Bloodless Surgical Field During Transnasal Endoscopic Procedures | 25669
Otolaryngology: Open Access
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The essential condition for precise and efficient endoscopic surgery of the praranasal sinuses and the skull base is good
visualization of the surgical field which depends mainly on the intraoperative bleeding intensity. Besides local application
of vasoconstrictors and putting the patient in the reverse Trandelenburg position reduction of the intraoperative bleeding is
usually achieved by decrease of hemodynamic parameters of the operated patients. Maintenance of slow heart rate and low
blood pressure is commonly practiced during endoscopic operations and is generally considered safe in healthy patients.
However due to low invasiveness of endoscopic methods more and more elderly patients with comorbidities are qualified
for this type of surgery and apparently, these patients are not likely to tolerate decreased hemodynamic parameters as well as
young healthy persons do. Because insufficient brain perfusion is a main hazard of systemic hypotension we assessed blood
flow velocity (BFV) in the middle cerebral artery (MCA) with transcranial color Doppler sonography during endoscopic
procedures. The sonographic assessments were performed during the surgery, at the time when satisfactory bloodless surgical
field was achieved due to reduced blood pressure and heart rate. It appeared that even a moderate reduction of blood pressure
and HR for improving surgical field conditions resulted in some patients in a profound decrease in blood flow velocity in MCA
to values well below the normal reference range. In order to assess possible metabolic consequences of controlled hypotension
and decrease in cerebral blood flow velocity during endoscopic operations, we determined pre- and postoperative serum
concentrations of neuron specific enolase (NSE) - marker suggestive for neural tissue damage. Although no patient suffered
any neurological complications after surgery we found correlation between the postoperative rise of NSE level and the drop of
blood flow velocity in MCA during the surgery. This fact may be suggestive for a minor and/or regional ischemic injuries to
the brain may in these patients.
The fact that bloodless surgical field during endoscopic transnasal operations may denote significant decrease of brain
perfusion should be well known by both otolaryngologist and anesthesiologist and precaution is warranted while attempting
to maintain dry surgical field especially during long lasting procedures.
Andrzej Sieskiewicz received PhD from the Medical Academy of Bialystok upon the presentation of Doctoral dissertation in 2000. He is a member of Polish Society
of Otolaryngologists Head and Neck Surgeons, Polish Society of Skull Base Surgeons, Polish Rhinologic Society. He is author of over 70 publications in medical
journals. He is an invited lecturer on polish and international conferences and teaching courses on endoscopic surgery of the nose, paranasal sinuses, skull base
and orbit. He is the head of many scientific and research projects sponsored by Medical University of Bialystok and Polish Ministry of Science and Education
focused mainly on endoscopic surgery and interdisciplinary cooperation during skull base pathology treatment.
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