|Background: Rhinoplasty is a complex but popular surgery in Iran. The main complications of the surgery are post-operative bleeding and nasal septal hematoma due to poor intra-operative controlled hypertension. This study aimed to compare the efficacy of isoflurane-remifentanil (I-R) versus propofol-remifentanil (P-R) to induce controlled hypotension and to assess surgeon satisfaction with each of these combinations during rhinoplasty. |
Methods: In 2020-2021, a single-blind clinical study was conducted on 98 patients aged 18-50 years undergoing rhinoplasty at Mother and Child Hospital (Shiraz, Iran). Patients were randomly divided into P-R (n=48) and I-R (n=50) groups. Changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were assessed during surgery and in the recovery room. A questionnaire was used to evaluate the level of surgeon satisfaction. Data were analyzed using independent samples t test, Chi-square test, and repeated measures ANOVA with SPSS software. P<0.05 was considered statistically significant.
Results: Five minutes after anesthesia induction, the P-R combination had a greater effect on reducing SBP (P=0.010), DBP (P=0.007), MAP (P=0.003), and HR (P=0.026) than I-R. However, from the 40th minute to the end of surgery and after 30 minutes of recovery, the I-R combination had a slightly better effect on blood pressure reduction than P-R. There was no difference in surgeon satisfaction with either of the two drug combinations.
Conclusion: Both P-R and I-R combinations are recommended to induce hypotension during rhinoplasty. However, I-R is more effective than P-R in inducing the desired controlled hypotension.
- Kalantar Motamedi MH, Ebrahimi A, Shams A, Nejadsarvari N. Health and Social Problems of Rhinoplasty in Iran. World J Plast Surg. 2016;5:75-6. PubMed PMID: 27308246; PubMed Central PMCID: PMCPMC4904144.
- Dinis PB, Dinis M, Gomes A. Psychosocial consequences of nasal aesthetic and functional surgery: a controlled prospective study in an ENT setting. Rhinology. 1998;36:32-6. PubMed PMID: 9569440.
- Singh P, Vijayan R, Nikkhah D. Filler Rhinoplasty: Evidence, Outcomes, and Complications. Aesthet Surg J. 2018;38:NP165-NP7. doi: 10.1093/asj/sjy223. PubMed PMID: 30265278.
- Rokhtabnak F, Djalali Motlagh S, Ghodraty M, Pournajafian A, Maleki Delarestaghi M, Tehrani Banihashemi A, et al. Controlled Hypotension During Rhinoplasty: A Comparison of Dexmedetomidine with Magnesium Sulfate. Anesth Pain Med. 2017;7:e64032. doi: 10.5812/aapm.64032. PubMed PMID: 29696129; PubMed Central PMCID: PMCPMC5903392.
- Milonski J, Zielinska-Blizniewska H, Golusinski W, Urbaniak J, Sobanski R, Olszewski J. Effects of three different types of anaesthesia on perioperative bleeding control in functional endoscopic sinus surgery. Eur Arch Otorhinolaryngol. 2013;270:2045-50. doi: 10.1007/s00405-012-2311-1. PubMed PMID: 23263204; PubMed Central PMCID: PMCPMC3669505.
- East C, Kwame I, Hannan SA. Revision Rhinoplasty: What Can We Learn from Error Patterns? An Analysis of Revision Surgery. Facial Plast Surg. 2016;32:409-15. doi: 10.1055/s-0036-1586176. PubMed PMID: 27494585.
- Degoute CS. Controlled hypotension: a guide to drug choice. Drugs. 2007;67:1053-76. doi: 10.2165/00003495-200767070-00007. PubMed PMID: 17488147.
- Testa LD, Tobias JD. Pharmacologic drugs for controlled hypotension. J Clin Anesth. 1995;7:326-37. doi: 10.1016/0952-8180(95)00010-f. PubMed PMID: 7546762.
- Han RQ, Li SR, Wang BG, Wang EZ, Liu W, Wang S, et al. The effect of isoflurane induced hypotension on intraoperative cerebral vasospasm in intracranial aneurysm surgery. Zhonghua Yi Xue Za Zhi. 2004;84:286-9. PubMed PMID: 15059509.
- Miller D, Lewis SR, Pritchard MW, Schofield-Robinson OJ, Shelton CL, Alderson P, et al. Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery. Cochrane Database Syst Rev. 2018;8:CD012317. doi: 10.1002/14651858.CD012317.pub2. PubMed PMID: 30129968; PubMed Central PMCID: PMCPMC6513211.
- 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;27:328-32. doi: 10.4103/0970-9185.83675. PubMed PMID: 21897501; PubMed Central PMCID: PMCPMC3161455.
- Alkan A, Honca M, Alkan A, Gulec H, Horasanli E. The efficacy of esmolol, remifentanil and nitroglycerin in controlled hypotension for functional endoscopic sinus surgery. Braz J Otorhinolaryngol. 2021;87:255-9. doi: 10.1016/j.bjorl.2019.08.008. PubMed PMID: 31668787; PubMed Central PMCID: PMCPMC9422684.
- Azemati S, Savai M, Khosravi MB, Allahyari E, Jahanmiri F. Combination of remifentanil with isoflurane or propofol: effect on the surgical stress response. Acta Anaesthesiol Belg. 2013;64:25-31. PubMed PMID: 23767174.
- Jouybar R, Nemati M, Asmarian N. Comparison of the effects of remifentanil and dexmedetomidine on surgeon satisfaction with surgical field visualization and intraoperative bleeding during rhinoplasty. BMC Anesthesiol. 2022;22:24. doi: 10.1186/s12871-021-01546-9. PubMed PMID: 35031005; PubMed Central PMCID: PMCPMC8759207.
- Tirelli G, Bigarini S, Russolo M, Lucangelo U, Gullo A. Total intravenous anaesthesia in endoscopic sinus-nasal surgery. Acta Otorhinolaryngol Ital. 2004;24:137-44. PubMed PMID: 15584584.
- Montazeri K, Dehghan A, Akbari S. Increase in intraocular pressure is less with propofol and remifentanil than isoflurane with remifentanil during cataract surgery: A randomized controlled trial. Adv Biomed Res. 2015;4:55. doi: 10.4103/2277-9175.151583. PubMed PMID: 25802824; PubMed Central PMCID: PMCPMC4361958.
- Hyun D, Ryu HB, Kim MW. Effect of isoflurane versus propofol-remifentanil anesthesia on neuromuscular blockade and hemodynamic responses by cisatracurium bolus injection. Korean J Anesthesiol. 2011;61:297-301. doi: 10.4097/kjae.2011.61.4.297. PubMed PMID: 22110882; PubMed Central PMCID: PMCPMC3219775.
- Wilhelm W, Grundmann U, Van Aken H, Haus EM, Larsen R. A multicenter comparison of isoflurane and propofol as adjuncts to remifentanil-based anesthesia. J Clin Anesth. 2000;12:129-35. doi: 10.1016/s0952-8180(00)00125-2. PubMed PMID: 10818327.