Hemodynamic changes after epinephrine (1:200000) infiltration with or without Lignocaine in ent surgeries.
The main aim of functional endoscopic sinus surgery is to clear air cells of disease and improve ventilation of the paranasal sinuses, thereby reducing the frequency and severity of infection. (1-2) The major limiting factors for endoscopic approaches to paranasal sinuses and the skull base are its complex anatomy and the high vascularity. Often, a slight haemorrhage is sufficient to dramatically reduce visibility creating a poor surgical field. (1-2) Thus, obtaining adequate haemostasis is of outmost importance during surgery to improve surgical field and prevent complications. Vasoconstriction is typically achieved by a combination of topical application and local infiltration of anaesthetic containing epinephrine. (3,4,5) Topical vasoconstriction can be achieved by local application of epinephrine, oxymetazoline hydrochloride. (3,6) Most otolaryngologists also use adequate submucosal infiltration of local anaesthetic containing epinephrine to further obtain haemostasis and reduce postoperative pain. (7,8)
Although epinephrine during functional endoscopic surgery provides excellent haemostasis, it can also be coupled with potential adverse effects such as hypertension, hypotension, tachycardia arrhythmias. Furthermore, these adverse effects may cause more serious complications in susceptible. (9,10) In our presence study we had designed a randomized controlled trail assessing the hemodynamic and haemostatic effects of 1:200000 epinephrine with or without lignocaine during Functional Endoscopic Sinus Surgery (FESS).
After obtaining approval from hospital ethical committee the present study was undertaken in Government SMHS (Which is one of the associated hospitals of Government Medical College, Srinagar). This is a prospective, randomized study undertaken in the patients with age group between, 1140 years belonging to physical status ASA I.
The criteria for exclusion from the study are:
1. The patients younger than 11 years and older than 40 years.
2. Patients with bleeding disorders.
3. Patients with coronary artery disease.
4. Patients on antihypertensive.
5. Patients with ASA class > I.
Patients selected for surgery were among those who stand admitted in ENT ward of the hospital. Pre-anaesthetic evaluation was done at least 24 hours prior to surgery. A history including previous anaesthetic exposure, medication and allergy to any drug was inquired about.
General physical examination and systematic examination including cardiovascular system, respiratory system and central nervous system was performed. Airway assessment was also done to predict any difficult intubation. All the investigations viz. CBC, BT, CT, LFT, KFT, CXR and ECG was checked. All the patients were weighed. The patients were advised to remain fasting overnight prior to surgery. On the day of surgery in operating room IV line was secured and RL started. The multichannel monitor was attached to the patient and baseline vitals viz. HR, NIBP, SP02 and ECG were recorded. Monitoring was continued intra-operatively.
This study was conducted in 60 patients who were distributed in two groups by systematic random sampling. Group A received 8-10ml of epinephrine 1:200,000 with lignocaine and Group B received 8-10ml of epinephrine 1:200,000 with normal saline. Each patient was induced with Propofol 1%, 22.5mg/kg body weight and muscle relaxation was achieved with Atracurium 0.5mg/kg body weight for endotracheal intubation and surgical procedure. Anaesthesia was maintained with N2O + O2 + isoflurane 0.6% - 1%, with Etco-2 between 32-42mmHg.
Intra-operatively data of the following patient parameters was collected during procedure using Datex-Ohmeda monitor: HR, ECG for arrhythmias, Systolic Blood Pressure, Diastolic Blood Pressure (SBP and DBP respectively), and Mean Arterial Pressure (MAP) measured from Blood Pressure (BP) cuff. These parameters were monitored throughout the procedure and were repeated 1 minute intervals for first 7 minutes. Two groups of patients were analysed: Group A received 8-10ml of epinephrine 1:200,000 with lignocaine and Group B received 8-10ml of epinephrine 1:200,000 with normal saline. There were no significant differences between the two groups with regard to age, sex, weight, ASA status and baseline SBP, DBP, MAP and HR. HR, SBP, DBP and MAP were recorded at 1 min interval for 7 minutes and the mean values were expressed as mean[+ or -]SD. Intraoperatively quality of surgical field will be assessed using the following scale of Fromm and Boezaart.
QUALITY OF SURGICAL FIELD
There was no significant difference in the demographic profile of the patients in terms of Age, Weight and Gender as depicted in Table 1.
In our study we found a statistically significant increase in SBP, DBP, MAP and HR from baseline values in Group B with the values reaching a peak at around 5 minutes and then the parameters start normalizing towards baseline over several minutes. Whereas in case of Group A patients, there was no significant change in baseline values excepting a mild decrease in all parameters including SBP, DBP, MAP and HR. The quality of the surgical field was comparable in both the groups without any significant differences.
The baseline vitals of the two groups were comparable without any significant differences.
*Statistically significant difference with baseline (P<0.05); #Non-statistically significant difference with baseline (P>0.05).
Group B patients showed a statistically significant increase in SBP from baseline value over time as compared to Group A where there was no significant increase in SBP from baseline value.
Group B showing statistically significant increase in DBP from baseline as compared to Group A.
MAP also showed a significant increase from baseline value in Group B as compared to Group A.
There was a significant increase in HR from the baseline in Group B as compared to Group A.
There was no significant difference in hemostatis and quality of the surgical field in the two groups.
Hemostatis including electric coagulation, compression, controlled hypotension etc., is one of the most important surgery techniques. FESS and mastoidectomy are commonly performed procedures in the Department of Otolaryngology and both require a good hemostatis to keep visualization clear and to decrease blood loss. Hemostatis can be achieved by vasoconstriction [11,12,13,14,15,16] Both topically applied and locally infiltrated vasoconstrictor agents reduces bleeding and improve visualization [11-12] Adrenaline is a commonly used vasoconstrictor agent, infiltrated locally reduce bleeding and improve visualization.
However, it may lead to significant changes in heart rate and blood pressure. Earlier studies have shown that these changes depend on total dose of adrenaline, speed of absorption of adrenaline into the systemic circulation (17) vascularity at the site of injection. (11) Lignocaine is generally added to the adrenaline solution to obviate these unfavourable cardiovascular side effects through its action on the myocardium and systemic vasculature. In addition, lignocaine also suppresses the highly nociceptive stimulus caused by the dissection of the subcutaneous tissue because of large amounts of solution used for infiltration. The increase in the baseline values seen in Group B (Adrenaline without Lignocaine) may be explained on the basis of vasoconstriction resulting from the effect of adrenaline on the alpha-1 receptors.
Decrease in the baseline values seen in Group A (Adrenaline with lignocaine), is probably as a result of potentiation of [beta]-2 effects of adrenaline by lidocaine. At small plasma concentrations adrenaline exerts a predominant
[beta]-2 effect. (18) The myocardial depressant and vasodilatory effects of lignocaine seem to potentiate [beta]-2 effects of adrenaline and cause hypotension. The [beta]-2 effects of adrenaline seem to cause hypotension only in the presence of lignocaine, because a similar decrease in BP was not seen in Group B, which received only adrenaline.
Other studies also reported a decrease in baseline parameters when adrenaline is used with lignocaine. Hanuman and Umamaheswara reported more than 20% decrease of MAP in 40 % of the patients compared to the pre-infiltration values. (13) Philips and his colleagues noted significant decrease in mean arterial pressure in 55% of the patients. (8) Yang and his colleagues found decrease in mean arterial pressure in 24% of patients when lignocaine was combined with adrenaline.
SUMMARY AND CONCLUSION
In patients undergoing ENT surgeries (FESS, Mastoidectomy etc.) local infiltration reduces bleeding and improves visualization of the surgical field but at the same time it causes cardiovascular side effects like tachycardia and hypertension, due to systemic absorption of the drug. Addition of lignocaine to the adrenaline attenuates the cardiovascular side effects of adrenaline without affecting the visualization of the surgical field.
(1.) Stammberger H, Kopp W. Functional Endoscopic Sinus Surgery: The Masserklinger Technique. Philadelphia, PA BC Decker 1991.
(2.) Stammberger H, Posawetz W. Functional endoscopic sinus surgery: concepts, indications and result of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247(2):63-76.
(3.) Hirshowitz B, Eliachar I. Effective haemostasis with local anaesthesia in nasal surgery. Br J Plast Surg 1972;25(3):335-341.
(4.) Lee WC, Kapur TR, Ramsden WN. Local and regional anaesthesia for functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1997;106(9):767-769.
(5.) McClymont LG, Crowther JA. Local anaesthetic with vasoconstrictor combinations in septal surgery. J Larryngol Otol 1988; 102(9):793-795.
(6.) Liao BS, Hilsinger RL Jr, Rasgon BM, et al. A preliminary study of cocaine absorption from the nasal mucosa. Laryngoscope 1999;109(1):98-102.
(7.) Wormald PJ, Athanasiadis T, Rees G, et al. An evaluation of effect of pterygopalatine fossa injection with local anaesthetic and adrenaline in the control of nasal bleeding during endoscopic sinus surgery. Am J Rhinol 2005;19(3):288-292.
(8.) Vanniasegaram I. Prospective study of the use of vasoconstrictor and saline in septal surgery for infiltration. J laryngol Otol 1991;105(8):638-639.
(9.) Horrigan R, Weger EI, Wilson C. Epinephrine-induced arrhythmias during enflurane anaesthesia in man: a nonlinear dose-response relationship and dose-dependent protection from lidocaine. Anesth Analg 1978;57(5):547-550.
(10.) Murthy HS, Rao GS. Cardiovascular responses to scalp infiltration with different concentrations of epinephrine with or without lidocaine during craniotomy. Anesth Analg 2001;92(6):1516-1519.
(11.) Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concepts, indications and result of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247:63-76.
(12.) Lee WC, Kapur TR, Ramsden WN. Local and regional anaesthesia for functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1997;106:767-769.
(13.) Sorensen WT, Wagner N, Aarup AT, et al. Beneficial effect of low-dose peritonsillar injection of lidocaine adrenaline before tonsillectomy. A placebo-controlled clinical trial. Auris Nasus Larynx 2003;30:159-162.
(14.) Kara CO, Kaftan A, Atalay H, et al. Cardiovascular safety of cocaine anaesthesia in the presence of adrenaline during septal surgery. J Otolaryngol 2001;30:145-148.
(15.) John G, Low JM, Tan PE, et al. Plasma catecholamine levels during functional endoscopic sinus surgery. Clin Otolaryngol 1995;20:213-215.
(16.) Dunlevy TM, O'Malley TP, Postma GN. Optimal concentration of epinephrine for vasoconstriction in neck surgery. Laryngoscope 1996;106:1412-1414.
(17.) Blackwell KE, Ross DA, Kapur P, et al. Propofol for maintenance of general anaesthesia: a technique to limit blood loss during endoscopic sinus surgery. Am J Otolaryngol 1993;14:262-266.
(18.) Homma Y, Ichinohe T, Kaneko Y. Oral mucosal blood flow, plasma epinephrine and haemodynamic responses after injection of lidocaine with epinephrine during midazolam sedation and isoflurane anaesthesia. Br J Anaesth 1999;82:570-574.
Shanaz Geelani , KhursheedAhmad Bhat , Mushtaq Ahmad Rather , Farhana Bashir , Ruksana Najeeb 
 Lecturer, Department of Anesthesiology & Critical Care, GMC, Srinagar.
 Senior Resident, Department of Anesthesiology & Critical Care, GMC, Srinagar.
 Senior Resident, Department of Anesthesiology & Critical Care, GMC, Srinagar.
 Senior Resident, Department of Anesthesiology & Critical Care, GMC, Srinagar.
 Professor, Department of Anesthesiology & Critical Care, GMC, Srinagar.
Financial or Other, Competing Interest: None.
Submission 22-12-2015, Peer Review 23-12-2015, Acceptance 26-12-2015, Published 30-12-2015.
Mushtaq Ahmad Rather, Senior Resident, Department of Anesthesiology & Critical Care, GMC, Srinagar-190006. E-mail: email@example.com
QUALITY OF SURGIGAL FIELD GRADE ASSESSMENT 0 Slight bleeding, cadaveric conditions. 1 Slight bleeding, no suctioning required. 2 Slight bleeding, occasional suctioning required. 3 Slight bleeding, frequent suctioning required. Bleeding threatens Surgical field a few seconds after suction is removed. 4 Moderate bleeding, frequent suctioning required, bleeding that Threatens surgical field a few seconds after suction is removed. 5 Severe bleeding, constant suctioning required. Bleeding appears faster than can be removed by the suction; surgical field severely threatened, and surgery usually not possible. Table 1: Demographic profile of the patients Group A (n =30) Group B (n=30) Mean [+ or -] SD Mean [+ or -] SD P value Age 26.3 [+ or -] 5.76 25.6 [+ or -] 6.32 0.625 Weight 50.4 [+ or -] 5.68 51.05 [+ or -] 4.43 0.270 Gender (M:F) 18:12 16:14 0.672 Table 2: Baseline Data Group A Group B (n=30) (n=30) P- Variable Mean SD Mean SD value Baseline 121.5 4.86 120.0 6.58 0.323 SBP Baseline 79.4 3.65 78.5 4.02 0.409 DBP Baseline 93.4 3.20 92.4 3.62 0.240 MAP Baseline HR 75.2 4.23 75.5 3.50 0.811 Table 3: Systolic Blood Pressure (SBP) Group A Group B Time (Mean+SD) (Mean+SD) BL 121.5 [+ or -] 4.86 120.0 [+ or -] 6.58 1 Min 122.0 [+ or -] 3.45# 126.0 [+ or -] 5.75 * 2 Min 123.7 [+ or -] 3.42# 131.1 [+ or -] 4.10 * 3 Min 123.1 [+ or -] 2.73# 137.77 [+ or -] 5.54 * 4 Min 122.4 [+ or -] 4.42# 142.2 [+ or -] 3.12 * 5 Min 121.0 [+ or -] 3.04# 148.73 [+ or -] 3.29 * 6 Min 120.4 [+ or -] 3.79# 146.47 [+ or -] 3.27 * 7 Min 121.4 [+ or -] 4.55# 142.1 [+ or -] 4.23 * Table 4: Diastolic Blood Pressure (DBP) Group A Group B Time (Mean [+ or -] SD) (Mean [+ or -] SD) BL 79.4 [+ or -] 3.65 78.5 [+ or -] 4.02 1 Min 80.3 [+ or -] 3.10 (#) 82.73 [+ or -] 3.38 * 2 Min 81.0 [+ or -] 2.19 (#) 84.4 [+ or -] 4.25 * 3 Min 80.9 [+ or -] 3.36 (#) 89.37 [+ or -] 3.12 * 4 Min 82.2 [+ or -] 5.87 (#) 93.03 [+ or -] 5.28 * 5 Min 80.7 [+ or -] 3.97 (#) 96.97 [+ or -] 2.93 * 6 Min 77.91 [+ or -] 4.09 (#) 91.27 [+ or -] 2.80 * 7 Min 76.91 [+ or -] 4.70 (#) 90 [+ or -] 3.52 * * Statistically significant difference with baseline (P<0.05); (#) Non-statistically significant difference with baseline (P>0.05). Table 5: Mean Arterial Pressure (MAP) Group A Group B Time (Mean [+ or -] SD) (Mean [+ or -] SD) BL 93.4 [+ or -] 3.20 92.4 [+ or -] 3.62 1 Min 94.2 [+ or -] 2.37 (#) 97.1 [+ or -] 3.38 * 2 Min 95.3 [+ or -] 1.69 (#) 100 [+ or -] 3.18 * 3 Min 94.3 [+ or -] 2.89 (#) 105.4 [+ or -] 3.21 * 4 Min 95.1 [+ or -] 4.15 (#) 109.3 [+ or -] 3.78 * 5 Min 94.8 [+ or -] 2.92 (#) 114.2 [+ or -] 2.24 * 6 Min 92.1 [+ or -] 3.25 (#) 109.7 [+ or -] 2.05 * 7 Min 92.1 [+ or -] 3.40 (#) 107.43 [+ or -] 2.62 * * Statistically significant difference with baseline (P < 0.05); (#) Non-statistically significant difference with baseline (P>0.05). Table 6: Heart Rate (HR) Group A Group B Time (Mean [+ or -] SD) (Mean [+ or -] SD) BL 75.2 [+ or -] 4.23 75.5 [+ or -] 3.50 1 Min 75.6 [+ or -] 3.52 (#) 82.8 [+ or -] 3.48 * 2 Min 73.7 [+ or -] 5.14 (#) 88.5 [+ or -] 3.91 * 3 Min 77.2 [+ or -] 4.83 (#) 93.7 [+ or -] 2.69 * 4 Min 75.6 [+ or -] 4.38 (#) 98.2 [+ or -] 3.71 * 5 Min 75.7 [+ or -] 4.00 (#) 108.2 [+ or -] 3.38 * 6 Min 74.4 [+ or -] 3.23 (#) 103.8 [+ or -] 3.45 * 7 Min 74 [+ or -] 5.08 (#) 98 [+ or -] 2.59 * * Statistically significant difference with baseline (P < 0.05); (#) Non-statistically significant difference with baseline (P > 0.05). Table 7: Quality Of The Surgical Field (Hemostatis) Group Mean SD P-Value Significance Group A 2.03 0.49 0.447 NSSD Group B 1.93 0.521 NSSD= non-statistically significant difference (P>0.05).
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|Title Annotation:||Original Article|
|Author:||Geelani, Shanaz; Bhat, KhursheedAhmad; Rather, Mushtaq Ahmad; Bashir, Farhana; Najeeb, Ruksana|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Article Type:||Clinical report|
|Date:||Dec 31, 2015|
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