Intraoperative Bleeding Control with Terlipressin in Functional Endoscopic Sinus Surgery.

OBJECTIVE: To evaluate the use of terlipressin for intraoperative bleeding reduction in functional endoscopic sinus surgery (FESS). METHODS: This prospective, randomized, single-center, single-blinded cohort study included 74 cases of FESS performed under general anesthesia (GA). The patients were randomized into two groups: WT (without terlipressin, n = 39) and T (with 200 µg terlipressin, n = 35). Bleeding intensity (BI) was assessed using a 6-point scale. Heart rate (HR), mean blood pressure (MBP), perfusion index (PI), and BI were recorded at 10, 30, and 60 min after surgery. A BI score ≥2 qualified as significant. RESULTS: The T group had significantly higher MBP compared with the WT group, but HR values did not differ significantly. PI and BI scores were significantly reduced in the T group compared with the WT group. The risk of significant bleeding in the treatment group was 35.5 times lower (odds ratio [OR], 0.028; 95% confidence interval [CI], 0.006-0.138) at 30 min and 7.1 times lower (OR, 0.140; 95% CI, 0.049-0.402) at 60 min. The prognostic model for significant bleeding at 60 min showed that only terlipressin played a significant role in bleeding control (p < 0.05). The model predicted a 13.9-fold decrease in significant bleeding risk in the T group. CONCLUSION: Low doses (200 µg) of terlipressin reduced intraoperative bleeding without decreasing blood pressure during FESS under GA. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:3313-3318, 2023.

Reducing kidney motion: optimizing anesthesia and combining respiratory support for retrograde intrarenal surgery: a pilot study.

BACKGROUND: One of the greatest challenges presented with RIRS is the potential for movement of the stone within the operative field associated with diaphragm and chest respiratory excursions due to mechanical ventilation. To overcome this challenge, we propose in this pilot study a new general anesthesia technique combining high frequency jet ventilation (HFJV) with small volume mechanical ventilation (SVMV). Data regarding safety, feasibility and surgeons' impression was assessed. METHODS: Patients undergoing RIRS for kidney stones from November 2017 to May 2018 were prospectively recruited to participate in the study. In each case after the beginning of general anesthesia (GA) with mechanical ventilation (MV) surgeons were asked to assess the mobility of the operative field and conditions for laser lithotripsy according to the developed questionnaire scale. The questionnaire consisted of 5 degrees of assessment of kidney mobility and each question was scored from 1 to 5, 1 being very mobile (extremely poor conditions for dusting) and 5 completely immobile (Ideal conditions for dusting). After the assessment GA was modified with combined respiratory support (CRS), reducing tidal volume and respiratory rate (small volume mechanical ventilation, SVMV) and applying in the same time transcatheter high frequency jet ventilation (HFJV) inside the closed circuit. After beginning of CRS, surgeons were once again asked to assess the mobility of the operative field and the conditions for laser lithotripsy. Main ventilation parameters were recorded and compared in both regimens. RESULTS: A total of 38 patients were included in the study. The mean age was 49 (range 45-53) with a mean stone size of 10 mm (range 10-14) and Hounsfield unit of 1060 (range 930-1190). All patients underwent successful RIRS and no intraoperative complications occurred throughout the duration of the study. A statistically significant difference between ventilation parameters prior to and after CRS institution was detected in all cases, however their clinical impact was negligible. Despite this, assessment via the questionnaire scale point values varied significantly before and after the application of CRS and were 2.3 (2.1; 2.6) and 3.8 (3.7; 4.0) respectively (p < 0.001). CONCLUSIONS: The novel combined respiratory approach consisting of HFJV and SVMV appears to provide better conditions for stone dusting through reduced respiratory kidney motion and is not associated with adverse health effects or complications. TRIAL REGISTRATION: NCT03999255 , date of registration: 25th June 2019 (retrospectively registered).