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INUSCENTRO
João Flávio Nogueira, MDOtolaryngologist
Taís Nogueira, MDAnesthesiologist
Sinus CentroFortaleza, Brazil
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www.sinuscentro.com.br/museu
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October, 16, 1846. William Morton demonstrates anesthesia
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• Anatomical landmarksidentification
• Complications
• Postoperative
• Trauma of the nasal mucosa may lead to formation of adhesions
Kalra G, Keir J, Tahery J. Prevention of blood staining of endoscope tip during Functional Endoscopic Sinus Surgery: sleevetechnique. J Laryngol Otol. 2009;123(12):1358-9.
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• Bleeding could obscure the view of the endoscope.
• Repeated cleaning intraoperatively is time consuming.
Endoscrub– Medtronic, Jacksonville, USA, 2008
Courtesy of Prof. Navarro
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Zachow S, Muigg P, Hildebrandt T, Doleisch H, Hege HC. Visual exploration of nasal airflow. IEEE Trans Vis Comput Graph. 2009;15(6):1407-14.
Courtesy of Prof. Navarro
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• Inflammatory mucosa
• Clinical conditions
– HBP
– Chronic diseases
– Fever
• Smoking
• Pre-operative assesment
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• Surgeon techniques
– Instruments
– Patient positioning
– Room temperature
• Local vasoconstriction
• Infiltrations ?
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Increases venous return 30%
1 °.C
Bleed
ing
Reduces coagulation capability 30%
Sarmento Junior KM, Tomita S, Kós AO. Topical use of adrenaline in different concentrations for endoscopic sinus surgery. Braz J Otorhinolaryngol. 2009;75(2):280-9.
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• Ideal patient temperature: 36°C
– Saline heat
• Lower temperatures
– Drug metabolism
• Epinephrine
• Cocaine
• Oxymetazoline
– 5 minutes
– 10 minutes
Sarmento Junior KM, Tomita S, Kós AO. Topical use of adrenaline in different concentrations for endoscopic sinus surgery. Braz J Otorhinolaryngol. 2009;75(2):280-9.
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• Wormald PJ, van Renen G, Perks J, Jones JA, Langton-Hewer CD.The effect of the total intravenous anesthesia compared withinhalational anesthesia on the surgical field during endoscopicsinus surgery. Am J Rhinol. 2005; 19(5):514-20.
• BACKGROUND: Bleeding during endoscopic sinus surgery (ESS) mayincrease complications and negatively effect the surgery and itsoutcome.
• The aim of this study was to compare TIVA (propofol+remifentanil)vs. inhalation anesthesia (sevoflurane).
• RESULTS: The two groups were matched for surgical procedure andcomputed tomography scores.
• Mean arterial pressure and pulse were found to influence thesurgical field.
• CONCLUSION: In patients undergoing ESS, TIVA results in a bettersurgical field than inhalational anesthesia.
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• CO2
– Vasodilatation to target organs
– Brain
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• Ideal parameters:
• Controlled hypotension
– BP: mean 60 – 70
– HR < 60 bpm
– CO2 < 35
– SPO2 > 97%
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History of dentistry. Sinus Centro MuseuAvailable at: www.sinuscentro.com.br/museu
1 : 2,00020 amps of epinefrine + 20 mL 0,9% saline solutionPhotosensitive (60 minutes)
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0
50
100
150
200
250
Dosage I Dosage II Dosage III
Control
1:50000
1:10000
1 2000
Ave
rage
Ad
ren
alin
e(p
G/m
L)
10 – 15 minutes 10th pledget End of surgery
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0,45
Blood loss (mL)
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• Operation time was shorter (1:2,000)• Less bleeding (1:2,000), p < 0,0001 • Plasmatic levels of epinephrine raised in all
groups, especially (1:2,000) • There was a trend towards elevation of blood pressure
in the groups using adrenaline 1:2,000 and 1:10,000, with a greater occurrence of hypertensive peaks.
• The elevation of blood pressure in the 1:2,000 and 1:10,000 was progressive but very slow throughout surgery, which could be related to the anesthesia technique.
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5 to 10 minutes
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1:100.000
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• Pterygopalatine fossa– Nasal – Endoscopy
– Oral
• Epinephine– 1:200,000 – 0,005 mg/mL
– 1:100,000 – 0,01 mg/mL
– 1:80,000 – 0,0125 mg/mL
– 1:50,000 – 0,02 mg/mL
– 1:10,000 – 0,1 mg/mL
– 1:2,000 – 0,5 mg/mL
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10 mL 1:100,000
10 mL 1:50,000
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1 mL 1:10,000
• Lidocain
• High BP
• Paradoxal bradicardia (severe)
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• Time is important
• Clean and dry surgical field is crutial
• Different techniques
• Talk to your anesthesiologist
– TESS: Tailored endoscopic sinus surgery
– TASS: Tailored anesthesia for sinus surgery
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