Haemostatic effect of topical application of saline adrenaline versus cold saline and tranexamic acid in nasal surgeries (comparative study)

INTRODUCTION

A restrictive problem in nasal operations was the difficulty in employing the surgical tools in the nasal fossae and obtaining a clear image of the surgical area. The main faced limiting problems were that there is no sufficient view of surgeons because of the tight and tortuous anatomy of nasal fossa, and bleedings of the mucosa due to the wide spread of vascularization in this area. Nasal endoscopic surgery, which was started in the early 1970, substantially minimized the obstacles mentioned before. Endoscopes have some advantages in that it can reach difficult areas; magnify the surgical area view, and providing the advantage of angular optics, which help surgeons to reach inaccessible recesses. While, the surgeons were directed via an endoscopic picture, any minor bleeding can screen the endoscope tip leading to the blocking of the endoscope image. Thus, hemostasis of the nasal mucosa, which was already important, has become major for operation.¹

General anesthesia together with hypotensive drugs such as beta-blockers, vasodilators, higher dose of inhalational or intravenous anesthetics would help for accurately recognize complex nasal anatomical structures. A combination of all of these drugs were used with high dose, which may lead to undue complications after opeartion.²

Therefore, the standard practice for hemostatic purpose during nose surgery is routinely using local infiltration of saline- adrenaline as a way to improve the field of visibility. ³

It was found that cooling has a promising effect in different vascular structure at all levels and also able to cause a reflex on vasoconstriction. The reason of this was unclear but there were some proposals were suggested for illustration. One proposal is that vasoconstriction happens because the cooling lead to raise the firing of sympathetic nerve fibers within the cooled tissues. Different opinion concluded that vasoconstriction occurs by direct tissues cooling influencing the blood vessels themselves but, it is found that the blood flow in the cooled tissues (at 18°C) was reduced by vasoconstriction. As the cooling continues, at about (2°C), vasodilation happens in a physiological attempt to raise the blood flow that prevents damage of the tissue. This is called a Hunting Reaction phenomenon. ⁴

TA (Tranexamic Acid) is an anti-fibrinolytic agent that blocks the lysine binding sites on plasminogen, leading to stop the reaction of plasminogen and the heavy chain of plasmin with lysine remains on the surface of fibrin. Some studies have concluded that there was a good performance of topical and oral forms of TA in performing hemostasis and improving the field of nasal operation. ⁵

PATIENT AND MATERIALS

According to the guidelines of the ethics committee, a clear written agreement was obtained from all cases.

A number of 84 cases were selected with bilateral CRS with/without polyp, both gender, with age ranging from 20 to 60 years, and distributed according to American Society of Anesthesiologists (ASA)class I&II selected from ENT department for functional endoscopic sinus surgery. 

Inclusion criteria: bilateral chronic sinusitis with or without polyps, weight range from 60 to 99 kg, age range from 20 to 60 years.

Exclusion criteria: age out of the range 20-60 years, not oriented with unstable mentality, cardiac or coagulation diseases, pregnant or breast-feeding women and unilateral or previous FESS surgery.

       Patients were categorized into 3 groups, each one of them consists of 28 cases, during the FESS operation group A used topical tranexamic acid (1gm diluted in 100 mL normal saline) group B used saline-adrenaline (1:20000) and group C used cold saline (2 - 8°C) for irrigation and packing.

Preoperatively: the patients have a systemic examination and routine blood evaluation including CBC (Complete Blood Count), PT/PTT (Prothrombin / Partial Thromboplastin Time), serum creatinine, urea; RBC (random blood sugar), SGOT, SGPT and ECG were done.

Intraoperatively:All patients were treated by fentanyl of concentration (2 mg/ kg) and midazolam of concentration (0.02 mg/ kg). After supervision, anesthesia induction with propofol of concentration (2 mg/ kg), lidocaine of concentration (1.5 mg/ kg) and atracurium of concentration (0.5 mg/kg) was given earlier intubation. At the start of the surgery, nasopharyngeal pack with gauze was employed to block blood from reaching the pharynx and topical nasal packs inserted for 4 minutes before start the operation. Isoflurane inhalation and muscle relaxant have an effect on preserving anesthesia. Mean arterial pressure (MAP) was kept in the range (60 -70) torr using nitroglycerine infusion (5–10) μg/ kg/min.

Postoperatively, muscle relaxant was inverted using neostigmine of concentration (0.05 mg/ kg) and atropine of concentration (0.02 mg/ kg). Hemodynamic factors like MAP and beat rate of the heart were monitored every 10 minutes. Blood wastage within the surgery was estimated from the blood-soaked mops, gauze pieces, and in suction bottles after discounting of the irrigation fluid. The operation area was cleared of blood and then graded by the surgeon. The surgeon follows the (wait &watch) way with the help of endoscopy during and at the termination of the operation to find fresh bleeding. Blinded surgeon’s satisfaction about reduction of bleeding intraoperatively was estimated and the significant was evaluated.

RESULTS

The current study was demonstrated on 84 cases of E.N.T operations. According to age there were no statistically significant changes among the studied groups (table 2).

According to sex, no statistically significant change was found among the studied groups (table 3).

There was a statistically significant elevation in the average arterial blood pressure in the first 10 miuntes after insert topical packs and corrected by hypotensive drugs between groups II in comparison with groups I and III while there was no statistically significant change among group I and III (table 4).

Regarding the bleeding score, there was a statistical decrease in it for groups II in comparison with group I & III while there was no statistically significant change among group I & III (table 5).

According to amount of blood loss during operation there was a statistical decrease in the amount of intraoperative blood lost in group II in comparison with group I & III. While there was no significant difference change among group I & III (table 6).

According to surgeon satisfaction, there was a statistically significant increase in the percentage of satisfied surgeons in group II in comparison with those of group I & III while there was no statistically significant change between group I & III regarding surgeon satisfaction (table 7).

According to duration of operation there was a statistical decrease in operation time in group II versus group I & III while there was no significant change in operation time when comparing group, I & III (table 8).

Table 1: Grading scale for scoring of surgical field bleeding Grades Assessment

Table 2: Age distribution in groups of the study

Table 3: Sex distribution in groups of the study

Table 4:   Mean arterial blood pressure(torr) in groups of the study

Table 5: The score of bleeding in groups of the study

Table 6:   Intraoperative blood loss (ml) in groups of the study

Table 7: Surgeon satisfaction in groups of the study

Table 8: The operative time (min.) in groups of the study.