Anesthesia for Endoscopic Sinus Surgery
Total intravenous anesthesia (TIVA) with propofol and remifentanil is the recommended anesthesia technique for endoscopic sinus surgery as it provides superior surgical field visibility, reduces blood loss, decreases operative time, and improves quality of recovery compared to inhalational anesthesia.
Anesthetic Technique Selection
Primary Recommendation
- TIVA with propofol and remifentanil is superior to inhalational anesthesia for endoscopic sinus surgery 1, 2
- This technique provides:
- Better surgical field visibility
- Reduced intraoperative bleeding
- Shorter operative times
- Improved quality of patient recovery
Supporting Evidence
- Meta-analysis of 12 randomized controlled trials with 560 patients demonstrated TIVA's superiority in improving surgical visibility, reducing estimated blood loss, and decreasing operative time compared to inhalational anesthesia 1
- A 2019 study showed significantly higher quality of recovery scores at 6 hours post-surgery with TIVA compared to desflurane anesthesia (188.2 vs 182.6, p=0.049) 2
- A 2017 study confirmed that TIVA provides better surgical field quality at the end of surgery with less total blood loss and fewer intraoperative complications 3
Specific Anesthetic Protocol
Induction
- Standard induction with propofol (1.5-2.5 mg/kg)
- Remifentanil infusion (0.25-0.5 μg/kg/min)
- Muscle relaxant for intubation
Maintenance
- Propofol infusion (100-200 μg/kg/min) titrated to maintain appropriate depth of anesthesia
- Remifentanil infusion (0.1-0.5 μg/kg/min) for analgesia and hemodynamic control
- Target mean arterial pressure of 70-80 mmHg for controlled hypotension 4
Positioning
- Reverse Trendelenburg position (15-20° head elevation) to reduce venous congestion and improve surgical field 5
Ventilation
- Controlled ventilation with normocapnia or mild hypocapnia
- Avoid excessive PEEP which may increase venous pressure in the surgical field
Special Considerations
Patient-Specific Factors
- For patients with high Lund-Mackay scores (≥12), indicating extensive sinus disease:
Monitoring
- Standard ASA monitoring
- Consider cerebral oximetry for patients undergoing deliberate hypotension to ensure adequate cerebral perfusion 5
- Depth of anesthesia monitoring (BIS/Entropy) to avoid awareness while maintaining adequate anesthetic depth
Emergence
- Smooth emergence is critical to avoid coughing, bucking, or hypertension that may cause postoperative bleeding
- Continue remifentanil at low dose until extubation
- Discontinue propofol with timing to allow prompt but smooth emergence
Potential Pitfalls and Complications
Hemodynamic Management
- Excessive hypotension (MAP <65 mmHg) may compromise cerebral perfusion
- Inadequate depth of anesthesia may lead to patient movement and surgical complications
- Rebound hypertension during emergence can increase postoperative bleeding risk
Airway Management
- Shared airway with surgeon requires secure endotracheal tube fixation
- Consider throat pack placement to prevent blood accumulation in the stomach
- Remember to remove throat pack before extubation to avoid airway obstruction
Postoperative Care
- Ensure adequate pain control with multimodal analgesia
- Monitor for postoperative bleeding
- Maintain head elevation in the recovery period to minimize bleeding and edema
Conclusion
TIVA with propofol and remifentanil provides optimal conditions for endoscopic sinus surgery with better surgical field visibility, reduced bleeding, and improved patient recovery compared to inhalational anesthesia techniques. This approach is particularly beneficial for patients with extensive sinus disease as indicated by high Lund-Mackay scores.