Benha' M. J. ^^

Vol. 26 No 2 May 2009

ANESTHETIC MANIPULATIONS TOMINIMIZE BLEEDING AND IMPROVE OUTCOMEOF FUNCTIONAL ENDOSCOPIC SINUS SURGERY

Ahmed El-Emshati MD & Ahmed Al-Arfaj MD*Departments of Anesthesia & Otorhinoktryngofopi/*, Faculty of Medicine,

Benha & King Saud Universities*, Egypt

AbstractObjectives: The present study was designed as a trial to improve field

visibility during functional endoscopic sinus surgery (FESS) by means ofpositional changes and the use of controlled hypotension achievedthrough maintenance of anesthesia using remifentanH and either ofpro-pofol infusion (Total Intravenous: TI) or isqflurane inhalation (CombinedIntravenous/Ihhalational; C1I).

Patients & Methods: The study included 32 patients; 23 males and9 females, with mean age of 39.28.4 years and assigned to undergo

FESS. Patients were divided randomly into two equal groups accordingmaintenance anesthetic regimen Group TI and Group CH. Each group

was subdivided according to patients' position during surgery into supineand anti-Trendelenburg by 30. Anesthesia was maintained in bothgroups by infusion of 0.5 pg/kg/min of remifentanil in addition to 10 pg/kg/min propofol infusion in Group TI or isoflurane 2% in Group CII. Patients were monitored non-invasively; before induction of anesthesia (TO)and 20 (T20), 40 (T40) and 60 min (T60) after induction of anesthesia, formean arterial pressure (MAP) and heart rate (HR). The approachfor FESSwas conducted totally endonasal The visibility of the operative field during FESS was evaluated using &points Fromme scale and total amountof bleeding as fudged by the amount evacuated was also recorded.

Results: Both anesthetic modalities reduced blood pressure significantly and decreased heart rate throughout times of observation compared to preoperative levels with significantly lower MAP measures inanti-Trendelenburg compared to supine position. All surgeries were con

ducted completely without intraoperative complications and no extensivebleeding was recorded. There was a significant increase in the frequency

83

84

Chronic sinusitis not respond

ing to medical treatment and nasal polyposis are two main classi

cal indications for performing

endoscopic sinus surgery. With

FESS, the advantage of good illumination and clear vision with

minimally invasive surgery, it is

possible to achieve consistently

good results, provided the surgeryis done accurately and with care,

(Bradley & Kountakis, 2005).

Huang et al., (2006) reported that

after endoscopic sinus surgery forchronic pediatric sinusitis, the an-

tral mucosa recovered and muco-

Introduction

Functional endoscopic sinus

surgery is a useful and wide

spread technique that allows the

treatment of a large number of na

sal pathologies aiming at main

taining physiological function andanatomical structure. The extent

of the operation is adapted according to each case. It is focused on

the ostiomeatal complex in the

middle meatus and the ethmoid

cells. FESS enables re

establishing sinus drainage andmucosal recovery, (Eisenberg et

al., 2008).

ofgoodjield visibility with TI compared to CII anesthesia with significantly improved field, visibility in patients maintained in anti-Trendelenburgposition compared to supine position. Estimated mean blood loss was sig

nificantly less and the recorded field visibility scores were significantlyhigher in TI group compared to CH group. There was a negative significant correlation between the field visibility score and mean MAP andmean amount of bleeding. Using regression analysis, the use of hypoten-

sive anesthesia was found to be a significant independent factor for improving filed visibility, and the use ofTl anesthesia was found to be significant determinant independent factor for induction of hypotensiveanesthesia. The receiver operating characteristic (ROC) carve analysisjudged by the area under the curve (AUC) defined the superiority of use ofTI over CII anesthesia as independent determinant for field visibility.

Conclusion: It could be concluded that maintaining patients in anti-Trendelenburg position and anesthetic manipulation using total intrave

nous anesthesia could minimize bleeding and improve field visibility during FESS and thus this combination of manipulations could be appropriate strategy for such type of surgery.

Ahmed El-Emshati & Ahmed Al-Arfaj

85

bleeding is an important task for

an anesthetist during a FESS. Inthe case of the expanded process,

still more numerous interventions

are performed with general anes

thesia, (Cincikas & Ivaskevicius,

2003).

To improve the control of bleeding during FESS, induced hypotension was tried. The state of "hy

potension" . was achieved by

reducing the peripheral blood vessel resistance, reducing the heart

rate per minute and by inter-

coordinating these two effects, (Ja-

cobi et al., 2000). Most frequentlyperipheral vasodilators, beta-

blockers, volatile anesthetics are

used to cause induced hypotension, (Praveen et al., 2001).

The present study was de

signed as a trial to improve thecontrol of bleeding during FESSby means of positional changes

and the use of controlled hypoten

sion achieved through maintenance of anesthesia using remi-

fentanil and either of propofolinfusion (Total Intravenous) or iso-

flurane inhalation (Combined In-travenous/Inhalational).•

Vol. 26 No 2 May 2009

ciliary clearance improved for bothtypes of antral mucosa, with im

proved ventilation and drainage.

Moretz & Kountakis. (2006) reported a significant decrease ofthe mean overall headache and

sino-nasal outcomes test scores

from 28.7 preoperatively to 6.7

postoperatively.

Intraoperative bleeding, which

reduces visibility in the operativefield, is one of the major problemsof such interventions, (Eberhart et

al., 2003). Complicated anatomicstructure, its unique variations,

vicinity of delicate cranial base,

brain, eyes, blood vessels and

nerves requires for the surgeon to

know anatomy in detail and to

precisely identify structures, thus

abundant bleeding during surger

ies undoubtedly is among the factors able to cause complications.

Upon reduced visibility the time ofintervention extends. Increased

bleeding sometimes causes finish

ing surgeries before the due time,

when targets raised at the begin

ning are given up in order to avoid

possible complications, (Zeng etal., 2003). Improvement of intra

operative visibility while reducing

Benha M. J.

86

duced by a bolus of remifentanil

(1 pg//kg), propofol (2 mg/kg) androcuronium (0.5 mg/kg). Two minutes later, trachea was intubated

and a posterior pharyngeal packwas placed to limit the risk of aspiration of blood and lungs wereventilated with 100% oxygen. Ven-

tilatory parameters were adjusted

so as to maintain end-tidal CO2around 32 mmHg. Anesthesia was

maintained in both groups by infusion of 0.5 gg/kg/min of remifentanil in addition to 10pg/kg/

min propofol infusion in Group TI

group or isoflurane 2% in GroupCII. Propofol infusion rate and

MAC of isoflurane were adapted

according to hemodynamic responses, in order to maintain MAP

values in the range of 60-70mmHg.

Immediately after tracheal intu

bation, all patients underwent

packing of the nasal cavity withadrenaline soaked pledgets

(1:100,000) to obtain maximumvasoconstriction of the mucosa

and thus better visuali^ation of

the main features of the cavity.

Prior to insertion in the cavity, liq

uid is removed from the pledgets

and then, under endoscopic guidance, carefully applied on the mu-

Patients and MethodsThis prospective comparative

study was conducted at Day-

Surgery Unit, Al-Habib MedicalGroup, Riyadh, KSA and included

32 patients; aged 21-53 years andassigned to undergo FESS. Afterobtaining patients' fully informed

written consents, they were divid

ed randomly into two equal main

groups (n=16) according maintenance anesthetic regimen used ei

ther total intravenous (Group TI),or combined Intravenous/Inhala-

tional (Group CII). Each main

group was further subdividedequally according to patient's posi

tion during surgery either supine

or inclined by approximately 30in anti-Trendelenburg. Patients

with the cardiovascular pathology,heart failure, hypertension, as

well as patients with bleeding di

athesis and those administering

aspirin or other medications affecting coagulation system and

patients with kidney or liver dysfunctions, as well as anemia

(Hb<10g/dl) were excluded off thestudy.

All patients were pre-medicatedwith midazolam (0.05 mg/kg), 2min thereafter, anesthesia was in

Ahmed El-Emshati & Ahmed Al-Arfaj

87

nate process was removed by

cutting around the site of attachment with a sickle knife or shaver

starting adjacent to the anterior

attachment of the middle turbinate. Shaver and ethmoid forceps

were used to remove nasal polyps

and to open the ethmoid air cell;then any retained secretions were

suctioned.

The visibility of the operative

field during FESS was evaluated

using Fromme et al., (1986) scale

adapted by Boezaart et al., (1995)

was used: 5= no bleeding, 4=slightbleeding and blood evacuation not

necessary, 3=slight bleeding andsometimes blood has to be evacu

ated, 2= low bleeding, blood has to

be often evacuated and operative

field is visible for some secondsafter evacuation, l=average bleed

ing, blood has to be often evacuat

ed and operative field is visibleonly after evacuation and O=high

bleeding and constant blood evac

uation is needed but sometimesbleeding exceeds evacuation and

surgery is hardly possible or impossible at all. The total amount

of bleeding as judged by theamount evacuated was also re

corded

Vol. 26 No 2 May 2009

cosa. The middle meatus, hiatus

semilunarls and the sphenoeth-

moldal recess were packed as pos

sible with cotton pads which wereintroduced using small auricularforceps, and after 5 minutes, the

pledgets were removed. Xylocalne

1% with adrenaline (1:100,000),1-1.5 ml, was injected under the

mucosa of the uncinate pro

cess, at the level of the head of

the middle turblnate and the inferior part of the bulla. Local anes

thetic was given at the point of in

sertion of the middle turbinate, so

as to block the vessels and thenerve fibers which come from the

artery and the anterior ethmoidal

nerve.

Patients were monitored non-

invasively; before induction of an

esthesia (TO) and 20 (T20), 40(T40) and 60 mm (T60) after induction of anesthesia, for systolic

arterial pressure (SAP), diastolic

arterial pressure (DAP) and MAP;

HR, SPO2 and Et CO2.

The approach for FESS wasconducted totally endonasal. The

maxillary ostium was identified by

locating the inferior posterior edge

of the uncinate process. The unci

Benha M. J.

88

tients underwent anterior and

posterior ethmoidectomy withopening of the middle lamina ofthe turbinate and/or sphenoidoto-

my and 7 patients underwent an

terior ethmoidectomy, opening of

the middle lamina of the turbinate

and/or opening of the frontal recess. There was a non-significant

difference between patients en

rolled in both groups as regardsage, sex, ASA grade distribution or

procedure performed, (Table 1).

Both anesthetic modalities reduced blood pressure significantly

(p<0.05) at the three times ofmeasurements compared to pres

sure levels determined preopera-

tively. Moreover, blood pressure

parameters showed progressive

significant (p<0.05) decrease at

T40 and T60 compared to meas

ures determined at T20 in both

groups with non-signiflcantly lower pressure measures with propof-

ol compared to isoflurane, (Fig. 1).

Mean HR showed progressive sig

nificant (p<0.05) decrease in bothgroups compared to their preoper-

ative rates with a non-significant

difference between mean HR re

ported in both groups, (Table 2,Fig. 2). However, irrespective of

Statistical analysisObtained data were presented

as mean+SD, ranges, numbers

and ratios. Data were analyzed us

ing Wilcoxon Z-test for unrelated

data and possible relationshipswere investigated using Pearson

linear regression. Regression anal

ysis (Enter Method) was used todefine independent factors for pro

viding proper field visibility andspecificity of these factors wereevaluated using the receiver oper

ating characteristic (ROC) curveanalysis judged by the area under

the curve (AUC). Statistical analysis was conducted using the SPSS

(Version 10, 2002) for Windowsstatistical package. P value <0.05

was considered statistically significant.

ResultsThe study included 32 patients;

23 males and 9 females withmean age of 39.28.4; range: 21-

53 years. According to American

Society of Anesthesiologists (ASA),

there were 25 ASA grade I and 7ASA grade II. Sixteen patients underwent anterior ethmoidectomy

(resection of the uncinate process

and opening of the bulla) and/ormiddle hiatal antrostomy; 9 pa

Ahmed El-Emshati & Ahmed Al-Arfaj

89

Mean blood loss estimated inpatients received If anesthesia

was 157.344.9; range 105-270

ml and was significantly (Z=3.184,p=0.001) less compared to those

received CII anesthesia: 23949.5;range: 135-355 ml, (Fig. 6). More

over, recorded field visibility scorewas 3.33+0.6; range 2-4 in TI

group and was significantly higher(Z=2.266, p=0.023) compared toscore recorded in patients received

CII group; 2.470.99; range 1-4,

(Table 4, Fig. 7).

There was a negative significantcon^lation between the field visi

bility score and mean MAP, (r=-

0.486, p=0.006) and mean

amount of bleeding, (r=-0.366,

p=0.047), (Fig. 8). Using regres

sion analysis to determine theindependent factor for improving

the field visibility, the use of hypo-tensive anesthesia was found to

be a significant independent factor

for improving filed visibility(0=0.370, t=2.222. p=0.035), and

the use of TI anesthesia was found

to be significant determinant inde

pendent factor for induction of hy-potensive anesthesia, ((1=0.242,t=2.500, p=0.015). Using ROCcurve to define the specific inde-

VoL26 No 2 May 2009anesthetic modality used, anti-

Trendelenburg position induced asignificantly lower (Z=2.484,p=0.013) mean arterial pressure

compared to those maintained in

supine position, (Fig.3).

All surgeries were conducted

completely without intraoperativecomplications. No extensive bleed

ing was recorded and no patient

had visibility score of 0 and only 3

patients in group CII (20%) had

visibility score of 1, 7 patients; 2

in TI (12.5%) and 5 in CH group

(31.2%) had visibility score of 2.

Fourteen patients; 8 in TI (50%)and 6 in CII group (37.5%) had

visibility score of 3 and 8 patients;

6 in TI (37.5%) and 2 in CII

(12.5%) had visibility score of 4.

There was a significant increase

(X2=5.544, p<0.05) in the frequency of good field visibility with TIcompared to CII anesthesia, (Fig.

4). Moreover, Patient's position

during surgery significantly in

fluenced surgical field visibility.Patient's positioning in anti-

Trendelenburg position significantly (X2=9.164, p<0.01) improved field visibility compared

to supine position, (Table 3, Fig.5).

Benha M J.

90

-0.0232.266

2.4710.99(1-4)3.3310.6 (2-4)Visibility score

=0.0013.184

239149.5 (135-355)157.3144.9(105-270)

Amount (ml)

DZGroup CR (n-16)Group TI (n-16)Group

Table (4): Mean collective amount of bleeding and field visibility score reported at 60minutes after induction of anesthesia in both groups

7 (43.7%)8 (50%)1 (6.3%)

0

Anti-Trendelenburg(n-16)

1 (6.3%)6 (37.5%)6 (37.5%)3(18.7%)

Supine(n-16)

Position

2(12.5%)6 (37.5%)5(31.2%)3(18.7%)

Group CII(n-16)

6(37.5%)8 (50%)

2 (12.5%)0

Group TI(n-16)

Anesthetic Modality

4321Visibility score

Table (3): Patients' distribution according to the Held visibility score reported in bothgroups categorized according to anesthetic modality and position during surgery

*: significant versus ToData are presented as meanSD66.23.3*t70.63.9*t

7513.8*82.813

67.53.3*t69.1l5.2"t73.314.5*81.812.9

HR (beat/min)

67.6l3.2*t7213. l*t74.213.9*89.914.4

68.53.5*t68.413.S*f67.7112.9*

92.816 9MAP (mmHg).

60.24.2*t65.12.9*t

68.114*76.515

63.U4.6*t64.214*t66.715.5*78.315.9

DAP (mmHg)

82.513.2*t83.114.1*t

86.415*116.715.279.47*t

76.77.6*t83.216.2*121.819.6

SAP (mmHB)

TwT,TmTnToTn,•pTn

(n-16)Group CII

(n-16)Group TI

Table (2): Mean blood pressure and heart rate changes reported in both groups at T3o, T40and Tso after induction of anesthesia in comparison to preoperative measures

Data are presented as meaniSD, numbers & ratios; ranges & percentages in parenthesis

7(21.9%)9(28.1%)

16 (50%)26:623:9

39-28.4(21-53)

Total (n-32)

349

13:311:5

40.218(23-51)

Group CH(n-16)

457

13:312:4

38.38.8(21-53)

Group TI(n-16)

Ant ethmoidectomy, opening of middlelamina of turbinate & frontal recess

Ant & Post ethmoidectomy^Anterior ethmoideclomv

perfumedProcedureASA trade 1:11Sex; M:F

Age (years)

Table (1): Patients' distribution in both studied groups according to patients' character andprocedure performed

thesia as independent determi

nant for field visibility,(AUC=0.778 vs 0.630, respective

ly), (Fig. 9).

Ahmed El-Emshati & Ahmed Al-Arfaj

pendent factor defined the su

periority of use of total intravenous anesthesia over combined

intravenous / inhalational anes

91

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Vol. 26 No 2 May 2009

Benha M J

92

Fig. (9): HOC curve analysis of mode of anesthetic maintenance as a specific independent predictor forimproving field visibility

-SO.751.00

1ii

i

FleW\*s*S(y scoreReHtrisfcifty scoreFig. (8): Correlation between field visibility and mean MAP and mean amount of intraoperative bleedingreported in studied patients

a. (7): Maul (SD) fluid visibility aeor* raoordac

im

_JBM̂^T o Group Tl OGranpcn

Ahmed El-Emshati & Ahmed Al-Arfaj

93

and heart rate measures through

out observation period compared

to preoperative measures with

progressive significant decrease atT4o and T60 compared to meas

ures determined at T20 in bothgroups, but with non-significantdifference between both groups.

These results agreed with Tirelli et

al., (2004) who reported progressive reduction of blood pressure

with both TIVA and inhalational

anesthesia during endoscopic si

nus nasal surgery and with Rath-

jen et al., (2006) who reported thatTTVA allows the reduction of themean arterial blood pressure to 60

mmHg and concluded that forgeneral anesthesia in endonasal

sinus surgery sodium nitroprus-

side is no longer recommended

and instead a TIVA using propofoland remifentanil should be used.

The reported significant hypotension showed non-significant

difference between both groups

and this could be attributed to themaintenance of anesthesia using

remifentanil infusion. In support

of this explanation, Manola et al.,

(2005) compared three types of

general anesthesia for FESS withcontrolled hypotension and report-

Benha M. J.

Vol. 26 No 2 May 2009

Discussion

FESS is most successful in patients who have recurrent acute or

chronic infective sinusitis. Pa

tients in whom the predominant

symptoms are facial pain and nasal blockage usually respond well.The sense of smell often improves

after this type of surgery. In pa

tients with nasal polyposis that isnot controlled with topical cortl-

costeroids, FESS permits the ac

curate removal of polyps, (Bugtenetal., 2008).

A number of previous studies

have tried to assess the effects of

various hypotension-inducing

drugs on the surgical field during

FESS to minimize bleeding so as

to improve the operative field visi

bility in FESS, (Nair et al., 2004).The present study was designed

as a trial to improve the control of

bleeding during FESS by means of

positional changes and the use of

controlled hypotension achieved

through maintenance of anesthe

sia using remifentanil and either

of propofol infusion or isofluraneinhalation.

Both anesthetic modalities sig

nificantly reduced blood pressure

94

with significantly improved quality

of visibility of the surgical fieldand concluded that TWA is effective in reducing bleeding duringFESS.

The obtained results support

that obtained by Sivaci et al.,

(2004) who found general anesthesia based on propofol Infusion

have the advantage of significantly

decreased bleeding compared withconventional inhalation agents

and therefore, making endoscopic

surgery technically easier and saf

er by improving endoscopic visualization of the surgical field and

with Manola et al., (2005) and

Wormald et al., (2005) who reported significant reduction of bleed

ing and higher field visibility with

propofol and remifentanil infusion

as opposed to inhalation anesthesia using sevoflurane.

Statistical analysis to define ifthese effects could be attributed to

induced decreased MAP or to the

use of TI anesthesia showed that

TI anesthesia was found to be a

significant independent factor for

determination of field visibilityand showed wider area under

ROC curve as specific determi-

ed proper blood pressure adjustment using either TWA or inhala-

tional anesthesia with a significant difference in favor of

remifentanil / propofol comparedto either of sufentanil / sevoflu-

rane or fentanyl / isoflurane.

Noseir et al., (2003) tried to explore the possible mechanisms ofhypotension during the adminis

tration of remifentanil in young

ASA I volunteers and reported direct effects of remifentanil on re

gional vascular tone that may play

a role in promoting hypotension.Also, Jones, (2003) concluded that

reductions in sympathetic outflow

with remifentanil would implicate

central effects of this anestheticon sympathetic control.

Mean blood loss estimated inpatients received TI anesthesia

was significantly less with significantly higher field visibility score

in TI group compared to CII group.

These results agreed with Tirelli etal., (2004) and Sun et al., (2003);

both studies reported that the

mean estimated blood loss for pa

tients received TWA was significantly reduced compared to thosereceived inhalatlonal anesthesia

Ahmed El-Emshati & Ahmed Al-Arfaj

95

ry to that reported by Beule et al.,(2007) who compared the effect ofpropofol versus sevoflurane anes

thesia on bleeding and field visibility during FESS and reported that

total blood loss, blood loss per

minute, and endoscopic visionshowed no group difference and

platelet function was significantly

impaired 45 minutes after onset of

surgery in both groups, but morepronounced after propofol anesthesia. On contrary to Beule et al.,

(2007) and in support of the re

sults of the current study. Aim etal., (2008) reported that in thehigh-Lund-Mackay score patients,

propofol/remifentanil anesthesia

results in less blood loss and abetter surgical conditions for

FESS than sevoflurane/remifenta-nil anesthesia.

Furthermore, patients' position

during surgery showed additional

impact on the reported beneficialeffects of hypotensive anesthesia,

irrespective of the type of anesthetic used manifested as significantly decreased MAP in patients

maintained in antt-Trendelenburg

position with significantly unproved field visibility in compari

son to those maintained in supine

Benha M. J.

Vol. 26 No 2 May 2009

nant. These findings could be attributed to the fact that in clinically relevant concentrations propofoldid not influence the surface ex

pression density of fibrinogen receptors, P-selectin molecules, and

the percentage of leukocyte-

platelet aggregates ex vivo; thusdid not allow interruption of eitherof platelet or coagulation func

tions, (Scheinicherf et al., 2002).Also, Dordoni et al., (2004) report

ed that propofol, in comparison to

other anesthetics, had no effect on

platelet function both ex vivo and

in vitro and propofol might be considered hemostatically safer.

As an explanation for the effectof propofol on platelet function,

Fourcade et al., (2004) experimentally reported that propofol doesnot significantly alter intracellular

calcium increases caused by re

ceptor activation and its inhibitionof platelet aggregation appears to

act distal to platelet receptors, in-

ositol phosphate 3, and phospholi-pase C.

The obtained results and the

previous experimental studiedconcerning effect of propofol on

platelet function were contradicto-

96

(2007) : Propofol versus sevoflurane: bleeding in endoscopic sinus

surgery. Otolaryngol Head Neck

Surg.; 136(l):45-50.

Boezaait A. P., Merwe J. and

Coetzee A. (1995) : Comparisonof sodium nitrbprusside and es-

molol induced controlled hypotension for functional endoscopic si

nus surgery. Can J Anaesth.; 42:

373-6.

Bradley D. T. and Kountakis

S. E. (2005) : Correlation between

computed tomography scores andsymptomatic improvement after

endoscopic sinus surgery. Laryn

goscope; 115(3): 466-9.

Bugten V., Nordgard S. and

Steinsvag S. (2008) : Long-termeffects of postoperative measures

after sinus surgery. Eur Arch

Otorhinolaryngol.; 265: 531-7.

Cincikas D. and Ivaskevicius

J. (2003) : Application of con

trolled arterial hypotension in en

doscopic rhinosurgery. Medicina

(Kaunas), 39(9): 852-9.

Dordoni P. L., Frassanlto L.,

Bruno M. F., Proietti R., de Cris-

position during surgery. Thesefindings go in hand with Ko et al.,(2008) who evaluated the factorsrelated to the volume of intraoper-

ative blood loss during endoscopicsinus surgery and reported thatreverse Trendelenburg position

may reduce intraoperative blood

loss.

It could be concluded thatmaintaining patients in anti-

Trendelenburg position and anes

thetic manipulation using total intravenous anesthesia could mini

mize bleeding and improve field

visibility during FESS and thusthis combination of manipulationscould be appropriate strategy forsuch type of surgery.

References

Ahn H. J., Chung S. K.,

Dhong H. J., Kim H. Y., Ahn J.

H., Lee S. M., Hahm T. S. and

Kim J. K. (2008) : Comparison of

surgical conditions during propof-ol or sevoflurane anesthesia for

endoscopic sinus surgery. Br J

Anaesth.; 100(l):50-4.

Beule A. G., Wilhelmi F.,

Kiihnel T. S., Hansen E., Lack-

ner K. J. and Hosemann W.

Ahmed El-Emshati & Ahmed Al-Arfaj

97

hypotension for orthognatic surgery. Anesth Analg.; 65: 683-6.

Huang H. M., Cheng J. J., Liu

C. M. and Lin E. N. (2006) :Mucosal healing and mucociliary

transport change after endoscopic

sinus surgery in children withchronic maxillary sinusitis. Int J

Pediatr Otorhlnolaryngol.; 70 (8):1361-7.

Jacobi K. ., Bohm B. E.,

Rickauer A. J., Jacobi C. and

Henunerling T. M. (2000) : Mod

erate controlled hypotension withsodium nitroprusside does not im

prove surgical conditions or de

crease blood loss in endoscopic sinus surgery. J Clin Anesth.;

12:202-7.

Jones P. (2003) : Mechanism(s) of remifentanil-induced hypotension in humans. Can. J

Anesth.; 18(3): 215-9.

Ko M. T., Chuang E. C. and

Su C. Y. (2008) : Multiple analyses of factors related to intra-

operative blood loss and the roleof reverse Trendelenburg positionin endoscopic sinus surgery. La

ryngoscope; 118 : 1687-91.

Benha M. J.

Vol. 26 No 2 May 2009

tofaro R., Ciabattoni G.. Ardito

G., Crocchiolo R., Landolfi R.

and Rocca B. (2004) : In vivo and

in vitro effects of different anesthetics on platelet function. Br J

Haematol.; 125(l):79-82.

Eberhart L. H., Folz B. J.,

Wulf H. and Geldner G. (2003) :Intravenous anesthesia provides

optimal surgical conditions during

microscopic and endoscopic sinus

surgery. Laryngoscope; 113 (8):1369-73.

Eisenberg G., Perez C, Her-

nando M., Taha M., Gonzalez R.,

Montojo J., Eeharri R., Garcia

V., Onrubia T. and Plaza G.

(2008) : Nasosinusal endoscopic

surgery as major out-patient sur

gery. Acta Otorhinolaringol Esp.;59(2):57-61.

Fonrcade O., Simon M. F.,

Litt L., Samli K. and Chap H.

(2004) : Propofol inhibits human

platelet aggregation induced by

pro-inflammatory lipid mediators.

Anesth Analg.; 99(2):393-8,

Fromme G. A., MacKenzie R.

A., Gonld A. B., Lund B. A. and

Offord K. P. (1986) : Controfled

98

MaxillSurg.; 39:138-40.

Rathjen T., Bockmiihl U. and

Greim C. A. (2006) : Modern an-

esthesiologic concepts supportingparanasal sinus surgery. Laryn-

gorhlnootologie.; 85(1): 20-3.

Scheinichen D., Bomscheuer

A, Jaeger K., Mahr K. H.,

Koksch M., Ruschulte H. and

Heine J. (2002) : Influence of a

bolus injection of thiopental and

propofol on the expression density

of P-selectin and fibrinogen receptors on the surface of human

platelets ex vivo. Anasthesiol In-

tensivmed Notfallmed Schmerz-

ther; 37(7): 403-8.

Sivaci R., Yilmaz M. D., Balci

C, Erincler T. and Unlu H.

(2004) : Comparison of propofoland sevoflurane anesthesia by

means of blood loss during endoscopic sinus surgery. Saudi Med

J.: 25(12): 1995-8.

Sun S., Zhang Z., Wu C. and

Song W. (2003) : A preliminary

study of reducing bleeding procedure during endoscopic sinus sur

gery. Lin Chuang Er Bi Yan HouKeZaZhi.;17(12):734-5.

Manola M., De Luca E., Mos-

cillo L. and Mastella A. (2005) :Using remifentanil and sufentanilin functional endoscopic sinus

surgery to improve surgical conditions. ORL J Otorhinolaryngol Re-lat Spec.; 67(2): 83-6.

Moretz W. H. and Kountakis

S. E. (2006) : Suhjective headache before and after endoscopic

sinus surgery. Am J Rhinol.; 20

(3):305-7.

Nair S., Collins M.. Hung P.,

Rees G., Close D. and Wonnald

P. J. (2004) : The effect of beta-

blocker premedication on the surgical field during endoscopic sinus

surgery. Laryngoscope; 114(6):1042-6.

Noseir R. K., Ficke D. J.,

Kundu A., Arain S. R. and

Ebert T. J. (2003) : Sympatheticand vascular consequences from

remifentanil in humans. Anesth

Analg.; 96(6): 1645-50.

Praveen K., Narayanan V.,

Muthusekhar M. R. and Baig M.

F. (2001) : Hypotensive anesthe

sia and blood loss in orthognathic

surgery: a clinical study. Br J Oral

Ahmed El-Emshati & Ahmed Al-Arfaj

99

thesia compared with inhalationalanesthesia on the surgical field

during endoscopic sinus surgery.

AmJRhinol.; 19(5):514-20.

Zeng Y., Wang Y. J., Xiao J.

X., Tan J. and Liao S. (2003) :

Factor analysis for bleeding in endoscopic sinus surgery and the

counter-measures. Di Yi Jun Yi Da

Xue Xue Bao.; 23(4): 380-1.

Benha M. J.

Vol. 26 No 2 May 2009

Tirelli G., Bigarini S., Russo-

lo M., Lucangelo U. and Gnllo A.

(2004) : Total Intravenous anesthesia in endoscopic sinus-nasal

surgery. Acta Otorhinolaryngol

Ital.: 24(3): 137-44.

Wonnald P. J., van Renen G.,

Perks J., Jones J. A. and Lang-

ton-Hewer C. D. (2005) : The ef

fect of the total intravenous anes