What does anesthesia for a Functional Endoscopic Sinus Surgery (FESS) procedure involve, particularly in pediatric patients?

Anesthesia for FESS Procedure

FESS is typically performed under general anesthesia with endotracheal intubation, though the specific anesthetic technique should be tailored to optimize the surgical field while maintaining hemodynamic stability.

Anesthetic Technique Options

General Anesthesia (Standard Approach)

• General anesthesia is the predominant technique for FESS, allowing complete airway control and optimal surgical conditions 1
• Endotracheal intubation (ETT) is preferred over laryngeal mask airway (LMA) for most cases, as it provides superior airway protection and allows for controlled hypotension 1

Induction Agents

• Propofol-based total intravenous anesthesia (TIVA) produces superior surgical conditions compared to volatile anesthetics 2
• In a comparative study, propofol resulted in significantly less intraoperative bleeding (155cc vs 291cc) and better surgeon satisfaction scores (1.9 vs 2.95 on VAS) compared to isoflurane 2
• Standard induction includes propofol, remifentanil, and a neuromuscular blocking agent (cisatracurium or rocuronium) 2

Maintenance Strategies

Two primary maintenance approaches exist:

Option 1: Total Intravenous Anesthesia (Preferred)

• Propofol infusion combined with remifentanil provides optimal surgical field visualization 2
• Results in less hemorrhage and better field conditions than volatile agents 2

Option 2: Volatile Anesthesia

• Isoflurane or sevoflurane with remifentanil infusion is an alternative 2
• Associated with more bleeding and reduced surgical field quality compared to TIVA 2

Hemodynamic Management

Controlled Hypotension

• Maintain systolic blood pressure around 90 mmHg to minimize surgical bleeding 2
• Diastolic blood pressure should not fall below 50 mmHg, as this can compromise optic nerve perfusion and affect visual evoked potential monitoring 3
• Careful titration of anesthetic depth and vasoactive medications is essential 1

Airway and Ventilation Considerations

Positioning and Airway Protection

• Endotracheal intubation provides definitive airway protection during the procedure 1
• Throat packing may be used to prevent blood from entering the gastrointestinal tract 1
• Maintain oxygen saturation at 98% or higher, particularly if intraoperative neuromonitoring is employed 3

Pediatric-Specific Considerations

Induction in Children

• Inhalational induction with sevoflurane is preferred for most pediatric FESS patients, as children typically resist intravenous access when awake 4
• Sevoflurane has replaced halothane due to its non-pungent odor, rapid onset, and superior cardiovascular safety profile 4
• Intravenous induction with propofol (1-2 mg/kg) or ketamine (1-2 mg/kg) is appropriate when venous access is already established 4

Airway Management in Pediatric Patients

• Endotracheal intubation is standard for pediatric FESS 4
• In children with upper respiratory infections, consider delaying elective surgery or administering inhaled salbutamol 30 minutes before induction to reduce perioperative cough and bronchospasm by approximately 50% 4

Neuromuscular Blockade

• Non-depolarizing agents (rocuronium, vecuronium, cisatracurium) are preferred 4
• Ensure complete reversal with train-of-four ratio ≥0.9 before extubation to prevent residual neuromuscular blockade 4

Analgesia and Pain Management

Multimodal Approach

• Combine non-opioid analgesics (NSAIDs, paracetamol) to reduce opioid requirements and associated respiratory depression 4
• Local anesthetic infiltration of surgical sites provides additional pain control 1
• Intravenous fentanyl in the post-anesthesia care unit for breakthrough pain 4

Pediatric Pain Management

• Rectal or intravenous NSAIDs and/or paracetamol during the entire postoperative period 4
• NSAIDs are contraindicated in very young infants (particularly those under 3 months) 5

Monitoring Requirements

Standard Monitoring

• Continuous pulse oximetry, capnography, ECG, and blood pressure monitoring throughout the procedure 1
• Children undergoing anesthesia for procedures must receive the same standard of care as adults, including full monitoring equipment 4

Specialized Monitoring (Selected Cases)

• Flash visual evoked potentials (VEP) can be monitored simultaneously from both eyes during FESS to detect optic nerve compression 3
• An increase in P100 latency serves as an indicator of optic nerve compression 3
• This monitoring is only reliable when diastolic BP remains above 50 mmHg, oxygen saturation is maintained at 98%, and bleeding is minimized 3

Emergence and Recovery

Extubation Criteria

• Patient should be fully awake and oriented before extubation 1
• Ensure complete reversal of neuromuscular blockade 4
• Cardiovascular and respiratory stability must be assured 1

Recovery Monitoring

• Continuous monitoring of oxygen saturation during the recovery period 4
• Children receiving opioids require continuous pulse oximetry monitoring for 24 hours due to apnea risk 5

Common Pitfalls and Caveats

• Avoid excessive bleeding by maintaining controlled hypotension, but do not compromise organ perfusion (keep diastolic BP >50 mmHg) 3
• Volatile anesthetics produce inferior surgical conditions compared to propofol-based TIVA 2
• In pediatric patients, inadequate monitoring or inappropriate sedation are the most common causes of life-threatening adverse events 4
• Residual neuromuscular blockade at extubation increases risk of respiratory complications 4