Hemostatic and hemodynamic effects of topical administration versus intranasal injection of adrenaline during endoscopic sinus surgery: A prospective observational study

Muhammed Rasheed; Vinod Felix; Veerasigamani Narendrakumar

doi:10.4103/jhnps.jhnps_29_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 9 | Issue : 2 | Page : 123-127

Hemostatic and hemodynamic effects of topical administration versus intranasal injection of adrenaline during endoscopic sinus surgery: A prospective observational study

Muhammed Rasheed¹, Vinod Felix¹, Veerasigamani Narendrakumar²
¹ Department of Otorhinolaryngology, KIMS HEALTH Trivandrum, Thiruvananthapuram, Kerala, India
² Pragathi ENT Clinic, Chennai, Tamil Nadu, India

Date of Submission	21-Jun-2021
Date of Decision	19-Sep-2021
Date of Acceptance	20-Sep-2021
Date of Web Publication	17-Dec-2021

Correspondence Address:
Dr. Muhammed Rasheed
KIMS HEALTH, Anayara P.O, Thiruvananthapuram, Kerala
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jhnps.jhnps_29_21

Abstract

Aim: The study intents to compare the hemostatic and hemodynamic effects of topical application versus intranasal injection of adrenaline during endoscopic sinus surgery (ESS) under general anesthesia (GA). Materials and Methods: This is a tertiary hospital-based, 1-year prospective observational study in fifty adults, within the age group of 18–70 years of both sexes with bilateral similar sinonasal pathology, who underwent ESS under GA. Intraoperative hemostatic and hemodynamic parameters following topical application and intranasal injection of adrenaline were analyzed. Results: It was found that Fromme–Boezaart grading for hemostasis did not show any statistically significant difference (P > 0.05) between topical versus injection adrenaline. Out of fifty patients, 74% showed <10-ml difference in blood loss and only 6% of the study population showed more than 20-ml difference in blood loss. The heart rate and mean arterial pressure were found to be increased following intranasal injection of adrenaline (P < 0.001). Six percent of the study population developed electrocardiogram variation in the form of sinus tachycardia following local infiltration of adrenaline. Conclusions: Topical application of 1:2000 dilution of adrenaline gives similar hemostatic effects compared to intranasal infiltration of 1:100,000 dilution of adrenaline during ESS, and thus, we can avoid the systemic adverse events such as tachycardia, arrhythmia, and mean arterial pressure changes due to adrenaline infiltration.

Keywords: Endoscopic sinus surgery, hemodynamics, hemostasis, topical adrenaline

How to cite this article:
Rasheed M, Felix V, Narendrakumar V. Hemostatic and hemodynamic effects of topical administration versus intranasal injection of adrenaline during endoscopic sinus surgery: A prospective observational study. J Head Neck Physicians Surg 2021;9:123-7

How to cite this URL:
Rasheed M, Felix V, Narendrakumar V. Hemostatic and hemodynamic effects of topical administration versus intranasal injection of adrenaline during endoscopic sinus surgery: A prospective observational study. J Head Neck Physicians Surg [serial online] 2021 [cited 2023 Jun 4];9:123-7. Available from: https://www.jhnps.org/text.asp?2021/9/2/123/332715

Introduction

Functional endoscopic sinus surgery (ESS) is a minimally invasive technique and provides magnified and angulated operating field.^[1],[2],[3] It is necessary to attain adequate hemostasis during ESS to prevent complication and to improve the quality of surgical field. Vasoconstriction of nasal mucosa provides more or less bloodless field and is usually achieved by a combination of topical application and local infiltration of local anesthetic drugs containing adrenaline.^[4],[5],[6] Systemic absorption of adrenaline following local infiltration through the nasal mucosa is often accompanied by hemodynamic instability such as hypertension, hypotension, tachycardia, and arrhythmias in patients with cardiovascular morbidity.^[7],[8],[9] Evidence indicates that topical application of adrenaline alone achieves similar hemostatic effects compared with the use of both topical and injection of adrenaline, and thus, we can avoid the systemic adverse effects of adrenaline.^[10]

Aim

The aim of this study was to compare the hemostatic and hemodynamic effects of topical application versus intranasal injection of adrenaline during ESS under general anesthesia (GA).

Objective

The objective of this study was to assess if topical administration of adrenaline will produce a similar hemostatic and decongestive effect on nasal mucosa as compared to intranasal injection of adrenaline and to observe whether any immediate intraoperative hemodynamic instabilty arises following intranasal injection of adrenaline in patients undergoing ESS under GA.

Materials and Methods

We conducted a prospective observational study to assess the hemostatic and hemodynamic effects of topical versus intranasal injection of adrenaline among fifty patients within the age group of 18–70 years, with bilateral similar sinonasal disease, who underwent ESS under GA.

Inclusion criteria

Patients of both sexes in the age group of 18–70 years who underwent ESS under GA for bilateral similar sinonasal diseases.

Exclusion criteria

Patients with history of bleeding disorders
Patients who are on antiplatelet medications
Nonconsenting patients.

Methodology

After receiving informed consent from patients who were posted for ESS under GA for bilateral similar sinonasal diseases, detailed history, general physical and ENT examination, and routine preanesthetic evaluation were done. Baseline heart rate (HR), lead II electrocardiogram (ECG), systolic blood pressure (BP), and mean arterial pressure (MAP) were noted from the multipara monitor. Induction of GA was done with injection propofol 1.5–2 mg/kg, injection fentanyl 0.002 mg/kg, and maintenance done with sevoflurane or propofol infusion. Throat pack was kept to prevent microaspiration. After induction of anesthesia, four cotton pledgets soaked in 1:2000 dilution of adrenaline were kept endoscopically in each nasal cavity at the floor of the nasal cavity, middle meatus, sphenoethmoidal recess, and at the uncinate process for about 5–10 min. Changes in HR, ECG rhythm, systolic BP, and MAP were noted after 1 min, 3 min, and 5 min, respectively, after nasal packing. After completion of ESS in one nasal cavity, hemostatic effect was analyzed using the Fromme–Boezaart Visual Analog Scale [Table 1] and the volume of blood in the suction apparatus was also measured.

Table 1: Fromme–Boezaart grading scale

Click here to view

Before proceeding to the other nasal cavity, 2% lignocaine with 1:100,000 dilution of adrenaline was injected intranasally at the axilla of the middle turbinate, posterior end of middle turbinate at the sphenopalatine area, and at the uncinate process. Changes in HR, ECG pattern, systolic BP, and MAP were noted after 1 min, 3 min, and 5 min of intranasal injection of adrenaline. After completion of the procedure, hemostatic effect was analyzed using the Fromme–Boezaart Visual Analog Scale and the remaining volume of blood in the suction apparatus was also measured.

All observations were entered by the principal investigator in the study pro forma sheet. With all these information, the analysis was done to obtain the outcome of the study.

Statistical analysis

All data were entered into Microsoft Excel sheet and analyzed using the Statistical Software Package for the Social Sciences (SPSS) version 16.0 (IBM, USA). Descriptive statistics were summarized using medians with interquartile ranges for continuous variables and frequency and percentages for categorical variables. The distributions were examined using pie charts. Wilcoxon signed-rank test was used to find the association between the continuous variables. P < 0.05 was considered statistically significant.

Results

In our study population, 29 (58%) were from middle age group (40–60 years), 11 (22%) were from young age (<40 years), and 10 (20%) were from old age group (>60 years) [Figure 1]. Most common were male. Twenty eight [56%, [Table 2]] and 20 (40%) patients were with comorbidities such as hypertension, diabetes, or thyroid disorders [Table 3]. Among the study population, 28 (56%) patients were having extensive sinonasal pathology symmetrically involving more than two sinuses and 22 (44%) were with limited sinus disease involving <2 sinuses [Table 4]. It was found that Fromme–Boezaart grading did not show any statistically significant difference (P > 0.05) between topical versus injection adrenaline among the study population [Table 5]. Out of 50 samples, 37 (74%) showed <10-ml difference in volume of blood loss and only 3 (6%) out of 50 study population showed more than 20-ml difference in blood loss between topical and intranasal injections of adrenaline [Figure 2]. Trachycardia was observed in majority of the study population who received intranasal injection of adrenaline, whereas no variation in heart rate was observed in those who had topical application. The P value of paired t-test for comparison of HR with topical verse injection adrenaline was <0.001, which is a statistically significant variation between these two variables [Table 6]. The MAP was also found to be increased following intranasal injection of adrenaline, compared with topical application of adrenaline, and the P value of paired t-test for comparison of MAP with topical versus injection adrenaline was <0.001, which is also statistically significant [Table 7]. Three out of fifty (6%) study population developed ECG variation in the form of sinus tachyarrhythmia following local infiltration of adrenaline.

Figure 1: Percentage distribution of age group

Click here to view

Figure 2: Percentage distribution of difference in blood loss between topical and injection of adrenaline

Click here to view

Table 2: Distribution of patients with gender

Click here to view

Table 3: Distribution patients with comorbidity status

Click here to view

Table 4: Distribution of patients with disease extension

Click here to view

Table 5: Comparison of Fromme–Boezaart grading with topical versus injection adrenaline

Click here to view

Table 6: Comparison of heart rate with topical versus injection adrenaline

Click here to view

Table 7: Comparison of mean arterial pressure with topical versus injection adrenaline

Click here to view

Discussion

Functional ESS (FESS) uses high-definition nasal endoscopes to visualize the endonasal anatomy to eradicate diseases from nose and paranasal sinuses and restore the sinus drainage pathways and improve its ventilation. The presence of significant bleeding in the operating field is a drawback in the outcome of endoscopic sinus surgeries. This necessitates a bloodless field for the surgeon to operate upon easily and to minimize the complications. Various techniques have been used during FESS to achieve an optimal surgical field, such as local and topical anesthetics containing adrenaline, total intravenous or hypotensive anesthesia, preoperative administration of nasal and oral steroids, and beta-blockers.^[11],[12] Local vasoconstriction is usually attained through a combination of topical and injectable decongestants containing adrenaline at various concentrations.^{[10],[12],[13]}

In this study, the hemostatic effect of topical versus injection adrenaline in ESS was compared by a Visual Analog Scale, Fromme–Boezaart grading, and also by the volume of blood loss from each nasal cavity after surgery.

It was found that Fromme–Boezaart grading did not show any statistically significant difference (P > 0.05) between topical versus injection adrenaline among the study population. Seventy-four percent of the study population showed only <10-ml difference in volume of blood loss between topical and injection adrenaline and only 6% of the study population showed more than 20-ml difference in blood loss between topical and intranasal injections of adrenaline.

From the observations, it showed that there is no significant difference in blood loss between topical and injection adrenaline and the topical application of 1:2000 dilution of adrenaline alone achieved a hemostatic effect similar to intranasal injection of 1:100,000 dilution of adrenaline.

Tangbumrungtham et al.^[14] studied the effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization and concluded that the addition of infiltration of 1% lidocaine with epinephrine 1:100,000 to topical application of adrenaline 1:1000 for ESS does not significantly improve the surgical field of view compared to topical epinephrine alone. In another study done by Lee et al.^[6] to determine the feasibility of the use of a topical vasoconstrictor for hemostasis during FESS, the conclusion was that topical use of adrenaline achieved a hemostatic effect similar to intranasal injection and also that the latter may be avoided during surgery in consideration of its adverse effects. Sarmento Junior Krishnamurti Matos et al.^[10] studied the topical use of adrenaline in different concentrations for ESS and concluded in favoring the use of topical adrenaline 1:2000 dilution due to a clear superiority in hemostasis.

All these studies correlated with the findings from our study that the topical application of 1:2000 dilution of adrenaline alone achieves a hemostatic effect similar to intranasal injection of 1:100000 dilution of adrenaline in ESS.

Hemodynamic effects were analyzed by observing the variations in HR, MAP, and ECG changes following the application of topical and intranasal injections of adrenaline. In our study, it was found that the HR and MAP were increased following intranasal injection of adrenaline compared with topical application of adrenaline (P < 0.001), which is again a statistically significant difference.

Anderhuber et al.^[15] analyzed the systemic absorption of injected epinephrine during FESS, and found a significant increase in the plasma catecholamine level after submucosal injection with associated hemodynamic fluctuations. Moshaver et al.^[16] conducted a randomized controlled trial (RCT) to determine the hemostatic and hemodynamic effects of two different concentrations of adrenaline in ESS and concluded that intranasal injection of local anesthetic containing adrenaline during ESS, while providing hemostasis, is associated with cardiac adverse effects such as tachycardia, hypertension, as well as arrhythmias. Another double-blind RCT by Cohen-Kerem et al.^[17] reported that increased hemodynamic fluctuations were noted after intranasal infiltration with 1:100,000 dilution of adrenaline. Another RCT done by Günel et al.^[18] concluded that the use of adrenaline infiltration during septal surgery is associated with cardiogenic side effects due to systemic absorption.

Avoiding hemodynamic fluctuations is the key factor in preventing cardiac complications during FESS. All these studies correlate with the findings from our study that intranasal injection of local anesthetic containing adrenaline during ESS was associated with cardiac adverse effects such as tachycardia and hypertension due to systemic absorption of adrenaline.

In our study, 6% of the study population, especially in older age group, developed ECG variation in the form of sinus tachyarrhythmia, following local infiltration of adrenaline. None of them had any ECG changes following the application of topical adrenaline. Hema et al.^[19] published a case report on ventricular tachycardia following intranasal injection of adrenaline in ESS. Myocardial infarction and visual field defects were also reported in literature, following local infiltration of adrenaline in sinus surgery.^[20]

Conclusions

From this study, we suggest that topical application of 1:2000 dilution of adrenaline can produce a similar hemostatic effect compared to intranasal injection of 1:100,000 dilution of adrenaline in endoscopic sinus surgeries under GA. Intranasal infiltration of local anesthetics containing adrenaline can be avoided in ESS under GA due to its systemic absorption causing hemodynamic instability in the form of tachycardia, hypertension, or arrhythmia, especially in patients with cardiovascular comorbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was taken from the Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the Ethical Standards of the Institutional and/or National Research Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

1.	Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247:63-76.
2.	Stammberger H. Functional Endoscopic Sinus Surgery – The Messerklinger Technique. Philadelphia: Decker; 1991.
3.	Slack R, Bates GJ. Functional endoscopic sinus surgery. Am Fam Physician 1998;58:707-18.
4.	Higgins TS, Hwang PH, Kingdom TT, Orlandi RR, Stammberger H, Han JK. Systematic review of topical vasoconstrictors in endoscopic sinus surgery. Laryngoscope 2011;121:422-32.
5.	Orlandi RR, Warrier S, Sato S, Han JK. Concentrated topical epinephrine is safe in endoscopic sinus surgery. Am J Rhinol Allergy 2010;24:140-2.
6.	Lee TJ, Huang CC, Chang PH, Chang CJ, Chen YW. Hemostasis during functional endoscopic sinus surgery: The effect of local infiltration with adrenaline. Otolaryngol Head Neck Surg 2009;140:209-14.
7.	Niwa H, Sugimura M, Satoh Y, Tanimoto A. Cardiovascular response to epinephrine-containing local anesthesia in patients with cardiovascular disease. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:610-6.
8.	Yang JJ, Zheng J, Liu HJ, Liu YX, Shen JC, Zhou ZQ. Epinephrine infiltration on nasal field causes significant hemodynamic changes: Hypotension episode monitored by impedance-cardiography under general anesthesia. J Pharm Pharm Sci 2006;9:190-7.
9.	Elhakim M, Omar NS, el-Kader AA, Zowel T. Cardiac dysrhythmias during nasal surgery – A comparison with lignocaine-adrenaline and prilocaine-octapressin during halothane anaesthesia. Anaesthesiol Reanim 1990;15:199-203.
10.	Sarmento Junior KM, Tomita S, Kós AO. Topical use of adrenaline in different concentrations for endoscopic sinus surgery. Braz J Otorhinolaryngol 2009;75:280-9.
11.	Drozdowski A, Sieśkiewicz A, Siemiatkowski A. Reduction of intraoperative bleeding during functional endoscopic sinus surgery. Anestezjol Intens Ter 2011;43:45-50.
12.	Khosla AJ, Pernas FG, Maeso PA. Meta-analysis and literature review of techniques to achieve hemostasis in endoscopic sinus surgery. Int Forum Allergy Rhinol 2013;3:482-7.
13.	McClymont LG, Crowther JA. Local anaesthetic with vasoconstrictor combinations in septal surgery. J Laryngol Otol 1988;102:793-5.
14.	Tangbumrungtham N, Hwang PH, Maul X, Borchard NA, Dholakia SS, Patel ZM, et al. The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: A double-blind randomized controlled study. Int Forum Allergy Rhinol 2020;10:147-52.
15.	Anderhuber W, Walch C, Nemeth E, Semmelrock HJ, Berghold A, Ranftl G, et al. Plasma adrenaline concentrations during functional endoscopic sinus surgery. Laryngoscope 1999;109:204-7.
16.	Moshaver A, Lin D, Pinto R, Witterick IJ. The hemostatic and hemodynamic effects of epinephrine during endoscopic sinus surgery: A randomized clinical trial. Arch Otolaryngol Head Neck Surg 2009;135:1005-9.
17.	Cohen-Kerem R, Brown S, Villaseñor LV, Witterick I. Epinephrine/Lidocaine injection vs. saline during endoscopic sinus surgery. Laryngoscope 2008;118:1275-81.
18.	Günel C, Sarı S, Eryılmaz A, Başal Y. Hemodynamic effects of topical adrenaline during septoplasty. Indian J Otolaryngol Head Neck Surg 2016;68:391-5.
19.	Hema HA, Kulkarni A, Ranjan RK, Ambareesha M. Ventricular tachycardia due to intranasal adrenaline in nasal surgery – A case report. Indian J Anaesth 2008;52:199. [Full text]
20.	Ferry DR, Henry RL, Kern MJ. Epinephrine-induced myocardial infarction in a patient with angiographically normal coronary arteries. Am Heart J 1986;111:1193-5.