Maniobras destinadas a minimizar el sangrado del campo quirúrgico durante la cirugía endonasosinusal: ensayo clínico aleatorizado de la utilización de un hipotensor agonista alfa adrenérgico

Abstract

Intense bleeding during functional endoscopic naso-sinusal surgery (FESS) difficults the visualization of the surgical field. The use of adjuvant hypotensive drugs during anaesthesia might reduce bleeding and thus reduce risks during surgery, but there are no objective evidence on the efficacy and safety of such approach. A first observational study was designed that compared intraoperative bleeding in routine clinical practice. Patients receiving a clonidine-based anaesthetic regimen (N=11) or fentanyl or remifentanil based regimens (N=26) were assessed by the operating surgeon for surgical field bleeding by an ordinal 1-5 scale (Boezaart score), which was lower for subjects receiving clonidine [mean (SD) 1.91(0.53) vs. 2.92(0.79), p<0.0001]. A multivariate analysis including bleeding risk factors showed that intense bleeding (Boezaart > 2) was best predicted by the adjuvant hypotensive drug used. Based on these results, a prospective clinical trial randomising patients undergoing FESS to receive a clonidine based or a remifentanil based anaesthetic regimen was designed. The trial randomised 47 subjects to clonidine (N=22) or remifentanil (N=25) at induction of anaesthesia. Differences in intense bleeding (4 (18%) clonidine vs 13 (52%) remifentanil, p= 0,014) as assessed by a third surgeon blind to treatment identity from video records obtained during endoscopy were observed. Better visualization of anatomical structures was achieved with clonidine, and concordant results were obtained from the unblinded assessment by surgeons. Hypotension was less marked with clonidine, suggesting that the effect on bleeding was not entirely due to the induced hypotension. In summary, the use of clonidine reduces intense bleeding and improves visualization of anatomical structures during endoscopic naso-sinusal surgery.

Date of Award	22 Jan 2015
Original language	Spanish
Awarding Institution	Universitat de Barcelona (UB)
Supervisor	Caridad Pontes Garcia (Director) & Manuel Bernal-Sprekelsen (Director)