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Introduction Functional endoscopic sinus surgery (FESS) is one of the common surgical procedures requiring hypotensive anesthesia; many agents have been tried to reduce the amount of blood loss. This study aims at comparing the efficacy of two agents for providing deliberate hypotension. Objectives The aim of this study was to evaluate the efficacy of esmolol and of dexmedetomidine and compare which one of the two is a better agent to produce induced hypotension during FESS. Materials and methods This was a comparative study conducted in a tertiary care hospital in Odisha, India. There were two study groups with 30 participants each who were given either esmolol or dexmedetomidine (group E and group DEX, respectively). Results Esmolol is an anti-hypertensive agent with better hemodynamic stability. The amount of drug and dose requirement was low in group DEX. The emergence time, sedation score, and time to first analgesic request were found to be highly statistically significant in group DEX. Conclusion Dexmedetomidine was found to be a better agent at controlling intra-operative blood pressure than esmolol and had beneficial effects on recovery from anesthesia and analgesia.

Background: Peripheral perfusion index (PPI) reflects changes in the vasomotor tone. The aim of this observational study is to explore the potentials of the PPI as a predictor of the response to ni...

Hypotensive anesthesia is such anesthetic technique where during general anesthesia the patient's mean arterial pressure is decreased by more than 20% of its preoperative value. Motivation: To prevent the occurrence of brain hypoxia during hypotensive anesthesia in patients undergoing septo- and rhinoplastic surgery. Aims: To determine the average values of brain saturation in awaken patients; to find the correlation between the mean arterial pressure and brain saturation during moderate hypotension, and to analyze the adverse reactions postoperatively. Materials and methods: Twenty (ASA 1) patients, anaesthetised in moderate hypotensive general anesthesia with Remifentanyl and Sevoflurane were enrolled in the study. They were observed at five times interval (T1-5): MAP, HR and rSO2, and a correlation between the parameters was determined. Results: A moderate hypotension was achieved in T4 (MAP = 69.05 ± 7.09). The average baseline values of brain saturation from 73.30 ± 5.44% to the left, 75.30 ± 5.18% to the right brain hemisphere were obtained. The curve of brain saturation had an upward trend, a peak that coincided with an introduction to anesthesia, in a further course with a downward trend. We found a mild to moderate positive correlation between MAP and rSO2 during hypotensive anesthesia, but throughout the entire period there was a higher rSO2 than the basal initial value. Conclusion: Moderate hypotension and stable mean arterial pressure (MAP) contribute to stable brain saturation (rSO2)., Хипотензивната анестезија е таква анестезиолошка техника при која средниот артериски при- тисок на пациентот се намалува за повеќе од 20% од неговата предоперативна вредност. Мотив: да се спречи појава на хипооксија на мозокот при употреба на хипотензивна анестезиолошка техника кај пациенти подложни на септо/ринопластика. Цели на трудот: да се утвр Хипотензивната анестезија е таква анестезиолошка техника при која средниот артериски притисок на пациентот се намалува за повеќе од 20% од неговата предоперативна вредност. Мотив: да се спречи појава на хипооксија на мозокот при употреба на хипотензивна анестезиолошка техника кај пациенти подложни на септо/ринопластика. Цели на трудот: да се утврди просечната вредност на мозочната сатурација кај будни пациенти, да се одреди корелацијата на средниот артериски притисок и мозочната сатурација при умерена хипотензија, и да се анализираат постоперативните несакани ефекти. Материјали и методи: во студијата беа вклучени 20 пациенти, АСА 1, водени со умерена хипотензивна анестезија предизвикана со ремифентанил и севофлуран. Во пет временски интервали (Т1-Т5) се следеа параметрите: MAP, HR, rSO2 и се одреди нивната корелација. Резултати: умерена хипотензија се постигна во Т4 (МАР=69,05±7,09). За просечна базална вредност на мозочната сатурација се утврдија: 73,30 ± 5,44% за левата и 75,30±5,18% за десната мозочна хемисфера. Кривата на мозочната сатурација покажуваше нагорен тренд и пик кој се совпаѓаше со воведот во анестезија, а во понатамошниот тек тенденција кон опаѓање. Се најде слаба до умерена позитивна корелација помеѓу MAP и rSO2 во текот на хипотензивната анестезија, а во целиот тек на мерењето rSO2 беше повисоко од базалната вредност. Заклучок: умерената хипотензија и стабилниот среден артериски притисок придонесуваат за стабилна мозочна сатурација.

Arthroscopic surgery of the shoulder joint and the subacromial space requires adequate visualization to be effectively performed. Visual clarity is essential to perform a safe and successful arthroscopic procedure. The major determinants to provide visualization in the subacromial space and the glenohumeral joint include adequate inflow (dependent on the dimension of the inflow cannula), flow rate versus pressure, pump system versus gravity, the use of electrocautery and radiofrequency devices, blood pressure control and hypotensive anesthesia, and the type of irrigation solution used with or without the use of epinephrine. In 2012, the cost of a 30-mL (30-mg) vial of epinephrine was $6 (adrenalin/epinephrine injection, USP, Par Pharmaceuticals), and approximately 3 to 4 bottles would be used on average for a single shoulder arthroscopy. In 2019, the same 30-mL bottle of epinephrine cost $237, a nearly 40-fold increase. The purpose of our study is to describe the various factors and techniques that can be used to maintain visual clarity in shoulder arthroscopy without the use of epinephrine in the irrigation solution and the cost savings associated without the use of epinephrine., Technique Video Video 1 Shoulder arthroscopy requires adequate visualization to be effectively performed. Visual clarity is essential to perform a safe arthroscopic shoulder procedure. In particular, bleeding in the subacromial space and the glenohumeral joint is an ever-present impediment to visualization. The major determinants to provide visualization are shown in this video. A couple of the key determinants include adequate inflow, flow rate versus pressure, the type of pump system used, and most importantly, blood pressure control and hypotensive anesthesia, along with the irrigation solution with or without the use of epinephrine. Visualization requires a properly functioning optical system of an arthroscopic lens, camera, and video equipment. Adequate joint distension is maintained by a pump system that delivers and maintains a clear medium into the joint. A pump pressure of 40 mm Hg is recommended as long as the systolic blood pressure is near 90 mm Hg, which provides adequate hydrostatic pressure on the capillaries to decrease bleeding. A proper arthroscopic cannula system is also key for shoulder arthroscopy. We recommend a 5.5-mm × 8.5-cm “J-lock” metal cannula system made by Smith and Nephew/Dyonics. The 5.5-mm cannula system provides an adequate inflow and flow rate through the arthroscope for adequate joint distension. With 3 portals being established, there is often no cannula placed in the anterior portal. This can sometimes lead to fluid outflow through this portal leading to bubbles or loss of visualization described as the Bernoulli Effect. Burkhart et al.3 described having his assistant place his finger over the portal. However, we recommend placing either a plastic or metal obturator into the portal to reduce or eliminate this effect. First, we demonstrate arthroscopic visualization of the glenohumeral joint in the lateral decubitus position, which we prefer. Again, we have adequate visualization viewing from posterior to anterior. The anterior-superior portal is hooked up to outflow, which is controlled by a clamp, and not to suction. Next, we visualize the subacromial space viewing from posterior to anterior. The shaver is placed through the anterior-superior portal, visualizing the rotator cuff and bursa down below. Adequate visualization is required, of course, in the subacromial space. Key is hypotensive anesthesia and the judicious use of the shaver versus the radiofrequency device to control bleeding. In 2012, the cost of a 30-mL vial of epinephrine was only $6. Seven years later, in 2019, that same 30-mL vial of epinephrine now costs $237. That is approximately a 390% increase in price over the past 7 years. Three or 4 bottles may be used during shoulder arthroscopy. We therefore discontinued the use of epinephrine in shoulder arthroscopy, saving over $900 per case, sometimes more depending on the duration of the case and number of vials used. Using the techniques described, we have found no problems with adequate visualization with shoulder arthroscopy, without the use of epinephrine. Attention to detail in all aspects of the surgical procedure is key in maintaining visual clarity.

Introduction The use of controlled hypotension during neuraxial anesthesia for joint arthroplasty is controversial. We conducted a large institutional database analysis to assess common in-hospital complications and mortality of patients undergoing primary total hip arthroplasty (THA) under controlled hypotension and neuraxial anesthesia. Methods We conducted a large retrospective case control study of 11,292 patients who underwent primary THA using neuraxial anesthesia between March 2016 and May 2019 in a single institution devoted to musculoskeletal care. The degree and duration of various mean arterial pressure (MAP) thresholds were analyzed for adjusted odds ratios with composite common severe complications (in-hospital myocardial infarction, stroke, and/or acute kidney injury) as the primary outcome. Results Sixty-eight patients developed common severe complications (0.60%). Patients with complications were older (median age 75.6 vs 64.0 years) and had a higher American Society of Anesthesiologists (ASA) classification (45.6% vs 17.6% ASA III). The duration of hypotension at various MAP thresholds (45 to 70 mm Hg) was not associated with increasing odds of common severe medical complications. Conclusions Controlled hypotension (ranging from 45 to 70 mmHg) for a moderate duration during neuraxial anesthesia was not associated with increased odds of common severe complications (myocardial infarction, stroke, and/or acute kidney injury) among patients receiving neuraxial anesthesia for elective THA.

Objective: We aimed to investigate the effects of hypotensive anesthesia on oxidative stress with serum thiol/disulfide balance in patients undergoing elective septoplasty procedures under general anesthesia. Methods: Seventy-two patients between the ages of 18-60, with a physical condition I –II, according to the American Society of Anesthesiologists, were included in this prospective observational study. Septoplasty was chosen for standard surgical stress. According to the maintenance of anesthesia, patients were divided into the groups as Hypotensive Anesthesia (n = 40) and Normotensive Anesthesia (n = 32). Serum thiol/disulfide levels were measured by the method developed by Erel & Neşelioğlu. Results: The native thiol and total thiol values of both groups measured at the 60th minute intraoperatively were significantly lower than the preoperative values (both p < 0.01). Intraoperatively, at the 60th minute, there was no significant difference in terms of post-native thiol and post-total thiol levels between hypotensive and normotensive anesthesia groups (p = 0.68, and p = 0.81, respectively). Age > 40 years and female gender were found to have a significant effect on dynamic oxidative stress (p = 0.002, and p = 0.001, respectively). Conclusion: This pilot study has found that hypotensive anesthesia had no adverse effect on dynamic thiol/disulfide balance in elective surgeries.

Objectives: Postoperative cognitive dysfunction (POCD) is multifactorial, which may be caused by anesthetic and surgical causes or cerebral injury. This study aimed to evaluate the effect of dexmedetomidine as a neuroprotective drug compared to esmolol on the prevalence of POCD in adult patients undergoing middle ear surgeries under hypotensive anesthesia. Methods: This study included male and female adult patients, according to American Society of Anesthesiology physical status (ASA) I, the patients who underwent middle ear surgeries under hypotensive anesthesia were randomly assigned to two groups that received esmolol and dexmedetomidine. The demographic data, heart rate, mean arterial blood pressure, duration of the surgery, evaluation of the surgical field, and the Mini-Mental State Examination (MMSE) (preoperatively and at 1, 6 and 24 hours postoperatively) were recorded. Results: There was a significant difference between the numbers of patients who had POCD in MMSE1: 12 cases in the esmolol group (41.37%) compared to three cases in the dexmedetomidine group (10.34%) (P = 0.016), in MMSE6: 10 cases in the esmolol group (34.48%) compared with two cases in the dexmedetomidine group (6.89%) (P = 0.023) and in MMSE24: seven cases in the esmolol group (24.13%) compared with one case in the dexmedetomidine group (3.44%) (P = 0.022), while the median and range of MMSE score were comparable between the two groups (P > 0.05). Conclusions: This study suggests that intraoperative use of dexmedetomidine as an adjuvant to hypotensive anesthesia reduces the incidence of POCD compared to esmolol.

Introduction: Hypotensive epidural anesthesia (HEA) is used in total joint arthroplasty as a safe and effective blood-saving modality. In order to maintain the blood pressure and heart rate patients, receive 1000 to 1500 mL of lactated Ringer&rsquo, s solution during surgery. While HEA reduces the intraoperative blood loss, the effect of intravenous fluid loading on hemoglobin levels is not fully understood. The current study investigates the effect of HEA on perioperative hemoglobin levels. Materials and Methods: The study included 35 patients operated on by a single surgeon undergoing primary total knee arthroplasty under HEA. Intraoperatively, at least 300 mL of intravenous fluid were given every 15 min over the first 60 min after HEA. Blood samples were drawn before entering the operating room, after HEA, as well as after inflation of the tourniquet, every 15 min thereafter, as well as in the recovery room and on postoperative days one and two. In addition, fluid in- and outtake was recorded. Results: Patients received a mean 1275 mL during the 60 min of tourniquet time. The mean arterial pressure (MAP) 5 min after HEA dropped to 60 mmHg and reached a constant level of around 58 mmHg 15 min after HEA. The average hemoglobin level dropped from 13.9 g/dL prior to HEA, to 12.5 g/dL immediately after HEA (p &lt, 0.001). Intraoperatively the hemoglobin level dropped further and reached 11.8 g/dL at 60 min in the absence of blood loss. Conclusions: Hypotensive epidural anesthesia and the resulting fluid substitution resulted in an average hemoglobin drop of 2.1 g/dL within the first 60 min. This needs to be taken into account when evaluating the need for blood transfusions after primary joint replacement surgery under HEA.

Atik, Bülent (Balikesir Author), Aims: The beach-chair position (BCP) imposes a risk to cerebrovascular hypoperfusion due to deep hypotensive events (DHEs) which may progress to catastrophic neurological complications. However, a controlled hypotensive anesthesia (CHA) management is often required for arthroscopic shoulder surgery to reduce blood loss and to improve visibility of surgical field. The aim of this retrospective study was to evaluate CHA managements, DHEs, and complications in patients who underwent shoulder arthroscopy in the BCP under general anesthesia (GA) between years 2017 and 2019. Methods: After hospital's ethic committee approval was obtained, medical records of 72 adult patients were retrospectively reviewed. Primary outcome measures were the frequency of CHA management and the incidence of DHE. Secondary outcome measures were to determine the stages of surgery at which DHEs have developed and the complications. Results: CHA was required in 46 of total 72 patients (63.9%). Among those 46 patients, 31 (67.4%) had at least one DHE. A total of 82 DHEs were detected in 49 patients whereas mean arterial pressure limits were normal (±30% of baseline) in the remaining 23 (68.1% vs. 31.9%; p

Background Spinal anesthesia is a type of regional anesthesia that has been practicing for obstetric anesthesia since the beginning of the 20th century. Despite the simplicity and lower maternal mortality risk, compared to general anesthesia, spinal anesthesia is linked to different adverse effects, of which hypotension is the most common complication. The main aim of this study was to determine the incidence and associated factors of hypotension after spinal anesthesia during cesarean section. Method Institution-based cross-sectional study was conducted with 410 clients. The study was conducted on cesarean section under spinal anesthesia from 5th January to 30th April 2019, at the Gandhi Memorial Hospital, Addis Ababa, Ethiopia. Both bivariable and multivariable logistic regression analysis were done on the associated factors. The level of statistical significance was represented at pT6 AOR = 2.230; 95%CI: (1.329–3.741), the time interval between spinal induction and skin incision > 6minutes AOR = 1.803; 95%CI: (1.044–3.114) and anesthetist experience AOR = 5.033(95%CI: 2.144–11.818) were also associated with hypotension. Conclusion The identified risk factors for hypotension, after spinal anesthesia are sensory height block, weight of the baby, the time interval between spinal induction and skin incision, baseline systolic blood pressure, and anesthetist experience.

Background: The aim of this study was to evaluate the efficacy of intravenous infusion of clevidipine or esmolol for producing controlled hypotension during endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea. Patients and methods: Fifty adult ASA I and II patients scheduled for endoscopic repair of CSF rhinorrhea were randomized into one of two groups. Group C (25 patients) received clevidipine 0.5 mcg/kg/min increased by 0.5 mcg/kg/min every 3–5 min to achieve the target mean arterial pressure (MAP) of 55–65 mmHg. Group E (25 patients) received esmolol infusion 50 mcg/kg/min increased by 50 mcg/kg/min every 3–5 min to achieve the target MAP. Surgical field Quality, blood loss, haemodynamic parameters, surgeons' satisfaction and adverse events were recorded. Results: Time to reach target MAP was significantly shorter in group C compared to group E. Number of patients needed nitroglycerine was significantly higher in group E compared to group C (8 versus 2 respectively). The nitroglycerine dose needed/patient in group E was significantly more compared to group C. Surgeon satisfaction score was significantly higher in group C compared to group E. More patients in group E developed bradycardia compared to group C. Mean arterial pressure was significantly lower in group C compared to group E after 5 and 10 min from the start of the studied drugs infusion while it was significantly higher in group C after 25 min from the start of the studied drugs. The heart rate (HR) was significantly lower in group E compared to group C 10 min after starting drugs infusion till the end of surgery. Conclusion: Both clevidipine and esmolol are effective for inducing controlled hypotension during endoscopic repair of CSF rhinorrhea. Clevidipine has the advantage of having shorter time to reach target MAP with less need of additional hypotensive agent and better surgeon satisfaction.

Background The field of cochlear implantation has been expanding rapidly and it has been hailed as one of the greatest advances in otology. The technique of anesthesia plays a crucial role in success of cochlear implant surgery as the anesthesiologist has to produce conditions which facilitate surgery by inducing bloodless operative field. Study objective To determine the efficacy of dexmedetomidine versus esmolol usage as an adjunct to induce controlled hypotension in children undergoing cochlear implant surgery. Design Clinical trial study. Setting Operating room in a university hospital. Patients 70 children aged 2–4 years scheduled for cochlear implant surgery under general anesthesia. Patients were randomly allocated according to drugs used into two equal groups (35 patients in each group). Interventions: Group (D): The patients in this group received a bolus dose of dexmedetomidine 0.5 ug/kg over 10 min followed by continuous infusion 0.2–0.5 ug/kg/h after induction of anesthesia but before surgery. Group (E): The patients in this group received a bolus dose of esmolol 0.5 mg/kg over 10 min followed by continuous infusion 100–300 ug/kg/min after induction of anesthesia but before surgery. Measurements Heart rate, Mean Arterial blood Pressure, Quality of surgical field, operative time, adverse events. Main results The quality of surgical field was comparable between both groups in all times of measurements. The time to first analgesic request was statistically significant longer in group (D) than in group (E) and the total tramadol consumption was statistically significant less in group (D) than in group (E). Conclusions In our study both dexmedetomidine and esmolol were effective in reducing MABP, and lowering the heart rate providing dry surgical field and ensured good surgical condition during cochlear implant surgery in pediatric patients.

Arterial hypotension during the early phase of anesthesia can lead to adverse outcomes such as a prolonged postoperative stay or even death. Predicting hypotension during anesthesia induction is complicated by its diverse causes. We investigated the feasibility of developing a machine-learning model to predict postinduction hypotension. Naïve Bayes, logistic regression, random forest, and artificial neural network models were trained to predict postinduction hypotension, occurring between tracheal intubation and incision, using data for the period from between the start of anesthesia induction and immediately before tracheal intubation obtained from an anesthesia monitor, a drug administration infusion pump, an anesthesia machine, and from patients' demographics, together with preexisting disease information from electronic health records. Among 222 patients, 126 developed postinduction hypotension. The random-forest model showed the best performance, with an area under the receiver operating characteristic curve of 0.842 (95% confidence interval [CI]: 0.736-0.948). This was higher than that for the Naïve Bayes (0.778; 95% CI: 0.65-0.898), logistic regression (0.756; 95% CI: 0.630-0.881), and artificial-neural-network (0.760; 95% CI: 0.640-0.880) models. The most important features affecting the accuracy of machine-learning prediction were a patient's lowest systolic blood pressure, lowest mean blood pressure, and mean systolic blood pressure before tracheal intubation. We found that machine-learning models using data obtained from various anesthesia machines between the start of anesthesia induction and immediately before tracheal intubation can predict hypotension occurring during the period between tracheal intubation and incision.

Background Beach chair position (BCP) is used in arthroscopic shoulder operations for its advantages. The BCP together with deliberate hypotension used to decrease intraoperative blood loss during arthroscopic shoulder procedures, this may have risk to cause postoperative neurological insults. Dexmedetomidine and esmolol are used to induce deliberate hypotension. Near-infrared spectroscopy (NIRS) provides a non-invasive technique of continuous monitoring of regional cerebral tissue oxygen saturation (rScO 2 ). In this study we evaluate the prevalence of rScO 2 during hypotensive anesthesia induced by intra-operative infusion of either dexmedetomidine or esmolol in patients undergoing elective arthroscopic shoulder surgery in the BCP. Patients and methods Fifty patients scheduled for elective arthroscopic shoulder surgery under general anesthesia with hypotensive technique in BCP, randomly assigned into two equal groups, dexmedetomidine group (D Group) and esmolol group (E Group) according to the drug used for deliberate hypotension. MAP, HR, BIS and rS c O 2 were recorded before induction of anesthesia T 0 , post-induction of anesthesia T 1 as baseline, 5 min after BCP T 2 , 5 min after starting the studied drug T 3 , 30 min T 4 , 60 min T 5 , 90 min T 6 , 5 min after stopping the studied drug T 7 , 5 min after return to supine T 8 and after extubation T 9 . Results In D group there was significant decrease in Lt.rs c o 2 and Rt.rs c o 2 , at T2 to T7 compared to T1. In E group there was significant decrease in Lt.rs c o 2 and Rt.rs c o 2 at T2, to T7 compared to T1. In D group two patients had CDEs compared to five patients in E group. Conclusion In patients undergoing shoulder arthroscopic surgery under general anesthesia, the BCP significantly decreases rS c O 2 , with further slight decrease of rS c O 2 with dexmedetomidine and esmolol induced hypotension with no affection of postoperative cognitive function with both drugs. Dexmedetomidine and esmolol are safe drugs with better safety of dexmedetomidine over esmolol.

Background/purpose We studied the correlation between clinical covariates and blood loss under hypotensive anesthesia, in patients undergoing a bilateral vertical ramus osteotomy (BVRO). Materials and methods BVROs were performed on 37 patients with mandibular prognathism. The preoperative and postoperative values of blood constituents were examined and analyzed. Correlations among blood loss, sex, age, operative time, and reduced values of blood constituents were statistically assessed. Results The average operative time was 255.5 ± 42.56 minutes, and blood loss was 105.9 ± 66.83 mL. No patient required a blood transfusion in this study. There were no significant correlations between blood loss and related factors (sex, operative time, and reductions in blood constituents). Comparing sexes, blood loss and reductions in blood constituents exhibited non-significant differences. However, male patients had significantly larger values for presurgical and postsurgical blood constituents than female patients. Conclusion In our study, blood loss was acceptable in patients who underwent a BVRO, and thus, no preoperative autologous blood donation was necessary.

Medical paradox of induced hypotension has arisen because bleeding during operative interventions has become a problem of increasing importance during the past few years. Certain surgical procedures are now so vastly extensive and that other operations have penetrated so deeply into the vital structure of the body. A number of workers, both on this continent and abroad, have suggested that one effective method of controlling either gross hemorrhage or excessive vascular ooze may be by the reduction of systemic arterial pressure. When such a deliberate hypotension is combined with proper posturing of the patient so that the operative site is superior, permitting gravitational venous drainage away from the wound to the dependent portions of the body, the technique has been called “controlled hypotension,” and has been employed to achieve a relatively ischemic operative field.

BACKGROUND Hypotensive anesthesia is routinely used during craniosynostosis corrections to reduce blood loss. Noting that cerebral oxygenation levels often fell below recommended levels, the authors sought to measure the effects of hypotensive versus standard anesthesia on blood transfusion rates. METHODS One hundred children undergoing craniosynostosis corrections were randomized prospectively into two groups: a target mean arterial pressure of either 50 mm Hg or 60 mm Hg. Aside from anesthesiologists, caregivers were blinded and strict transfusion criteria were followed. Multiple variables were analyzed, and appropriate statistical testing was performed. RESULTS The hypotensive and standard groups appeared similar, with no statistically significant differences in mean age (46.5 months versus 46.5 months), weight (19.25 kg versus 19.49 kg), procedure [anterior remodeling (34 versus 31) versus posterior (19 versus 16)], or preoperative hemoglobin level (13 g/dl versus 12.9 g/dl). Intraoperative mean arterial pressures differed significantly (56 mm Hg versus 66 mm Hg; p < 0.001). The captured cell saver amount was lower in the hypotensive group (163 cc versus 204 cc; p = 0.02), yet no significant differences were noted in postoperative hemoglobin levels (8.8 g/dl versus 9.3 g/dl). Fifteen of 100 patients (15 percent) received allogenic transfusions, but no statistically significant differences were noted in transfusion rates between the hypotensive [nine of 53 (17.0 percent)] and standard anesthesia [six of 47 (13 percent)] group (p = 0.056). CONCLUSIONS No significant difference in transfusion requirements was found between hypotensive and standard anesthesia during craniosynostosis corrections. Considering potential benefits of improved cerebral blood flow and total body perfusion, surgeons might consider performing craniosynostosis corrections without hypotension. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.

Objectives: The objective of this study is to evaluate the effect of esmolol-induced hypotensive anesthesia (EIHA) on intra-operative (IO) bleeding during open myomectomy. Patients and Methods: Eighty-eight women were randomly divided into the study group received EIHA without uterine tourniquet and control group who received normotensive anesthesia with uterine tourniquet. EIHA was provided as priming dose of esmolol (0.5 mg.kg-1) before the induction of anesthesia and esmolol infusion (0.05-0.3 mg.kg-1.min-1) to maintain mean arterial pressure at 60–70 mmHg that was stopped on completion of myomectomy. Fentanyl was used as IO analgesia (loading dose: 1.0 μg.kg-1 then infusion of 0.2-0.4 μg.kg-1.h-1). All patients received 6% hydroxyethyl starch (HES; initially, 3 mL.kg-1 over 5-10 minutes and supplemental doses according to requirements) and Lactated Ringer's solution (LR; 5 mL.kg-1.h-1). Trigger for blood transfusion was hemoglobin concentration (HBC)

Intraoperative bleeding during endoscopic sinus surgery poses an additional dimension to an already technically challenging surgical approach because of the narrow sinonasal surgical field, single working hand, and the use of endoscopic instruments. Poor visualization is one of the most important factors that increase the risk of intraoperative complications such as inadvertent injury to major vessels and nerves, and incomplete surgery. This article provide a logical approach to improving the surgical field, minimizing risk of inadvertent vascular injury, and managing intraoperative bleeding.

BackgroundFunctional Endoscopic sinus surgery (FESS) is a delicate and time consuming procedure; it is performed routinely under general anesthesia. Hypotensive techniques should be employed for best visualization of operative field. Gabapentin is a structural analog of gamma amino butyric acid. The aim of this study was to determine the analgesic efficacy of gabapentin and its role in deliberate hypotension during and after FESS.MethodsEighty patients ASA physical status I–II patients were scheduled to undergo elective FESS under general anesthesia. Patients were randomly assigned to one of two groups using a computer-generated table. Patients in the control group (40 patients) received oral placebo capsules and the study group (40 patients) patients received oral gabapentin (Conventin 400mg; Evapharma Egypt) 1.2g 1h before surgery. Intraoperative, mean arterial blood pressure, infusion rates of the hypotensive agent (sodium nitroprusside) were recorded at 15min interval. Assessments of pain, opioid usage, and side effects were performed at 1h interval after arrival in the PACU.ResultsGabapentin group patients required significantly lower (p value

We evaluated the feasibility and safety of laparoscopic and robotic assisted partial nephrectomy with controlled hypotensive anesthesia to avoid hilar clamping and eliminate renal ischemia.A total of 60 patients with renal tumors who were candidates for nephron sparing surgery and had no contraindication to hypotensive anesthesia underwent partial nephrectomy without hilar clamping and with controlled hypotension during tumor excision. A total of 40 laparoscopic partial nephrectomies and 20 robotic assisted partial nephrectomies were done. All patients who were candidates for laparoscopic or robotic assisted partial nephrectomy regardless of tumor site, size or growth pattern were included in study. The surgical field was assessed for bleeding and visibility using a numerical rating scale.Median tumor size was 3.6 cm (range 1.8 to 10), median operative time was 2 hours (range 1 to 3.5), median blood loss was 200 ml (range 30 to 700 ml) and median hospital stay was 3 days (range 3 to 8). All margins were negative. The median duration of controlled hypotension with a median mean arterial pressure of 65 mm Hg (range 55 to 70) was 14 minutes (range 7 to 16). No patient required intraoperative transfusion but 4 (6.6%) required transfusion postoperatively. Complications developed postoperatively in 3 patients, ie port site bleeding, hemorrhage and hematoma, respectively. Median preoperative and postoperative serum creatinine was 0.9 and 1.10 mg/dl, respectively. The median preoperative and postoperative estimated glomerular filtration rate was 87.20 and 75.60 ml/minute/1.73 m2, respectively.Controlled hypotension allowed laparoscopic and robotic assisted partial nephrectomy to be done without renal hilar clamping. All procedures were completed safely and perioperative outcomes are encouraging.

Prostaglandin E(1) (PGE(1)) has been shown to provide short-term neuroprotection against various types of brain ischemia in a dose-dependent manner in mice. However, these findings were obtained from experiments performed without any control over physiological parameters. We performed an outcome study where physiological parameters were controlled in an attempt to confirm the dose-dependant neuroprotective effects of PGE(1).A rat model of severe forebrain ischemia was used. Two doses of PGE(1) were administered during the pre-ischemic period, a low dose (LowPG group) and a high dose (HighPG group). Normotension was maintained in the LowPG group, while hypotension was induced in the HighPG group. In separate groups, normal saline (Control) or sodium nitroprusside (SNP) were infused to compare outcomes under similar blood pressure conditions. Histological outcomes in the hippocampal CA1 and entorhinal cortex were evaluated 5 days post-ischemia.HighPG resulted in hyperglycemia. The percentage of dead neurons in the hippocampal CA1 and entorhinal cortex were similar in the Control, SNP, and HighPG groups, the percentage being significantly attenuated in the LowPG group (CA1: Control = 92.8 +/- 2.4%, LowPG = 85.0 +/- 8.5%, HighPG = 95.3 +/- 2.4%, and SNP = 96.4 +/- 0.7%, P0.01; entorhinal cortex: Control = 73.8 +/- 4.0%, LowPG = 53.2 +/- 12.3%, HighPG = 72.1 +/- 12.6%, and SNP = 76.5 +/- 4.1%, P0.01).Pre-ischemic administration of low-dose PGE(1) in rats provided neuroprotection against severe forebrain ischemia. A dose dependency was not observed with PGE(1) dose and outcome.

Study objective Controlled hypotension is a preferred method in various surgical operations, but limited data are available for the effects of drug combinations that are used to ensure the desired level of hypotension on cardiac repolarization. Design Randomized, prospective, double-blinded study. Patients The study comprised 65 patients undergoing septorhinoplasty surgery under general anesthesia. Interventions Group S received sevoflurane inhalation alone, group R received sevoflurane and remifentanil, and group N received sevoflurane and nitroglycerine in a way that a mean arterial pressure of 60 ± 5 mm Hg was achieved. Measurements Electrocardiogram was performed before induction (T1), 30 minutes after induction (T2), and 5 minutes after extubation (T3). Corrected QT (QTc), QT dispersion (QTd), and corrected Tp-e (Tp-ec) intervals and Tp-e/corrected QT (Tp-e/QTc) ratio were calculated. Main results QTc prolongation was observed at T2 and T3 in all groups, but only QTc prolongation at T2 was statistically significant in group S ( P > .05). Significant prolongation of QTd interval at T2 and T3 was observed in group S ( P P = .103) and group R ( P = .058). Tp-e/QTc was significantly decreased on T2 in all 3 groups, and it was returned to baseline at T3 ( P Conclusion The present study demonstrated that none of the 3 hypotensive anesthesia methods has an overall negative effect on Tp-e and Tp-e/QTc. Therefore, we conclude that all 3 methods can be used safely in terms of proarrhythmic risk, but increased sevoflurane consumption may require more attention due to significant prolongation of QTc and QTd.