical maneuvers could be performed ([Table 2]).
Table 1: Demographic data

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Table 2: Operative data

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According to the hemodynamic parameters, as regards the SBP, there were no statistical differences between the two groups in the baseline mean values (P=0.32). The mean values of SBP showed statistically and clinically significant decrease over time in group X after induction of anesthesia, after incision of the nasal m.m. (P<0.001), during the 20 min following incision of the nasal m.m. (recorded every 5 min; P=0.02, 0.002, <0.001, and 0.03, respectively), and in the PACU (P=0.03) and statistically nonsignificant decrease at 25 and 30 min after incision of the nasal m.m. (P=0.07 and 0.08, respectively). In group S the mean values of SBP showed statistically and clinically significantly higher values than the baseline values after induction of anesthesia, after incision of the nasal m.m. (P<0.001), and during the 25 min after incision of the nasal m.m. (recorded every 5 min; P<0.001, 0.03, <0.001, 0.006, and 0.004, respectively) and statistically nonsignificant increase at 30 min after incision of the nasal m.m. and in the PACU (P=0.196 and 0.024, respectively). Also, the mean SBP recorded in group S was statistically and clinically significantly higher than that recorded in group X at the same time periods (P<0.001) after induction of anesthesia, after incision of the nasal m.m., in the 15 min after incision of the nasal m.m. (recorded every 5 min), and in the PACU, whereas at 20, 25, and 30 min after incision of the nasal m.m. (P=0.01, 0.04 and 0.023, respectively; [Figure 1]).
Figure 1: Changes in mean values of systolic blood pressure (SBP) over time. Lines are mean SBP and error bars are SD. *Statistical significance between groups.

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As regards the DBP, there were no statistical differences between the two groups regarding the baseline mean values of the DBP (P=0.056). The mean values of DBP showed statistically and clinically significant decrease over time in group X after induction of anesthesia, after incision of the nasal m.m. (P<0.001), and during the 30 min following incision of the nasal m.m. (recorded every 5 min; P<0.001, <0.001, 0.048, 0.049, 0.003, and 0.033, respectively). The DBP then showed a statistically significant increase over baseline values in the PACU (P=0.038). In group S the mean values of the DBP showed statistically higher values than the baseline values after induction of anesthesia, after incision of the nasal m.m. (P=0.02 and 0.013, respectively), and during the 15 min after incision of the nasal m.m. (recorded every 5 min; P=0.001, <0.001, and <0.001, respectively), whereas at 20, 25, and 30 min after incision of the nasal m.m. and in the PACU the increase was statistically nonsignificant (P=0.21, 0.14, 0.53, and 0.61, respectively). Also, the mean values of DBP recorded for group S were statistically higher than that recorded in group X at the same time periods, with P-values of less than 0.001 after induction of anesthesia, after incision of the nasal m.m., in the 10 min after incision of the nasal m.m., and in the PACU, whereas at 15, 20, 25, and 30 min after incision of the nasal m.m. (P=0.04, 0.01, 0.01, and 0.03, respectively; [Figure 2] ).
Figure 2: Changes in mean values of diastolic blood pressure (DBP) over time. Lines are mean DBP and error bars are SD. *Statistical significance between groups.

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As regards the MBP, there were no statistical differences between the two groups regarding the baseline mean values of the MBP (P=0.056). The mean values of MBP showed a statistical decrease over time in group X after induction of anesthesia, after incision of the nasal m.m. (P<0.001), and during the 30 min after incision of the nasal m.m. (recorded every 5 min, P<0.001, <0.001, <0.001, <0.001, <0.001, and 0.021, respectively) and increased to reach almost the baseline values in the PACU (P=0.43). In group S the mean values of the MBP showed statistically higher values than the baseline values after induction of anesthesia, after incision of the nasal m.m., and during the 10 min after incision of the nasal m.m. (P=0.001, <0.001, <0.001, and <0.001, respectively) and showed statistically nonsignificantly higher values at 15, 20, 25, and 30 min after incision of the nasal m.m. (recorded every 5 min; P=0.27, 0.207, 0.333, and 0.726, respectively) and reached more than the baseline values in the PACU (P=0.119). Also, the mean values of the MBP recorded for group S were statistically higher than that recorded in group X at the same time periods (P<0.001), after induction of anesthesia, after incision of the nasal m.m., in the 15 min after incision of the nasal m.m. (recorded every 5 min), and in the PACU, whereas at 20, 25, and 30 min after incision of the nasal m.m. (P=0.045, 0.03, and 0.032, respectively; [Figure 3] ).
Figure 3: Changes in mean values of mean blood pressure (MBP) over time. Lines are MBP and error bars are SD. *Statistical significance between groups.

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As for the HR there were no statistical differences between the two groups with respect to the baseline mean values of HR (P=0.06). In group X the HR showed statistically and clinically significant decrease starting from after incision of the nasal m.m. (P<0.001) and during the 30 min following incision of the nasal m.m. (recorded every 5 min, P<0.001), whereas the mean HR showed nonsignificant increase from the baseline values after induction of anesthesia (P=0.1) and a statistically significant but clinically nonsignificant increase in the PACU (P=0.018). In group S the mean values of HR showed statistically and clinically higher values than the baseline values after induction of anesthesia, after incision of the nasal m.m., and in the 15 min after incision of the nasal m.m. (P<0.001); propranolol (maximum dose of 2 mg) was given to 18 (66.66%) patients after induction of anesthesia, which started to slow down the increased HR starting from that recorded at 15 min until that recorded at 30 min after incision of the nasal m.m., but this decrease was still statistically and clinically higher than the baseline value (recorded every 5 min, P<0.001) and continued to be higher in the PACU (P<0.001). Also, the mean HR recorded in group S was statistically and clinically higher than that recorded in group X at the same time periods: after induction of anesthesia, after incision of the nasal m.m., and in the PACU (P<0.001) and in the 30 min after incision of the nasal m.m. (recorded every 5 min; P<0.001, <0.001, <0.001, 0.054, 0.04, and 0.03, respectively; [Figure 4] ). Only two patients in group X required 0.5 mg propranolol as they developed mild intraoperative tachycardia, whereas 2 mg of propranolol was given to the 18 patients in group S (P<0.001).
Figure 4: Changes in mean values of heart rate (HR) over time. Lines are mean HR and error bars are SD. *Statistical significance between groups.

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  Discussion Top


In our study, adequate anesthetic depth was maintained with a propofol multistep infusion regimen. Its use seems to be ideal because of the following reasons: it quickly blunts the sympathetic response to endotracheal intubation and periods of surgical stimulation [5]; it decreases cerebral metabolism and hence cerebral blood flow, reducing the flow through the ethmoidal and the supraorbital artery, which supplies the ethmoid, sphenoid, and frontal sinuses [17]; it has a good safety profile; and the precise dose can be prepared and delivered easily. Moreover, it does not accumulate in the body and has no impact on postanesthetic recovery ensuring that consciousness and psychomotor functions are recovered quickly upon termination of anesthesia administration [18]. In 2010, Amorocho and Sordillo [8] found that propofol improved the quality of the surgical field and reduced the intraoperative blood loss. However, Baker and Baker [19] and Boonmak et al. [5] concluded that propofol improved the quality of the surgical field but did not reduce the surgical blood loss by less than one category on a scale of 0 (no bleeding) to 5 (severe bleeding), with no significant difference in operative times. The intraoperative blood loss was reduced with propofol TIVA compared with volatile agents as volatile anesthetic agents decrease systemic vascular resistance with increased tissue perfusion contributing to surgical bleeding [20],[21]. Therefore, propofol TIVA anesthesia was chosen in our study to aid in improving the quality of the surgical field without affecting the duration of surgery or the TBL measurements, which is our primary outcome.

In our study, cisatracurium was used as the skeletal muscle relaxant because of its hemodynamic stability as it affords a good pharmacological profile with respect to eliciting histamine release, thus avoiding peripheral vasodilatation and tachycardia. Cisatracurium boluses were used to avoid any coughing or straining resulting in an increase in the intrathoracic pressure impairing the venous drainage from the head [22].

Injected and topical local anesthetics (LAs) and vasoconstrictors can help decrease mucosal congestion, blood loss, and relieve postoperative pain. Epinephrine is the commonly used vasoconstrictor. In the study by Cohen-Kerem et al. [23] comparing the effectiveness of topical 1 : 1000 epinephrine versus injected lidocaine containing 1 : 100 000 epinephrine during FESS, it was reported that submucosal injection of lidocaine–epinephrine facilitated improvement in the surgical field; however, increased hemodynamic fluctuations were noted after infiltrations. It is important to be aware of the possibility of LA toxicity in view of the generous amount that is administered to the patient through packs and injections preoperatively and intraoperatively by the surgeon, and hence good communication should exist between surgeons and anesthetists [24]. Xylometazoline hydrochloride 0.1% nasal drops is a sympathomimetic agent with marked α-adrenergic activity. Its effect begins within a few minutes and lasts for up to 10 h [11]. Therefore, in our study the use of topical vasoconstrictor nasal drops (xylometazoline hydrochloride 0.1%) avoided the hemodynamic fluctuations and aided in vasoconstriction of the mucosal blood vessels of the nose and neighboring regions of the pharynx, thus decreasing mucosal congestion, decreasing the absorption of the applied topical LA, and consequently decreasing the required dose and the incidence of LA toxicity.

According to the US National Library of Medicine, controlled hypotension is defined as a pharmacologically induced reduction of the SBP to 80–90 mmHg, a reduction of MAP to 50–65 mmHg, or a 30% reduction in baseline MAP. Deliberate hypotension can reduce blood loss in FESS by between 80 and 141 ml [5]. Controlled hypotension can be induced using a number of different hypotensive drugs. Disadvantages are associated with these approaches; the use of nitroprusside or nitroglycerine may require escalating doses because of tachyphylaxis [25], nitroprusside in large doses may result in cyanide intoxication and both require invasive monitoring of arterial blood pressure [26]. Volatile anesthetics can prolong recovery and delay discharge. Fentanyl, which is commonly used, does not allow for a precise manipulation of hemodynamic parameters and can accumulate in the body depending on the dose applied [27].

Surgery performed with drug-induced hypotension does not always assure the desired effect of reducing perioperative bleeding caused by the diastole of the peripheral vessels and the automatic tachycardia, conditions that ultimately increase bleeding. Therefore, it is essential to prevent recurrent automatic tachycardia and to maintain the HR at 60 beats/min [28],[29]. In 2010, Sieśkiewicz et al. [28] evaluated the relationship between MBP and perioperative bleeding during FESS in patients with a low HR. They concluded that optimal surgical conditions with decreased intraoperative bleeding are largely a function of MAP (between 65 and 78 mmHg) and HR (maintained at 60 beats/min). Therefore, the use of β-blockers in FESS is highly beneficial for inducing moderate hypotension with better operating conditions compared with vasodilating agents, and thus propranolol was chosen in our study. It is a nonselective β adrenergic receptor blocker; it decreases the HR, myocardial contractility, and blood pressure. The usual dose of intravenous propranolol is 1–2 mg administered under careful ECG monitoring. The rate of administration should not exceed 1 mg (1 ml) per minute, to diminish the possibility of causing cardiac standstill. Sufficient time should be allowed for the drug to reach the site of action even in the presence of slow circulation. If necessary, a second dose may be given after 2 min. Thereafter, additional drugs should not be given in less than 4 h [30].

Lidocaine hydrochloride nasal spray (10%) provides its anesthetic effect as a sodium pump inhibitor; it inhibits conduction of neural impulses by decreasing the permeability of the neuron membrane to sodium. It acts by blocking neural transfer from the sphenopalatine ganglion and the maxillary branch of the trigeminal nerve. The sphenopalatine ganglion resides just posterior and immediately above the posterior tip of the middle turbinate, beneath the nasal mucosa, at a depth of 1–9 mm. This ganglion along with the internal carotid and cavernous sinus ganglion provides parasympathetic innervation of cerebral blood vessels [31]. The efficacy profile of lidocaine hydrochloride nasal spray (10%) is characterized by a rapid onset of action (45–90 s) and intermediate duration of efficacy (elimination half-life 90–120 min) [32]. In our study, the use of lidocaine hydrochloride (10%) nasal spray after induction of anesthesia and before endotracheal intubation helped to decrease the incidence of hemodynamic disturbances during periods of stress like laryngoscopy and endotracheal intubation and the incision of the nasal m.m.. The SBP, DBP, MBP, and HR showed clinically significantly lower values in group X than in group S with the maximum decrease recorded less than 30% from the preinduction values. It decreased the need for the use of intraoperative propranolol as a rescue drug to improve the quality of the surgical field in group X, whereas 18 patients in group S required the use of 2 mg propranolol. Although propranolol has a distribution half-life (T½ α) of 5–10 min and onset of action of less than 2 min [30], the propranolol given started to decrease the tachycardia and thus the elevated SBP, DBP, and MBP after induction of anesthesia in group S at 15 min after incision of the nasal m.m. and they were still clinically higher than the preinduction values. This delay of effect was considered because of the significant tachycardia developing after incision of the nasal m.m. in FESS.

In our study, although the mean values of HR and MBP in group X were higher than the values in the study by Sieśkiewicz et al. [28], the TBL was statistically significantly lower in group X, and the surgical field was satisfactory for the surgeon and hence the surgeon did not enquire about the HR or the blood pressure of the patient during the course of the operation. This goes hand in hand with what Donald [33] reported that for many patients the correlation between decrease in blood pressure and blood loss is not linear.


  Conclusion Top


A multimodal anesthetic approach is required in FESS. Adding lidocaine hydrochloride (10%) nasal spray and xylometazoline hydrochloride 0.1% nasal drops to TIVA with propofol increases patient safety, results in stable hemodynamics, and decreases TBL and the need for β-blockers, with better surgical field operating conditions and decreased surgical duration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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