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INUSCENTRO

João Flávio Nogueira, MDOtolaryngologist

Taís Nogueira, MDAnesthesiologist

Sinus CentroFortaleza, Brazil

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www.sinuscentro.com.br/museu

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October, 16, 1846. William Morton demonstrates anesthesia

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• Anatomical landmarksidentification

• Complications

• Postoperative

• Trauma of the nasal mucosa may lead to formation of adhesions

Kalra G, Keir J, Tahery J. Prevention of blood staining of endoscope tip during Functional Endoscopic Sinus Surgery: sleevetechnique. J Laryngol Otol. 2009;123(12):1358-9.

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• Bleeding could obscure the view of the endoscope.

• Repeated cleaning intraoperatively is time consuming.

Endoscrub– Medtronic, Jacksonville, USA, 2008

Courtesy of Prof. Navarro

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Zachow S, Muigg P, Hildebrandt T, Doleisch H, Hege HC. Visual exploration of nasal airflow. IEEE Trans Vis Comput Graph. 2009;15(6):1407-14.

Courtesy of Prof. Navarro

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• Inflammatory mucosa

• Clinical conditions

– HBP

– Chronic diseases

– Fever

• Smoking

• Pre-operative assesment

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• Surgeon techniques

– Instruments

– Patient positioning

– Room temperature

• Local vasoconstriction

• Infiltrations ?

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Increases venous return 30%

1 °.C

Bleed

ing

Reduces coagulation capability 30%

Sarmento Junior KM, Tomita S, Kós AO. Topical use of adrenaline in different concentrations for endoscopic sinus surgery. Braz J Otorhinolaryngol. 2009;75(2):280-9.

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• Ideal patient temperature: 36°C

– Saline heat

• Lower temperatures

– Drug metabolism

• Epinephrine

• Cocaine

• Oxymetazoline

– 5 minutes

– 10 minutes

Sarmento Junior KM, Tomita S, Kós AO. Topical use of adrenaline in different concentrations for endoscopic sinus surgery. Braz J Otorhinolaryngol. 2009;75(2):280-9.

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• Wormald PJ, van Renen G, Perks J, Jones JA, Langton-Hewer CD.The effect of the total intravenous anesthesia compared withinhalational anesthesia on the surgical field during endoscopicsinus surgery. Am J Rhinol. 2005; 19(5):514-20.

• BACKGROUND: Bleeding during endoscopic sinus surgery (ESS) mayincrease complications and negatively effect the surgery and itsoutcome.

• The aim of this study was to compare TIVA (propofol+remifentanil)vs. inhalation anesthesia (sevoflurane).

• RESULTS: The two groups were matched for surgical procedure andcomputed tomography scores.

• Mean arterial pressure and pulse were found to influence thesurgical field.

• CONCLUSION: In patients undergoing ESS, TIVA results in a bettersurgical field than inhalational anesthesia.

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• CO2

– Vasodilatation to target organs

– Brain

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• Ideal parameters:

• Controlled hypotension

– BP: mean 60 – 70

– HR < 60 bpm

– CO2 < 35

– SPO2 > 97%

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History of dentistry. Sinus Centro MuseuAvailable at: www.sinuscentro.com.br/museu

1 : 2,00020 amps of epinefrine + 20 mL 0,9% saline solutionPhotosensitive (60 minutes)

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0

50

100

150

200

250

Dosage I Dosage II Dosage III

Control

1:50000

1:10000

1 2000

Ave

rage

Ad

ren

alin

e(p

G/m

L)

10 – 15 minutes 10th pledget End of surgery

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0,45

Blood loss (mL)

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• Operation time was shorter (1:2,000)• Less bleeding (1:2,000), p < 0,0001 • Plasmatic levels of epinephrine raised in all

groups, especially (1:2,000) • There was a trend towards elevation of blood pressure

in the groups using adrenaline 1:2,000 and 1:10,000, with a greater occurrence of hypertensive peaks.

• The elevation of blood pressure in the 1:2,000 and 1:10,000 was progressive but very slow throughout surgery, which could be related to the anesthesia technique.

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5 to 10 minutes

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1:100.000

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• Pterygopalatine fossa– Nasal – Endoscopy

– Oral

• Epinephine– 1:200,000 – 0,005 mg/mL

– 1:100,000 – 0,01 mg/mL

– 1:80,000 – 0,0125 mg/mL

– 1:50,000 – 0,02 mg/mL

– 1:10,000 – 0,1 mg/mL

– 1:2,000 – 0,5 mg/mL

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10 mL 1:100,000

10 mL 1:50,000

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1 mL 1:10,000

• Lidocain

• High BP

• Paradoxal bradicardia (severe)

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• Time is important

• Clean and dry surgical field is crutial

• Different techniques

• Talk to your anesthesiologist

– TESS: Tailored endoscopic sinus surgery

– TASS: Tailored anesthesia for sinus surgery