Control of Bleeding in Endoscopic Skull Base Surgery: Current Concepts to Improve Hemostasis

Table 2

Comparison of clinical trials study between inhalation-and intravenous-based techniques in controlled hypotension during endoscopic endonasal surgery.

Author (year)	Technique		Mean arterial pressure	Heart rate (beat/min)	Intraoperative bleeding	Surgical field score	Complication	Comment
Ankichetty et al. [23] (2011)	Inhalation based:	Iso/Fen	Mean time to achieve target MAP: 18±8 min	No significant difference	No significant difference	No significant difference; (𝑃=0.34)	No intra- and postoperative complications	No significant difference in sedation score, pain, nausea, vomiting, and hospital stay
	Intravenous based:	Pro/Fen	Mean time to achieve target MAP: 16±7 min
Yoo et al. [24] (2010)	Inhalation based:	Sevo/Rem	Initial: 91.1±12.9; 30 min: 67.1±5.7; 60 min: 67.2±4.8	88.0±21.8; 77.1±10.8; 74.6±10.7	N/A	2.21 (1–3)	N/A	No significant differences of MAP (𝑃>0.05), HR (𝑃>0.05), and surgical grade score (𝑃=0.83) among three groups
		Des/Rem	Initial: 92.2±11.8; 30 min: 67.4±6.0; 60 min: 67.3±4.6	94.4±20.0; 78.2±10.1; 73.9±12.1	N/A	2.07 (1–3)	N/A
	Intravenous based:	Pro/Rem	Initial: 91.3±11.3; 30 min: 69.3±6.7; 60 min: 69.2±5.2	79.1±13.2; 77.1±15.7; 74.9±11.8	N/A	2.06 (1–3)	N/A
Ragab and Hassanin [25] (2010)	Inhalation based:	Induction: Pro/Fen; Maintenance: Iso/Fen/Emo	Mean time to achieve target MAP: 3±1.4 min	Decreased by; 20%±5%	Mean 120±43 mL	VAS 4.2±1.4; Six-point scale 1.6±0.6	No serious adverse effects in both groups	(i) Significant difference in time to achieve target MAP and decreased HR (𝑃<0.05); (ii) Better visualization and bloodless in intravenous-based group (VAS; 𝑃=0.005; Six-point scale; 𝑃=0.02)
	Intravenous based:	Induction: Pro; Maintenance: Pro/Rem	Mean time to achieve target MAP: 4±1 min	Decreased by; 24%±5%	Mean 100±39 mL	VAS 3±1.2; Six-point scale 1.2±0.4
Ahn et al. [26] (2008)	Inhalation based:	Sevo/Rem	N/A	N/A	135 mL/h (in patient with high LM score)	Numeric rating scales: 5.8±2.3; (in patient with high LM score)	N/A	Significant better visualization in the high LM score patients in the intravenous based-group (blood loss 𝑃<0.01; numeric rating scale 𝑃<0.05); however, no significant difference in patient low LM score
	Intravenous based:	Pro/Rem	N/A	N/A	19 mL/h; (in patient with high LM score)	Numeric rating scales: 2.3±1.0; (in patient with high LM score)	N/A
Beule et al. [27] (2007)	Inhalation based:	Sevo/Fen	70±9.3	64.6±6.6	Mean; 4.1±2.1 mL/min; VAS of bleeding impending surgical progress 3.7 (1.9–8.4)	VAS 4.6; (3.0–7.8)	More impairment of platelet function in intravenous-based group (𝑃=0.0006)	No significant difference in all parameters (𝑃>0.05); Although test of platelet function showed more impairment in intravenous-based group, but it is not relevant to clinical practice
	Intravenous based:	Pro/Fen	71.5±8.63	64.6±7.3	Mean 3.8±1.6 mL/min; VAS of bleeding impending surgical progress 4.3 (2.4–7.8)	VAS 4.9; (3.9−7.5)
Wormald et al. [28] (2005)	Inhalation based:	Sevo/Fen	71.65±1.62	57.81±1.69	N/A	2.8±0.12	N/A	No significant differences in HR (𝑃=0.05), but significant difference in MAP (𝑃=0.045) and better surgical grade score in intravenous-based group (𝑃<0.001)
	Intravenous based:	Pro/Rem	67.43±1.62	62.34±1.69	N/A	2.21±0.11	N/A
Sivaci et al. [29] (2004)	Inhalation based:	Induction: Pro; Maintenance: Sevo/Fen	Initial: 83±5.7; 15 min: 83±3.7; 30 min: 79±4.0; 45 min: 82±6.7; 60 min: 80±6.3; End: 80±4.7	76±5.3; 79±4.3; 71±3.3; 78±2.7; 79±5.0; 73±5.3	Mean; 296.9±97.8 mL	N/A	N/A	(i) Significant lower blood loss in intravenous-based group (𝑃<0.01); (ii) No significant difference in MAP and HR (𝑃>0.05)
	Intravenous based:	Induction: Pro; Maintenance: Pro/Fen	Initial: 81±3.7; 15 min: 84±5.7; 30 min: 82±4.7; 45 min: 83±5.7; 60 min: 84±8.7; End: 85±4.7	65±3.7; 66±3.3; 67±4.1; 75±3.3; 76±4.0; 72±3.3	Mean; 128.1±37.3 mL	N/A	N/A
Eberhart et al. [30] (2003)	Inhalation based:	Iso/Alf	67 (63–72) mmHg	72 (66–83)	Estimated blood loss; 170 (100–270) mL	VAS 4.9; (3.5–4.7); Six-point scale 2 (2–4)	N/A	Significant decreased HR and better visualization in the intravenous based group (𝑃≤0.001); however, these results should be carefully interpreted due to using different opioids.
	Intravenous based:	Pro/Rem	65 (61–69) mmHg	55 (51–64)	Estimated blood loss; 100 (50–240) mL	VAS 2.8; (2.0–3.4); Six-point scale 1 (1-2)	N/A

Values are presented as mean ± SD or mean/medians (range); Iso: isoflurane; Sevo: sevoflurane; Des: desflurane; Pro: propofol; Fen: fentanyl; Rem: remifentanil; Esm: esmolol; Alf: alfentanil; VAS: visual analogue score; MAP: mean arterial pressure; HR: heart rate; LM: Lund-Mackay score; N/A: not available; P: 𝑃value.