Hypotension on Induction Clinical Trial
Official title:
Efficacy of Oral Diltiazem Versus Combination of Oral Diltiazem With Intravenous Tranexamic Acid on the Intraoperative Bleeding in Functional Endoscopic Sinus Surgery
- The primary endpoint is the effect of the addition of oral Diltiazem and Tranexamic Acid
to general anesthesia aided reduction in blood loss during functional endoscopic sinus
surgery (FESS).
- The secondary endpoint is surgeon's assessment of the surgical field and hemodynamics.
Functional endoscopic sinus surgery (FESS) is a minimally invasive technique used to restore
sinus ventilation and function in patients with recurrent acute or chronic infective
sinusitis in whom medical therapy has failed.
Continued bleeding into the surgical field during FESS not only impairs endoscopic vision but
can lead to complications.
Controlled hypotension is a technique used to limit intraoperative blood loss to provide the
best possible field for surgery. The physiological principle which underlies hypotensive
anesthesia is a natural survival mechanism. When profuse bleeding occurs, the blood pressure
drops. This drop leads to a reduction or cessation of the bleeding, blood pressure
stabilization, and recovery. Accordingly, reducing the patient's blood pressure during
surgery can potentially reduce overall bleeding. Since bleeding in the surgical field is also
reduced, the surgical field operating conditions are improved In hypotensive anesthesia, the
patient's baseline mean arterial pressure (MAP) is reduced by 30 %. Consequently, the
systolic blood pressure values are about 80-90mmHg and the MAP is reduced to 50- 65mmHg.
Hypotensive anesthesia is considered to be a suitable anesthetic technique for those patients
who will be undergoing spinal surgery, hip or knee arthroplasty, craniosynostosis, hepatic
resections, and major maxillofacial operations. Benefits for controlled hypotension for FESS
include the reduction in blood loss with improved quality of the surgical field.
Various agent's anesthetic agents, analgesics, and hypotensive drugs, that have been used for
achieving hypotensive anesthesia:
1. Volatile Anesthetic Agents. Most anesthetic agents have a hypotensive effect such as
isoflurane, sevoflurane, and desflurane, high concentrations are required to achieve a
significant reduction in intraoperative bleeding, and these concentrations may lead to
hepatic or renal injury.
2. Propofol. has a potent hypotensive capability, but normal blood pressure will be rapidly
restored when the propofol infusion is discontinued. Although a short-term propofol
infusion is safe, a long-term Propofol infusion can cause propofol infusion syndrome in
children.
3. Alfentanil, Sufentanil, and Remifentanil. potent synthetic and short-acting opioid
drugs, Since the recovery times from this type of anesthesia are also short, they are
widely used for hypotensive anesthesia.
d.Nitrates. SNP and NTG are two very potent hypotensive agents that are commonly used for
inducing hypotensive anesthesia. Reflex tachycardia is an unwanted effect which often occurs
with nitrates administration and can be prevented by a small dose of the beta-adrenoceptor
antagonist, such as esmolol or propranolol premedication.
e-beta-Adrenoceptor Antagonists. They effectively used for inducing hypotensive anesthesia
when administered either as a single hypotensive agent or in combination with SNP.
Nonselective beta-antagonists, such as labetalol, may cause bronchoconstriction and should be
avoided in asthmatic patients. The hypotensive action of beta-adrenoceptor antagonists is
achieved by reducing cardiac output. So, not suitable for the patient with underlying heart
failure.
f-Calcium Channel Antagonists. such as nifedipine or nicardipine, are commonly used as
hypotensive drugs.
Diltiazem, a calcium channel blocker, blocks the influx of calcium into smooth muscle cells
and cardiac muscle cells. This causes relaxation of the muscle, thereby causing reduced
arteriolar tone and fall in blood pressure.
Tranexamic acid is a synthetic amino acid that inhibits fibrinolysis, which reduces blood
loss and the need for blood transfusion in total knee arthroplasty, spine surgery, and
cardiac surgery. It has seen wide application in a variety of surgical procedures since then.
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