Perioperative Management for Optimization of the Surgical Field
Rhinologist Martin J. Citardi, MD, professor and chair of the Department of Otorhinolaryngology at McGovern Medical School at UTHealth Houston, and anesthesiologist Davide Cattano, MD, PhD, professor of anesthesiology, critical care, and pain medicine at the medical school, have worked together in the operating room for nearly 14 years. Among their recent collaborations is an article published in 2023 on the importance of close anesthesiologist-ENT cooperation during functional endoscopic sinus surgery (FESS).
“We work in a narrow passage using tiny cameras, and even a small amount of blood can obscure visibility,” says Dr. Citardi, who has served as vice dean for clinical technology at UTHealth Houston since 2019. “As surgeons, we need to optimize the surgical field in every way possible, and although we collectively have used various techniques to improve visibility, there is no consensus about best practices. Our goal with the retrospective review was describe if and how we can improve outcomes by decreasing bleeding and improving visibility in the surgical field through anesthetic choice.”
Dr. Citardi, Dr. Cattano, and their international research team analyzed evidence-based practices published on PubMed from 2011 to 2021 describing perioperative care, intravenous and inhalation anesthetics, and operative approaches for FESS and their effects on blood loss and surgical field visibility. While four out of five meta-analyses and six out of 11 randomized controlled trials favored total intravenous anesthesia over inhalation anesthesia for improved visibility, the researchers found that visibility was more dependent on perioperative medications used than on anesthesia technique.
“Thanks to technological and instrumental advances, endoscopic sinus surgery has evolved into a relatively benign surgery, but certain tweaks and techniques make the procedure smoother and safer,” says Dr. Cattano, who is chief of head and neck anesthesia at Memorial Hermann-Texas Medical Center and an adjunct professor in the Department of Otorhinolaryngology. “While there are seemingly simple things the anesthesiologist can do to make a significant difference in visibility, the most important aspect is preparation of the patient by the surgeon, which includes use of preoperative decongestants, nasal cavity and sinus irrigations, and anti-inflammatory medications. Poor-quality visibility often is due to untreated inflammatory disease in a patient who hasn’t been optimized and is more prone to bleeding.”
“Our analysis of clinical practice and numerous studies using different techniques showed that even if a genuine difference exists between intravenous and inhalation anesthesia, it probably doesn’t matter clinically,” Dr. Citardi adds. “So we recommend, in the interest of patient safety, that the anesthesiologist use the anesthetic technique with which he or she is most comfortable. We have based our review not just on published references but also on what we do in the OR on a daily basis. Success always depends on good team communication about patient care, and the importance of the anesthesiologist-surgeon relationship cannot be overemphasized.”
Reference
Stamenkovic DM, Ahmad JG, Corso RM, Unic Stojanovic D, Radabaugh JP, Citardi, MD, Cattano D. Perioperative management and surgical field optimization in functional endoscopic sinus surgery. Minerva Anestesiologica. 2023 Apr;89(4):316-330. Epub 2023 Feb 21. PMID:36800807.