*Lechosław P. Chmielik1, Marcin Rawicz2, Mieczysław Chmielik1
Problems of operational bleeding during functional endoscopic operations in child
1Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
2Anaesthesia and Intensive Therapy Department, Medical University, Warsaw, Poland
Head of Department: Marcin Rawicz, MD
Summary
Summary
Operational bleeding during the FESS operation can be a serious problem, both because of the volume of blood lost (especially in children), and the fact that it can make the operation impossible. In reducing bleeding, an important element is the correct preparation of the patient for the operation, seeking any blood clotting complications, and correct haematological preparation of patients with these complications. Thanks to the development of operation techniques, we have the possibility of removing the chosen changes in the area of the nasal sinuses. Functional endoscopic methods of operating on the nasal sinuses have been described by Wigand and by Stammberger, These methods are based on the use of 0, 30, 70 and 120 endoscopes, and the correct set of forceps. A rinsing-suction set is an especially useful device when operating on the sinuses in children, and a micro-debrider with a set of endings at the correct angle allows the surgeon to reach the chosen area.
In FESS, intra-operational and post-operational bleeding can be a serious problem, especially with heavy bleeding or bleeding in to the orbit.
A very significant factor is the overall anaesthetic care. The anaesthetist must examine and qualify the patient with great care, and may do so in conjunction with doctors from other specialities.
All the patients were counted into 1 and 2 in ASA. Most children were not pre-medicated, but put straight on to general anaesthesia. Fifteen to twenty minutes before the end of the operation, 10 ug/Kg of morphine was given under the skin. The addition of propofol and remifentanil was stopped during the period of anterior nasal packing.
In the case of bleeding during a FESS operation, haemostasis must be achieved by physical means in addition to pharmacological.
The described method of anaesthesia seems to be optimal because of the minimising of pressure changes, helping to ensure a bloodless operating area, and comfort of the surgeon.
INTRODUCTION
Operational bleeding during the FESS operation can be a serious problem, both because of the volume of blood lost (especially in children), and the fact that it can make the operation impossible. Because of this, the authors present their own experience in controlling mid- and post-operation bleeding in children during or after the FESS operation.
Thanks to the development of operation techniques, we have the possibility of removing the chosen changes in the area of the nasal sinuses. Functional endoscopic methods of operating on the nasal sinuses have been described by Wigand and by Stammberger. These methods are based on the use of 0, 30, 70 and 120 endoscopes, and the correct set of forceps. A rinsing-suction set is an especially useful device when operating on the sinuses in children, and a microdebrider with a set of endings at the correct angle allows the surgeon to reach the chosen area.
The correct equipment significantly eases the progress of the operation in a small patient, but it does not solve all the problems. An endoscopic operation on the sinuses not only has a different specification for the anatomy of the sinuses, but also due to the different conditions there are more blood vessels in the nose of a child than in an adult. Mid-operational bleeding during FESS can cause insufficient removal of pathology or be the reason for stopping the operation. Because of this, it is important to have the possibility of a good mid-operational haemostasia. In reducing bleeding, an important element is the correct preparation of the patient for the operation, seeking any blood clotting complications, and correct haematological preparation of patients with these complications. When qualifying a patient for the operation, we must look very carefully for fresh infections of the upper airways, and for any sign of intensification of the long inflammatory process. In the case of either of these, surgery should be delayed for some time.
A very significant factor is the overall anaesthetic care. The anaesthetist must examine and qualify the patient with great care, and may do so in conjunction with doctors from other specialities.
All the patients were counted into 1 and 2 in ASA. Most children were not pre-medicated, but put straight a on to general anaesthesia. If this was not possible, or if the children were very frightened, they were given midazolam orally, as 0.5 mg/Kg, or if the body weight was over 20 Kg, a 7.5 mg tablet. All anaesthetic procedures were carried out intravenously. The children were started on propofol 3 mg/Kg, 0.1 mg/Kg vecuronium, and 1 ug/Kg remifentanil.
After intubation, lung ventilation was started with a mixture of oxygen and air (FiO2 0.35), with propofol at a rate of 6-10 mg/Kg/hr, depending on age (younger patients had bigger doses) and remifentanil at 0.5 ug/Kg/min. In cases of pain reaction, characterized by a faster pulse rate and/or a rise in arterial pressure, 1 ug/Kg of remifentanil was given and additionally, vecuronium at 30 ug/Kg of given 30 minutes. Fifteen to twenty minutes before the end of the operation, 10 ug/Kg of morphine was given under the skin. The addition of propofol and remifentanil was stopped during the period of anterior nasal packing. The nerve/muscle block was cancelled if needed by giving neostygmine (0.25 mg/Kg) after anaesthetizing the patient.
It is necessary to shrink the nasal linings first (with e.g. xylometazoline), one nostril at a time. In some departments local anaesthesia is given, but in our cases it didn´t have much influence on the bleeding. Use of the correct set of suction allows correct cleaning of the operating area. In our clinic this is done through the unaffected nostril to a nose-throat canula connected with a suction tube, this having a rigid nose ending and a microshav.
In the case of excessive bleeding we use a sucking-rinsing set, and an additional suction tube with an angled canula. We stop mucous bleeding, by the use of monopole coagulation in an argon shield. When bleeding is heavy we use a tampon made from setons for a period of 5-10 minutes, or carry on the operation in a different area. In the case of arterial bleeding e.g. from the ethmoidal arteries, we use coagulation and a press made from a tampon.
In the post-operative period, in cases of arterial bleeding, and during the operation, it is very important to observe the eyeballs, to avoid missing a haematoma of the orbit. In cases where this cannot be stopped, it is necessary to tampon the nostril, and then carry out embolisation or tying of the supplying vessel(s).
In cases of heavy bleeding from the maxillary sinus, a tampon filling this must be used. After operations on the sinuses it is routine to use a tampon made from setons, removing this on the day after the operation. In children where intra-operative bleeding has been very heavy, we use exacyl and cyclonamine in the post-operative period.
For endoscopic operations of the sinuses to be successful, it is important to ensure that the surgeon and the patient are as comfortable as possible. Endoscopic operations on the sinuses require a special stabilization of the blood system, keeping a low blood pressure, because of the need for a maximally dry operating area. Local analgesia can be used with adults (1), but is not possible with children, because of them being frightened, the inability to remain perfectly still, and the small but harassing pain. Before giving intravenous anaesthesia using remifentanil, this operating was done in our staff, in controlled hypotension, with sodium nitroprusside administration (2). But this is associated with cannulation of the arteries, significant arterial pressure changes, and occasional substandard condition in the operating area. Using this technique was not possible with all patients, especially those with cardiac problems.
Total intravenous anaesthesia (TIVA) has been used for many years with good results in children, using propofol and a short-period opioid such as fentanyl, alfentanil, or remifentanil (3). The main use are in operations on the inner ear, substantial intestinal operations, and spinal operations (4). Recently, most authors have preferred remifentanil, because of its safety, practically no possibility of overdosing, and significant stabilization of the circulation, with a tendency to reduce blood pressure (5). Remifentanil is a synthetic opioid cure, a clean agonist of the ?-1 receptors and is quickly hydrolysed in non-specific lymph esterases. The clearance of remifentanil does not depend on the dose, and is five times faster than alfentanil, an older, ultra-short period anaesthetic opioid (3). It is important to note that the drug action practically stops working in a few minutes after administration, more quickly in children than in adults (6), and so a different analgesic should be given before stopping use.
The doses of propofol quoted are quite high, which is open to discussion, due to opinions concerning toxic reaction after a longer period of use, which may exceed the maximum dose limit for adults (4 mg/Kg/hr). The faster metabolism of propofol in children, and the shorter effective time, makes the doses important. The short duration of endoscopic sinus operations does not cause any danger (8).
In our clinical experience of 15 years, and after approximately 60 endoscopic functional sinus operations per year, we have not had a case in which we have had to stop an operation. In one case, the child required a blood transfusion.
CONCLUSIONS
In FESS, intra-operational and post-operational bleeding can be serious problem, especially with heavy bleeding or bleeding into the orbit.
In the case of bleeding during an FESS operation, haemostasis must be achieved by physical means in addition to pharmacological.
The described method of anaesthesia seems to be optimal because of the minimisation of pressure changes, helping to ensure a bloodless operating area, and comfort of the surgeon.
Piśmiennictwo
1. Danielsen A, et al.: Anaesthesia in endoscopic sinus surgery. Eur. Arch. Otorhinolaryngol., 2003; 260(9): 481-486.2. Risavi R, et al.: Our experience with FESS in children. Int. J. Pediatr. Otorhinolaryngol., 1998; 15; 43(3): 271-275. 3. Eyres R: Update on TIVA. Paediatr Anaesth 2004; 14(5): 374-379.4. Hill M, et al.: Paediatric total intravenous anaesthetic use: a nationwide study. Paediatr. Anaesth., 2007;17(6):606.5. Degoute CS, et al.: Remifentanil induces consistent and sustained controlled hypotension in children during middle ear surgery. Can. J. Anaesth., 2003; 50(3): 270-276. 6. Roulleau P, et al.: Remifentanil infusion for cleft palate surgery in young infants. Paediatr. Anaesth., 2003; 13(8): 701-707. 7. Rigby-Jones A, et al.: Paediatric propofol pharmacokinetics: a multicentre study. Paediatr. Anaesth., 2007; 17(6): 610.8. Wysowski DK, Pollock ML.: Reports of death with use of propofol Diprivan) for nonprocedural (long-term) sedation and literature review. Anesthesiology. 2006; 105(5): 1047-1051.
