Clonidine and dexmedetomidine for controlled hypotension during functional endoscopic sinus surgery: a comparative study.

Functional endoscopic sinus surgery (FESS) is minimally invasive, ambulatory endoscopic surgical procedure usually performed in most paranasal sinus diseases. Controlled hypotension during anaesthesia (hypotensive anesthesia) improves surgical field visibility and reduces risk of injuring surrounding structures. Clonidine (C) and dexmedetomidine (D) are both used to reduce blood pressure and heart rate while maintaining tissue perfusion. This study was conducted to evaluate the efficacy of clonidine compared to dexmedetomidine for controlled hypotension during FESS. After ethical approval, 80 patients undergoing elective FESS were included in the study and randomly allocated to Group C or Group D. In Group C, 40 patients received intravenous clonidine with a loading dose of 3µg/Kg for 10 min and titrated maintenance dose of 0.4-0.8 µg/Kg/hour. In Group D patients received intravenous dexmedetomidine with a loading dose of 1µg/Kg for 10 min and titrated maintenance dose of 0.4-0.8µg/Kg/hour. The target was mean arterial blood pressure (MAP) between 55 and 65 mmHg and heart rate (HR) above 50 beats per minute. The primary outcome was blood loss. The secondary outcomes were surgical field quality assessed by Fromme Bezooart score, variations in MAP and HR intraoperatively, duration of surgery and anesthesia, and post-operative sedation assessed by Ramsay Sedation Score (RSS). Demographic data of both groups were comparable. The difference between both groups in terms of blood loss and surgical field quality was not statistically significant (p = 0.579, 1.000). MAP and HR were statistically significantly reduced to targeted level in both groups compared to baseline (p<0.001). Dexmedetomidine led to severe hypotension compared to clonidine, and the difference was statistically significant. Duration of return to baseline MAP and HR, duration of anesthesia and postoperative sedation were prolonged in group D compared to Group C. Clonidine and dexmedetomidine provided good to excellent quality of surgical field visibility to surgeons during FESS. Dexmedetomidine produce more hypotension and bradycardia compared to clonidine which may be preferable for controlled hypotension in the setting of ambulatory surgery. However, considering the small sample of this study which could not detect small but clinically differences between both drugs, there is a need for a much larger and multicenter study to confirm these findings. This trial was retrospectively registered in the Pan African Clinical Registry (pactr.samrc, ac.za) on 15 August 2024 under trial number PACTR202408565688611.

Mugabo EN ，Kulimushi YM ，Pollach G ，Sabra RA ，Beltagy RS ，Blaise Pascal FN ... -  《BMC Anesthesiology》

Comparison of the effects of remimazolam and dexmedetomidine on the quality of recovery in functional endoscopic sinus surgery: a randomized clinical trial.

Postoperative pain usually occur in patients who have undergone functional endoscopic sinus surgery (FESS). Remimazolam and dexmedetomidine could enhance the quality of recovery (QoR) after surgery. The aim of this study was to compare the effects of remimazolam and dexmedetomidine with respect to the QoR-40 score of patients who have undergone FESS. A total of 120 patients (18-65 years) scheduled for FESS were randomly allocated to Group R, Group D or Group C. Group R received 0.075 mg/kg remimazolam loading and 0.1 mg/kg/h infusion. Group D received dexmedetomidine (1.0 µg/kg loading, 0.5 µg/kg/h infusion). Group C received a placebo equal to dexmedetomidine. Anaesthesia was induced with propofol, sufentanil and cisatracurium. Anaesthesia maintenance was performed via target-controlled infusions (TCIs) of propofol and remifentanil. The primary outcome was the QoR-40 score on the day before surgery and postoperative Day 1 (POD1). The secondary outcomes were the time to return to consciousness, length of stay in the PACU, sedation score upon PACU arrival, pain, postoperative nausea and vomiting (PONV) and cumulative consumption of propofol and remifentanil. Adverse effects were recorded. The total QoR-40 scores (median, IQR) on POD1 decreased less (154.5, 152.0 -159.0) in Groups R and D (155.0, 154.8 -159.3) than in Group C (139.0, 136.8 -142.0) (P < 0.001). The time to return of consciousness and the length of stay in the PACU were significantly shorter in Groups R and C than in Group D (P < 0.001). The level of sedation upon PACU arrival (median, IQR) in Groups R (-2.0, -2.0--1.0) and D (-2.0, -3.0--2.0) was greater than that in Group C (1.0, 0.0 -1.0) (P < 0.001). The cumulative consumption rates of propofol and remifentanil in Groups R and D were lower than that in Group C (P < 0.001). Compared with that in Group C, the pain intensity was lower in Groups R and D (P < 0.001).The number of patients occurring PONV was less in Groups R (3/40) and D (4/40) than in Group C (11/40) (P = 0.024). Fifteen patients had bradycardia in Group D, whereas no bradycardia was noted in Groups R or C (P < 0.001). Administration of remimazolam could provide a similar QoR to that of dexmedetomidine. In addition, remimazolam may be a promising option for improving the QoR of patients who have undergone FESS. ChiCTR2300076209. (Prospectively registered). The initial registration date was 27/9/2023.

Li Y ，Zhou H ，Gao F ，Guan Q ，Wang S ，Tan Y ，Hu S ... -  《BMC Anesthesiology》

Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery.

Tzelnick S ，Alkan U ，Leshno M ，Hwang P ，Soudry E ... -  《Cochrane Database of Systematic Reviews》

A Randomized Study to Compare the Efficacy Between Intranasal and Intravenous Dexmedetomidine for the Removal of Foreign Bodies in the Esophagus at the Cricopharynx Level in Pediatric Patients.

Foreign body (coins, magnets, button batteries, and metallic foreign bodies) ingestion is common and causes significant morbidity and mortality in children aged six months to three years. Endoscopic removal of swallowed foreign substances is widely accepted, but sedation and general anesthesia may be required to alleviate pain and anxiety during the procedure. Dexmedetomidine is used as a sedative, hypnotic, anxiolytic, and analgesic. In this study, we aimed to investigate and compare the efficacy between the intranasal (IN) and intravenous (IV) routes for the administration of dexmedetomidine as an adjunct to propofol for the removal of foreign bodies in the esophagus at the cricopharynx level in pediatric patients. This prospective, double-blinded, randomized study was conducted on 80 patients of either sex and American Society of Anaesthesiologists physical status (ASA PS) I and II aged one month to 12 years with a foreign body in the esophagus at the cricopharynx level undergoing endoscopic foreign body removal. Patients were randomly allocated into groups A and B, with 40 patients each. In the preoperative area group A, IN, 3 mcg/kg, was dripped equally in both nostrils (supine position). In Group B, IV, 3 mcg/kg, diluted in normal saline, was administered intravenously slowly over 10 minutes. The onset of sedation was assessed using the Ramsay Sedation Scale (RSS) every 10 minutes following dexmedetomidine administration, and when an RSS score of 3 or above was achieved, the patient was transferred to the operation theater. In the operation room, patients were induced with injection propofol in a dose of 2 mg/kg or until the loss of verbal response. Parent separation scale scoring was used to evaluate the child's behavior on separation from parents as a tool to assess the anxiolytic property of dexmedetomidine. Perioperative pain using the Wong-Baker Faces pain rating scale, heart rate (HR), oxygen saturation (SpO2), ECG, and blood pressure (BP) were monitored before drug delivery till the end of the procedure. Statistical analysis was done using SPSS version 24.0 (IBM Corp., Armonk, NY). The mean time (minutes) in shifting to operation theater (33.8 ± 5) was significantly higher in group A compared to group B (10.7 ± 2.1) (p = 0.001). The mean Ramsay Sedation Score was higher at 10 and 20 minutes in group B as compared to group A. Group B had significantly lower pain (2.2 ± 1.4) (p ≤ 0.001) at 10 minutes, while in group A, the pain score decreased slowly and took more time but remains lower (1.35 ± 0.94) for longer duration (120 minutes) in the postoperative period in comparison to Group B (1.94 ± 0.35) (p = 0.002). Group B had a sharp hemodynamic decrease, while group A had slow, persistent changes. IN administration of dexmedetomidine is a safer and more effective mode of sedation to remove a foreign body from the esophagus at the cricopharyngeal level in pediatric patients. It provides stable and sustained hemodynamic parameters and longer postoperative pain relief compared to IV dexmedetomidine.

Kumar M ，Mishra P ，Singh AK ，Gupta R ... -  《Cureus》

Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation.

Brown S ，Hind D ，Strong E ，Bradburn M ，Din FVN ，Lee E ，Lee MJ ，Lund J ，Moffatt C ，Morton J ，Senapati A ，Shackley P ，Vaughan-Shaw P ，Wysocki AP ，Callaghan T ，Jones H ，Wickramasekera N ，PITSTOP Management Group ... -  《-》