Comparison of Labetalol, Nitroglycerine and High Dose Propofol for Induced Hypotension in Functional Endoscopic Sinus Surgery in Massive Nasal Polyposis: A Randomized Trial
Background: The aim of this study was to assess the quality of the surgical field, amount of blood loss, and duration of surgery following induced hypotension with labetalol, nitroglycerin, and high dose propofol in patients undergoing FESS under general anesthesia.
Methods: One hundred and eight patients scheduled for FESS under general anesthesia were recruited in this randomized trial and were allocated to one of the three study groups: 1) Nitroglycerine (NTG) group: nitroglycerine with a dose of 2-5 μg/kg/min was administered; 2) Labetalol (LAB) group: an IV bolus dose of labetalol (20 mg) was injected at first and then IV infusion of labetalol at a rate of 1-2 mg/min; 3) High dose propofol plus normal saline (0.5-1 ml/min) group. Hemodynamic variables and the amount of bleeding were recorded intraoperatively and the surgeons' satisfaction was asked following each surgery considering the surgical field quality using a 5-item Likert scale.
Results: The average blood loss (ml) in patients in the LAB group was significantly less than patients in NTG and high dose propofol groups (127 ml vs 198 and 145 ml, respectively) (p- value=0.001) and the surgeons expressed greater satisfaction with the surgical field quality in the LAB group (p- value=0.001).
Conclusion: Labetalol infusion may be a safe and effective method for induction of controlled hypotension to provide a comparatively bloodless field. High dose propofol may be a second choice if labetalol is not available.
 Kelly EA, Gollapudy S, Riess ML, Woehlck HJ, Loehrl TA, Poetker DM. Quality of surgical field during endoscopic sinus surgery: a systematic literature review of the effect of total intravenous compared to inhalational anesthesia. Int Forum Allergy Rhinol. 2013; 3(6):474-81.
 Beule AG, Wilhelmi F, Kühnel TS, Hansen E, Lackner KJ, Hosemann W. Propofol versus sevoflurane: bleeding in endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2007; 136(1):45-50.
 Eberhart LHJ, Folz BJ, Wulf H, Geldner G. Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery. Laryngoscope. 2003; 113(8):1369–1373.
 Sajedi P, Rahimian A, Khalili G. Comparative evaluation between two methods of induced hypotension with infusion of remifentanil and labetalol during sinus endoscopy. J Res Pharm Pract .2016; 5(4):264-71.
 Bajwa SJ, Kaur J, Kulshrestha A, Haldar R, Sethi R, Singh A. Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: a comparative evaluation. J Anaesthesiol Clin Pharmacol. 2016; 32(2): 192-97.
 Jacobi KE, Böhm BE, Rickauer AJ, Jacobi C, Hemmerling TM. Moderate controlled hypotension with sodium nitroprusside does not improve surgical conditions or decrease blood loss in endoscopic sinus surgery. J Clin Anesth. 2000; 12(3):202-7.
 Shen P-H, Weitzel EK, Lai J-T, Wormald P-J, Ho C-S. Intravenous esmolol infusion improves surgical fields during sevoflurane-anesthetized endoscopic sinus surgery: a double-blind, randomized, placebo-controlled trial. Am J Rhinol Allergy. 2011; 25(6): 208-11.
 Nair S, Collins M, Hung P, Rees G, Close D, Wormald PJ. The effect of β‐blocker premedication on the surgical field during endoscopic sinus surgery. Laryngoscope. 2004; 114(6):1042-6.
 El-Shmaa NS, Ezz HAA, Younes A. The efficacy of Labetalol versus Nitroglycerin for induction of controlled hypotension during sinus endoscopic surgery. A prospective, double-blind and randomized study. J Clin Anesth .2017; 39:154-8.
 Das A, Mukherjee A, Chhaule S, ChattopadhyayS, Halder PS, Mitra T et al. Induced hypotension in ambulatory functional endoscopic sinus surgery: A comparison between dexmedetomidine andclonidine as premedication. A prospective, double-blind, and randomized study. Saudi J Anaesth. 2016; 10(1):74-80.
 Srivastava U, Dupargude AB, Kumar D, Joshi K, Gupta A. Controlled hypotension for functional endoscopic sinus surgery: comparison of Esmolol and nitroglycerine. Indian J Otolaryngol Head Neck Surg. 2013; 65 (Suppl 2):440-4.
 S. McNulty, S. Sharifi-Azad, A. Farole. Induced hypotension with labetalol for orthognathic surgery. J Oral Maxillofac Surg. 1987; 45(4): 309–311.
 Hadavi MR, Zarei Y, Tarogh S. Comparison of Effects of Labetalol and Nitroglycerine on Intraoperative Blood Loss and Surgical Field Quality in Rhinoplasty Surgery. World J Plast Surg. 2015; 4(1):60-5.
 Ahn HJ, Chung SK, Dhong HJ, Kim HY, Ahn JH, Lee SM, et al. Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery. Br J Anaesth. 2008; 100(1):50–54.
 Ankichetty SP, Ponniah M, Cherian V, Thomas S, Kumar K, Jeslin L, et al. Comparison of total intravenous anesthesia using propofol and inhalational anesthesia using isoflurane for controlled hypotension in functional endoscopic sinus surgery. J Anaesthesiol Clin Pharmacol; 2011; 27(3):328–32.
 Boonmak S, Boonmak P, Laopaiboon M. Deliberate hypotension with propofol under anaesthesia for functional endoscopic sinus surgery (FESS). Cochrane Database Syst Rev. 2016; 10(10):CD006623.
 Koch M, De Backer D, Vincent JL, Barvais L, Hennart D, Schmartz D. Effects of propofol on human microcirculation. Br J Anaesth. 2008; 101(4):473-478.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.