ISRN SurgeryVolume 2013 (2013), Article ID 191543, 11 pageshttp://dx.doi.org/10.1155/2013/191543

Review Article

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

Cattleya Thongrong,1,2 Pornthep Kasemsiri,3,4 Ricardo L. Carrau,³ and Sergio D. Bergese1,5

¹Department of Anesthesiology, Wexner Medical Center at The Ohio State University, Columbus, OH, USA²Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine, 123 Mitraparp Highways, Khon Kaen University, Khon Kaen 40002, Thailand³Department of Otolaryngology, Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA⁴Department of Otorhinolaryngology, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand⁵Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA

Received 24 March 2013; Accepted 27 May 2013

Academic Editors: C. C. Chuang and A. Polydorou

Copyright © 2013 Cattleya Thongrong et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Hemostasis is critical for adequate anatomical visualization during endoscopic endonasal skull base surgery. Reduction of intraoperative bleeding should be considered during the treatment planning and continued throughout the perioperative period. Preoperative preparations include the optimization of comorbidities and cessation of drugs that may inhibit coagulation. Intraoperative considerations comprise anesthetic and surgical aspects. Controlled hypotension is the main anesthetic technique to reduce bleeding; however, there is controversy regarding its effectiveness; what the appropriate mean arterial pressure is and how to maintain it. In extradural cases, we advocate a mean arterial pressure of 65–70 mm Hg to reduce bleeding while preventing ischemic complications. For dealing intradural lesion, controlled hypotension should be cautious. We do not advocate a marked blood pressure reduction, as this often affects the perfusion of neural structures. Further reduction could lead to stroke or loss of cranial nerve function. From the surgical perspective, there are novel technologies and techniques that reduce bleeding, thus, improving the visualization of the surgical field.

1. Introduction

Endoscopic surgery is a minimally invasive technique that has found a niche in all surgical fields. Endoscopic endonasal surgery ranges from basic and relatively straightforward procedures (e.g., endoscopic septoplasty, endoscopic turbinoplasty, and functional endoscopic sinus surgery) to advanced surgery (e.g., endoscopic orbital and/or optic nerve decompression, endoscopic dacryocystorhinostomy, and endoscopic endonasal skull base approaches). Its advantages are obviating external scars, reducing damage to normal tissue and bone, and shortening recovery time and length of hospital stay. However, intraoperative bleeding presents a larger obstacle to endoscopic visualization. Blood obscures the anatomy of the surgical field and dirties the endoscope lens causing greater difficulty with visualization. This situation increases the risk of complications, including brain injury, orbital or optic nerve injury, and catastrophic bleeding from major vessels (e.g., internal carotid artery).

We advocate careful consideration of all factors regarding the control of bleeding throughout the entire perioperative period. Preoperative preparations include the optimization of co-morbidities and cessation of drugs that may increase the tendency for bleeding. Intraoperative considerations comprise anesthetic and surgical aspects. Some anesthetic aspects are controversial including the use of controlled hypotension and whether inhalation-based or intravenous-based technique is most effective in reducing intraoperative bleeding. Additionally, novel surgical technologies, materials, and techniques help to improve the quality of surgical visualization. This paper aims to review controversies and current concepts regarding how to minimize intraoperative bleeding in endoscopic endonasal skull base surgery. We classify endoscopic endonasal skull base surgery into extradural and intradural surgery. The principles of extradural surgery are similar to those of the endoscopic sinus surgery.

2. Preoperative Evaluation

2.1. Dealing with Bleeding Disorders

Coagulation comprises three major components: vascular compartment, platelets, and coagulation factors [1]. Inherited and acquired coagulopathies can arise from any of these components. Vascular problems include hereditary hemorrhagic telangiectasia (e.g., Osler-Weber-Rendu syndrome), which is an inherited disorder commonly occurring on the face and nose. Platelet-related bleeding disorders can occur by a low number of available platelets (thrombocytopenia), by dysfunction of their aggregation, or by a combination of the two (e.g. idiopathic thrombocytopenic purpura, renal failure, liver failure, medications such as aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], and dietary supplements such as vitamin E, fish oil, Echinacea, Aloe, and garlic extract). Disorders related to deficiencies of the coagulation factors include hemophilia, von Willebrand’s disease, and medications such as warfarin and heparin (Table 1).

Table 1: Various causes of bleeding tendency.

Components
Causes

Vascular
Inherited Disorder

    (i) Hereditary hemorrhagic telangiectasia

    (ii) Ehlers-Danlos syndrome

Autoimmune disorder

     Allergic purpura

Reduce the integrity of the blood vessel wall

    (i) Advanced age

    (ii) Prolonged steroid use

    (iii) Vitamin C deficiency

Platelets
Chronic diseases

    (i) Kidney failure

    (ii) Liver disease: hepatitis, cirrhosis, and liver failure

    (iii) Splenic sequestration

    (iv) Hematologic malignancy: leukemia, lymphoma, and multiple myeloma

    (v) Bone marrow diseases

    (vi) Human immunodeficiency virus/acquired immunodeficiency syndrome

    (vii) Rare autosomal recessive disorders (Glanzmann’s thrombasthenia and Bernard-Soulier syndrome)

Autoimmune diseases

    (i) Idiopathic thrombocytopenic purpura

    (ii) Systemic lupus erythematosus

Medications

    (i) Antiplatelet: aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs)

    (ii) Antibiotic including penicillin, quinine, and sulfa

Dietary supplements

     Vitamin E, fish oil, Echinacea, Aloe, Ginkgo, Ginseng, and garlic extract

Coagulation factors
Inherited disorder

    (i) von Willebrand’s disease

    (ii) Hemophilia

    (iii) Other inherited clotting factor deficiencies (factors II, V, VII, X, and XII)

Medications

    (i) Warfarin (coumadin), heparin

    (ii) Chemotherapies

    (iii) Vitamin K deficiency

Other disorders

    (i) Autoimmune disorders

    (ii) Disseminated intravascular coagulation (also results in thrombocytopenia)

    (iii) Liver disease

Anamnesis should include symptoms specific to bleeding, such as a history of unexplained bleeding associated with surgical procedures, trauma, or menses, unexplained bruises or hematomas family history suggesting bleeding tendency and use of prescribed and over-the-counter medications and supplements. However, patients may be asymptomatic; therefore, physical examination should investigate the presence of petechiae, ecchymotic lesions, telangiectasias, hepato-splenomegaly, and hemarthrosis of the joints. Furthermore, preoperative laboratory evaluations, including platelet count, prothrombin time, and activated prothrombrin time, are helpful to confirm a suspected diagnosis and for the preoperative planning. However, systematic screening is inefficient and should be confined to patients at high risk [2]. Bleeding time is purported to evaluate platelet function, but it is associated with poor accuracy due to operator technique and patient variation (e.g., skin thickness, skin temperature, and vascular pattern) [3, 4]. Therefore, this test is not recommended [5].

Identification and preoperative management of patients who are receiving anticoagulants and/or antiplatelet medication cannot be emphasized. Current recommendations include holding both aspirin and clopidogrel for 7–10 days prior to surgery to allow new platelets to replace those that are dysfunctional [6]. Warfarin is usually discontinued 5 days prior to surgery, which is an adequate time span to reconstitute the coagulation factors; however, this depends on the condition of each patient. Recent studies demonstrated that most procedures can be done if the international normalized ratio (INR) is less than 1.5 [6, 7]. Another study demonstrated that most patients had an INR of less than 1.5 after discontinuing warfarin for 5 days [8]. If the patient is at moderate to high risk for thromboembolic phenomena, the recommendation is to use low-molecular-weight heparin (LMWH) to “bridge” the effect of the two anticoagulant therapies. One should start the LMWH three days before surgery or two days after discontinuing warfarin, stopping it approximately 24 hours prior to surgery [9].

2.2. Preoperative Embolization

Vascular tumors present a surgical challenge. Preoperative embolization of vascular tumors reduces bleeding, and the need for transfusion, as well as improves the visualization of intraoperative surgical field [10]. Embolization should be performed 24 to 72 hours before surgery to allow adequate thrombosis while avoiding recanalization and/or formation of collateral blood supply. Embolic agents include polyvinyl alcohol, transacryl microspheres, liquid n-butylcyanoacrylate (n-BCA), ethyl-vinyl alcohol copolymer (EVOH), and microcoils [11]. These agents occlude the main arterial feeder and may advance further downstream to occlude the blood supply at the capillary level. Traditional transarterial embolization is the most common technique; however, reports of alternative direct tumor puncture show some promise claiming greater efficacy. A claim of greater safety, seemingly due to lower risk for the migration of agents through nontarget arterial vessels, should be taken in context. An initial experience with this technique was fraught with catastrophic complications including blindness, stroke, and death [12, 13].

2.3. Preoperative Corticosteroid Administrations

Inflammatory mediators produce diffuse vasodilatation, transudation, and edema in the sinonasal mucosa. Thus, preoperative administration of steroids is beneficial due to their anti-inflammatory and antiedematous effects. These advantages include having a wider nasal corridor, thus, improving visibility of the surgical field. A recent study demonstrated that corticosteroids significantly improved the hemostasis within the operative field () and shortened the surgery time () in patients with chronic polypoid rhinosinusitis [14].

3. Anesthesia Considerations

3.1. Controlled Hypotension

Controlled hypotension technique includes various modalities associated with different potency and adverse effects. Its safety is dependent on a thorough knowledge about the mechanism of action for each modality, adequate monitoring of the patient, and choosing the appropriate modality with consideration to history of drug allergies and co-morbidities.

3.1.1. Patient’s Positioning

Positioning is important for the safety of the patient and to facilitate the surgeon’s ergonomic approach. Reverse Trendelenburg or anti-Trendelenburg position is a common surgical position in which the head is up and feet are down. Head elevation reduces mean arterial pressure in the elevated part by about 2 mm Hg for each 2.5 cm above the cardiac level [15]. A reverse Trendelenburg position is used in numerous surgical procedures and presents multiple benefits. It reduces venous return from the lower extremities, therefore, reducing total blood loss (), blood loss per minute () and improving hemostasis of the surgical field () when compared with the supine position [16]. Sudden shift in blood pressure is a serious complication of the reverse Trendelenburg position; the patient must be tilted in and out slowly to avoid this complication.

3.1.2. Using a Laryngeal Mask Airway

The laryngeal mask airway (LMA) is a supraglottic device that is associated with less respiratory and cardiovascular reflex responses due to reduced stimulation of the larynx as compared to endotracheal intubation. Moreover, LMA facilitates controlled hypotension. One study suggested that LMA is more effective than endotracheal intubation in regard to rapid onset to achieve a target systolic arterial blood pressure (), less blood loss ( mL; ), and use of lower doses of remifentanil (). Visibility of the operative field improved in the first 15 minutes () [17].

3.1.3. Technique of Ventilation

Ventilation with normocapnia or mild hypocapnia has been advocated to minimize bleeding and optimize the surgical field during endoscopic endonasal skull base surgery. However, a recent study demonstrated no significant difference in the surgical conditions or blood loss among hypocapnia (end tidal carbon dioxide (ETCO₂)   mm Hg), normocapnia (ETCO₂   mm Hg), or hypercapnia (ETCO₂   mm Hg) in patients under propofol plus remifentanil anesthesia when heart rate and blood pressure were controlled [18]. Although this study showed that hypercapnia does not yield significantly different intraoperative bleeding, it is known that high hypercapnia produces vasodilatation, increasing cerebral blood flow and brain fullness. These conditions are detrimental to endoscopic approaches to the skull base.

Furthermore, mode of ventilation is important to control hypotension. Traditional intermittent positive pressure ventilation (IPPV) has a troublesome hemodynamic effect due to high intrathoracic pressures and reduced venous return to the heart [19]. This result provides decreased blood circulation from the upper part of the body; therefore, it is a high risk for intraoperative bleeding. Conversely, high-frequency jet ventilation (HFJV) is small volume ventilation that provides adequate gas exchange at a lower pressure than intermittent positive pressure ventilation. A recent study compared efficacy between intermittent positive pressure ventilation and high frequency jet ventilation demonstrating that the total mean blood loss in the high-frequency jet ventilation group (170 mL) was significantly lower than the intermittent positive pressure ventilation group (318.8 mL; ). The quality of the surgical field in high-frequency jet ventilation was significantly better than the intermittent positive pressure ventilation group () [20]. However, high-frequency jet ventilation is not practical for skull base surgery.

3.1.4. Medications for Controlled Hypotension

(1) Inhalation Anesthetics. Controlled hypotension with inhalation agents (e.g., isoflurane, sevoflurane, and desflurane) decreases arterial blood pressure through peripheral vasodilatation due to blockage of -adrenoceptors. However, higher concentrations can increase cerebral blood flow, increase the intracranial pressure, and deteriorate cerebral autoregulation. Therefore, a combination of inhalation anesthetics with other drugs has been advocated to help reduce the concentration and adverse effects of each agent [21]. Combination of an inhalation agent <1 minimum alveolar concentration (MAC) with other adjuvant drugs prevents adverse events including rebound hypertension, reflex tachycardia, and distressed myocardial function.

(2) Intravenous Anesthesia. Intravenous anesthesia has been introduced for analgesia, hypnosis, sedation, and general anesthesia (induction phase or maintenance phases). Agents currently used for general anesthesia include propofol and opioids.

Propofol has a depressant effect on the central nervous system via direct activation of the gamma-aminobutyric acid (GABA [A]) receptors, inhibition of the n-methyl d-aspartate (NMDA) receptor, and modulation of the calcium influx through slow calcium ion channels. Propofol has rapid onset of action and recovery time with a dose-related effect. However, dose-dependent hypotension is its most common complication, especially high-dose infusions that are associated with propofol infusion syndrome. This condition is a potentially fatal complication with severe metabolic acidosis and circulatory collapse [22].

Traditional opioids have been used as analgesic drugs and they bring some hypotensive effect. However, this effect is difficult to use for controlled hypotension due to their long half-life. Remifentanil is a new potent ultrashort-acting opioid agonist with a short half-life; therefore, its action has a rapid onset and offset. It offers a reduction in sympathetic nervous system tone and dose-dependent effects, decreasing heart rate and blood pressure.

In general anesthesia, opioids are often used as an adjunct of intravenous-based technique (opioids combined with antihypertensive drugs or propofol) or inhalation-based technique (opioids combined with an inhalation agent). There is controversy regarding whether intravenous- or inhalation-based technique is more efficient for controlled hypotension (Table 2).

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:  min
No significant difference
No significant difference
No significant difference ()
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:  min

Yoo et al. [24] (2010)
Inhalation based:
Sevo/Rem
Initial:   30 min:   60 min:   

N/A
2.21 (1–3)
N/A
No significant differences of MAP (), HR (), and surgical grade score () among three groups

Des/Rem     
Initial:   30 min:   60 min:   

N/A
2.07 (1–3)
N/A

Intravenous based:
Pro/Rem     
Initial:   30 min:   60 min:

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:  min
Decreased by
Mean  mL
VAS   Six-point scale
No serious adverse effects in both groups
(i) Significant difference in time to achieve target MAP and decreased HR () (ii) Better visualization and bloodless in intravenous-based group (VAS; ; Six-point scale; )

Intravenous based:
Induction: ProMaintenance: Pro/Rem
Mean time to achieve target MAP:  min
Decreased by
Mean  mL
VAS   Six-point scale

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:   (in patient with high LM score)
N/A
Significant better visualization in the high LM score patients in the intravenous based-group (blood loss ; numeric rating scale ); 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:   (in patient with high LM score)
N/A

Beule et al. [27] (2007)
Inhalation based:
Sevo/Fen

Mean  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 ()
No significant difference in all parameters ()Although test of platelet function showed more impairment in intravenous-based group, but it is not relevant to clinical practice

Intravenous based:
Pro/Fen

Mean  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

    N/A

    N/A
No significant differences in HR (), but significant difference in MAP () and better surgical grade score in intravenous-based group ()

Intravenous based:     
Pro/Rem     

N/A     

N/A     

Sivaci et al. [29] (2004)
Inhalation based:
Induction: Pro Maintenance: Sevo/Fen
Initial:   15 min:   30 min:   45 min:   60 min:     End:   

Mean  mL
N/A
N/A
(i) Significant lower blood loss in intravenous-based group () (ii) No significant difference in MAP and HR ()

Intravenous based:
Induction: Pro Maintenance: Pro/Fen
 Initial:   15 min:   30 min:   45 min:   60 min:   End:

Mean  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 ; 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: value.

(3) Antihypertensive Drugs. Antihypertensive drugs have numerous classifications and mechanisms of action to control blood pressure [31]. Controversy exists regarding which is the ideal mean arterial pressure (MAP) in controlled hypotension to reduce bleeding and the correlation between blood loss and MAP (Table 3). MAP at a very low level did not correlate with decreased intraoperative blood loss. However, severe hypotension may further reduced blood supply to vital organs.

Table 3: Review of controlled hypotension series in endoscopic endonasal surgery.

Author (Year)
Target mean arterial pressure
Grading quality of surgical field
Blood loss
Comment

Boezaart et al. [32] (1995)
 >65 mmHg 60–64 mmHg 55–59 mmHg 50–54 mmHg
In SNP group*        
In Esm group*       
N/A
The optimum surgical conditions were provided with minimum Esm-induced hypotension (MAP > 65 mmHg); conversely, SNP induced hypotension (MAP 50–54 mmHg)

Jacobi et al. [33] (2000)
Moderate controlled hypotension with SNP (65–75 mmHg)

 mL
(i) Total blood loss and grading quality of surgical field did not show significant difference between the groups(ii) There was no correlation between blood loss and MAP

Normotensive situation

 mL

Mengistu et al. [34] (2007)
Controlled hypotension group 50–55 mmHg
N/A
In Esm group  mL In SNP group  mL
Blood loss shows significant difference between the controlled hypotension group and controlled group

Controlled group 70–80 mmHg
N/A
 mL

Using quality scale is proposed by Fromme et al. [35];Using numeric rating scale.

SNP: sodium nitropusside; Esm: esmolol; MAP: mean arterial pressure.

Our recommendation allows to maintain MAP at 65–70 mm Hg, to avoid organ hypoperfusion [24, 36]. Although controlled hypotension seems to be effective in reducing intraoperative bleeding during endoscopic sinus surgery, its use during endoscopic endonasal skull base surgery for intradural lesion is cautious. Impairments of blood flow and oxygen supply to the brain and cranial nerves are major considerations. Hugosson and Högström [37] reported one cerebral hypoxia resulting from the induced deep hypotension led to death in their patients who underwent intracranial surgery.

4. Surgical Considerations

There are many methods to deal with intraoperative bleeding during endoscopic endonasal skull base surgery. Their choice often depends on whether the bleeding is from venous or arterial origin, the size of the vessel, and its location [38] (Table 4).

Table 4: Controlled bleeding techniques in endoscopic endonasal surgery.

Situation
Source
Technique

Artery

    Low-flow bleeding
Small perforating vessels Small arteriole
Bipolar electrocautery

Hemostatic biomaterial agents

    High-flow bleeding
Medium to large artery
Bipolar electrocautery

Clips

Angiography embolization

Venous

    Low-flow bleeding
Bleeding from mucosa, bone
Warm saline irrigation Drilling with diamond bur or applied bone wax with pledget (if presented focal bleeding from bone)

Focal bleeding from venous sinus
Hemostatic biomaterial agents

    High-flow bleeding
Venous sinus bleeding
Hemostatic biomaterial agents

4.1. Topical Vasoconstrictors

The aim of topical vasoconstrictors is to decongest the nasal cavity, thus widening the nasal corridor and minimizing bleeding. Commonly used topical vasoconstrictors include cocaine, epinephrine, phenylephrine, and oxymetazoline. All topical vasoconstrictors have potential adverse effects; therefore, the property of each agent should be considered.

4.2. Local Anesthetic with Vasoconstrictor Injection

Infiltration of a solution of local anesthetic with vasoconstrictor has been introduced to minimize intraoperative bleeding. Hemostatic efficacy of local anesthetic with vasoconstrictor was demonstrated in a study that showed decreased bleeding when lidocaine/epinephrine was injected as compared to injection of placebo () [39]. However, intraoperative estimated blood loss was not significantly different between the anesthetic/epinephrine and control groups () [29, 30]. Furthermore, epinephrine can be injected directly into pterygopalatine fossa (containing the main nasal arterial supply) resulting in significantly better hemostasis () [40].

Arterial pressure and heart rate were affected immediately after injection of lidocaine/epinephrine but were not elevated over the normal range [39]. Another study found no significant difference between bupivacaine/epinephrine and control groups () [41].

4.3. Hemostatic Biomaterials

Low-flow bleeding (capillary, venous, and small arteries) can be inhibited by the topical application of absorbable biomaterials. Recent development of numerous biomaterials has provided new methods for effective intraoperative and postoperative hemostasis, while avoiding complications, such as adhesions, excessive granulation tissue, and crusting.

4.3.1. Topical Antifibrinolytics

Topical antifibrinolytics (i.e., epsilon-aminocaproic acid, tranexamic acid) mechanism of action is competitive binding with the lysine site on plasminogen. This prevents fibrinolysis and stabilizes the blood clot potentially decreasing further bleeding. However, the epsilon-aminocaproic acid was demonstrated to be ineffective in reducing intraoperative bleeding. Conversely, a low dose (100 mg) of tranexamic acid provided hemostasis and improved quality of the surgical field at 2, 4, and 6 minutes after application (). No adverse effects were found after topical application [42].

4.3.2. Gelatin-Thrombin Matrix

Topical matrix sealant consists of human thrombin and gelatin matrix granules of bovine or porcine gelatin. It provides tamponade of injured vessels and rapid clot formation on the tissue surface. Topical gelatin-thrombin matrixes have been modified to allow their use during endoscopic skull base endonasal surgery. It stops bleeding on an average of 2 minutes (range 1–5 minutes) after its application [43]. In addition, a recent study showed that bovine gelatin can effectively stop bleeding from the venous sinus [44, 45]. Some studies reported its adverse effects, including extensive loss of cilia on the epithelium [46], significant increase of adhesion () and of granulation tissue formation () [47, 48].

A prospective one-arm study evaluated the efficacy and complications associated with porcine gelatin. Hemostasis was achieved within 10 minutes after application. No serious adverse effects, such as synechiae, adhesions, or infections, were encountered [49].

4.3.3. Microporous Polysaccharide Hemispheres

Microporous polysaccharide hemispheres are a novel hemostatic biomaterial agent produced from purified potato starch that acts to dehydrate blood and concentrate bloody components, including platelets, red blood cells, and clotting factors. One study demonstrated its hemostatic effect at approximately 30 to 45 seconds and no significant break-through bleeding in 5 minutes after application [50]. Adverse effects, including synechiae formation (), edema (), and infection () were not significantly different from the untreated side [51].

Other biomaterial agents such as oxidized methylcellulose [52], fibrin glue [53], microfibrillar collagen [44], and gelatin sponges [54] can be used to control intraoperative bleeding (e.g., cavernous bleeding). However, there is a lack of scientific evidence comparing the efficacy of these agents.

4.4. Surgical Techniques

4.4.1. Hot Water Irrigation

Hot water irrigation was originally introduced as a treatment of epistaxis [55]. The hemostatic mechanism of hot water irrigation is unclear but may include (1) edema and narrowing of the intranasal lumen that contributes to the compression of the leaking vessel; (2) decreasing the flow and the intraluminal blood pressure due to mucosal vasodilatation; and (3) cleaning of blood coagulates from the nose [56]. Hot water irrigation for epistaxis is simple and effective, less painful, and less traumatic to the nose than nasal packing [57]; therefore, this technique was adopted to reduce intraoperative bleeding. Hot water irrigation with 40°–42° saline reduces diffuse oozing from sinonasal mucosa as well as intracranial bleeding from minor vessels [58]. Another benefit of warm water irrigation is that it allows the cleaning of the endoscopic lens.

4.4.2. Direct Control of Feeding Vessels

Sinonasal and skull base tumors, especially vascular tumors, are challenging for endoscopic skull base surgeons. One principle for the resection of vascular tumors is that of early control of the feeding vessels [58, 59], aiming for devascularization prior to extirpation. Moreover, having an effective instrument for coagulation, such as endoscopic bipolar electrocautery or radiofrequency coagulator, is important. Several studies have reported that coblation-assisted endoscopic resection of juvenile nasopharyngeal angiofibroma is associated with minimal morbidity and low-intraoperative blood loss [60, 61].

4.4.3. Other

Visualization of the surgical field (making the anatomy more discernible) is greatly enhanced by preventing bleeding. Gentle manipulation is required for resection of tumors, especially those that are intradural, where the technique includes sequential subcapsular debulking, extracapsular sharp dissection, and gradual countertraction using meticulous and light suctioning. Avulsion of tumor tissue should be avoided as it may injure adjacent vital structures. In addition, adequate visualization of dissection planes, avoiding blind instrumentation, and avoiding direct or indirect injury from powered instruments (e.g., drills, microdebriders, and ultrasonic aspirators) are fundamental [38]. These techniques yield excellent control of the surgical field and a fluid surgery.

5. Conclusion

Numerous strategies are available to minimize intraoperative bleeding and improve the endoscopic surgical field. Regardless, anesthetic techniques (controlled hypotension, anesthetic agents) and surgical techniques (surgical techniques, topical vasoconstrictor, and hemostatic biomaterials) enhance the ability of each other to control bleeding. Therefore, cooperation between the anesthetic and surgical teams is of utmost importance to apply the appropriate techniques on each patient.

Abbreviations

HFJV: | High-frequency jet ventilation
LMA: | Laryngeal mask airway
NSAIDs: | Nonsteroidal anti-inflammatory drugs
INR: | International normalized ratio
LMWH: | Low-molecular-weight heparin
n-BCA: | n-Butylcyanoacrylate
EVOH: | Ethyl-vinyl alcohol copolymer
ETCO₂: | End tidal carbon dioxide
IPPV: | Intermittent positive pressure ventilation
GABA: | Gamma-aminobutyric acid
NMDA: | N-methyl d-aspartate
ACE: | Angiotensin-converting enzyme
TIVA: | Total intravenous anesthesia
GFR: | Glomerular filtration rate
MAP: | Mean arterial pressure
MAC: | Minimum alveolar concentration
cGMP: | Cyclic guanosine monophosphate.

Disclosure

All authors have no personal financial or institutional interest in any of the materials and devices described in this article. The authors identified no conflict of interests.

References

M. Cobas, “Preoperative assessment of coagulation disorders,” International Anesthesiology Clinics, vol. 39, no. 1, pp. 1–15, 2001.

P. Sié and A. Steib, “Central laboratory and point of care assessment of perioperative hemostasis,” Canadian Journal of Anesthesia, vol. 53, no. 6, supplement, pp. S12–S20, 2006.

R. P. Channing Rodgers and J. Levin, “A critical reappraisal of the bleeding time,” Seminars in Thrombosis and Hemostasis, vol. 16, no. 1, pp. 1–20, 1990.

P. Peterson, T. E. Hayes, C. F. Arkin et al., “The preoperative bleeding time test lacks clinical benefit: College of American Pathologists' and American society of clinical pathologists' position article,” Archives of Surgery, vol. 133, no. 2, pp. 134–139, 1998.

P. Harrison, I. Mackie, A. Mumford et al., “Guidelines for the laboratory investigation of heritable disorders of platelet function,” British Journal of Haematology, vol. 155, no. 1, pp. 30–44, 2011.

J. D. Douketis, P. B. Berger, A. S. Dunn et al., “The perioperative management of antithrombotic therapy: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition),” Chest, vol. 133, no. 6, supplement, pp. 299S–339S, 2008.

M. J. Kovacs, C. Kearon, M. Rodger et al., “Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of warfarin,” Circulation, vol. 110, no. 12, pp. 1658–1663, 2004.

R. H. White, T. McKittrick, R. Hutchinson, and J. Twitchell, “Temporary discontinuation of warfarin therapy: changes in the international normalized ratio,” Annals of Internal Medicine, vol. 122, no. 1, pp. 40–42, 1995.

J. D. Douketis, K. Woods, G. A. Foster, and M. A. Crowther, “Bridging anticoagulation with low-molecular-weight heparin after interruption of warfarin therapy is associated with a residual anticoagulant effect prior to surgery,” Thrombosis and Haemostasis, vol. 94, no. 3, pp. 528–531, 2005.

T. Kanazawa, R. Inoue, Y. Ohta, Y. Watanabe, and Y. Iino, “Maxillary haemangioma successfully resected by endoscopic approach,” Journal of Laryngology and Otology, vol. 123, no. 7, pp. 793–795, 2009.

J. J. Gemmete, S. A. Ansari, J. McHugh, and D. Gandhi, “Embolization of vascular tumors of the head and neck,” Neuroimaging Clinics of North America, vol. 19, no. 2, pp. 181–198, 2009.

A. Casasco, D. Herbreteau, E. Houdart et al., “Devascularization of craniofacial tumors by percutaneous tumor puncture,” The American Journal of Neuroradiology, vol. 15, no. 7, pp. 1233–1239, 1994.

M. S. Elhammady, E. C. Peterson, J. N. Johnson, and M. A. Aziz-Sultan, “Preoperative onyx embolization of vascular head and neck tumors by direct puncture,” World Neurosurgery, vol. 77, no. 5, pp. 725–730, 2012.

A. Sieskiewicz, E. Olszewska, M. Rogowski, and E. Grycz, “Preoperative corticosteroid oral therapy and intraoperative bleeding during functional endoscopic sinus surgery in patients with severe nasal polyposis: a preliminary investigation,” Annals of Otology, Rhinology and Laryngology, vol. 115, no. 7, pp. 490–494, 2006.

P. Simpson, “Perioperative blood loss and its reduction: the role of the anaesthetist,” British Journal of Anaesthesia, vol. 69, no. 5, pp. 498–507, 1992.

M.-T. Ko, K.-C. Chuang, and C.-Y. Su, “Multiple analyses of factors related to intraoperative blood loss and the role of reverse Trendelenburg position in endoscopic sinus surgery,” Laryngoscope, vol. 118, no. 9, pp. 1687–1691, 2008.

A. M. Atef and A. Fawaz, “Comparison of laryngeal mask with endotracheal tube for anesthesia in endoscopic sinus surgery,” The American Journal of Rhinology, vol. 22, no. 6, pp. 653–657, 2008.

V. Nekhendzy, H. J. M. Lemmens, W. C. Vaughan et al., “The effect of deliberate hypercapnia and hypocapnia on intraoperative blood loss and quality of surgical field during functional endoscopic sinus surgery,” Anesthesia and Analgesia, vol. 105, no. 5, pp. 1404–1409, 2007.

J. C. Kubitz, G. I. Kemming, G. Schultheiss et al., “The influence of PEEP and tidal volume on central blood volume,” European Journal of Anaesthesiology, vol. 23, no. 11, pp. 954–961, 2006.

P. Gilbey, Y. Kukuev, A. Samet, Y. Talmon, and S. Ivry, “The quality of the surgical field during functional endoscopic sinus surgery-the effect of the mode of ventilation: a randomized, prospective, double-blind Study,” Laryngoscope, vol. 119, no. 12, pp. 2449–2453, 2009.

C.-S. Degoute, “Controlled hypotension: a guide to drug choice,” Drugs, vol. 67, no. 7, pp. 1053–1076, 2007.

P. E. Marik, “Propofol: therapeutic indications and side-effects,” Current Pharmaceutical Design, vol. 10, no. 29, pp. 3639–3649, 2004.

S. P. Ankichetty, M. Ponniah, V. T. Cherian et al., “Comparison of total intravenous anesthesia using propofol and inhalational anesthesia using isoflurane for controlled hypotension in functional endoscopic sinus surgery,” Journal of Anaesthesiology Clinical Pharmacology, vol. 27, no. 3, pp. 328–332, 2011.

H.-S. Yoo, J. H. Han, S. W. Park, and K. S. Kim, “Comparison of surgical condition in endoscopic sinus surgery using remifentanil combined with propofol, sevoflurane, or desflurane,” Korean Journal of Anesthesiology, vol. 59, no. 6, pp. 377–382, 2010.

S. M. Ragab and M. Z. Hassanin, “Optimizing the surgical field in pediatric functional endoscopic sinus surgery: a new evidence-based approach,” Otolaryngology, vol. 142, no. 1, pp. 48–54, 2010.

H. J. Ahn, S.-K. Chung, H.-J. Dhong et al., “Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery,” British Journal of Anaesthesia, vol. 100, no. 1, pp. 50–54, 2008.

A. G. Beule, F. Wilhelmi, T. S. Kühnel, E. Hansen, K. J. Lackner, and W. Hosemann, “Propofol versus sevoflurane: bleeding in endoscopic sinus surgery,” Otolaryngology, vol. 136, no. 1, pp. 45–50, 2007.

P. J. Wormald, G. Van Renen, J. Perks, J. A. Jones, and C. D. Langton-Hewer, “The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery,” The American Journal of Rhinology, vol. 19, no. 5, pp. 514–520, 2005.

R. Sivaci, M. D. Yilmaz, C. Balci, T. Erincler, and H. Unlu, “Comparison of propofol and sevoflurane anesthesia by means of blood loss during endoscopic sinus surgery,” Saudi Medical Journal, vol. 25, no. 12, pp. 1995–1998, 2004.

L. H. J. Eberhart, B. J. Folz, H. Wulf, and G. Geldner, “Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery,” Laryngoscope, vol. 113, no. 8, pp. 1369–1373, 2003.

D. B. Tulman, S. P. A. Stawicki, T. J. Papadimos, C. V. Murphy, and S. D. Bergese, “Advances in management of acute hypertension: a concise review,” Discovery Medicine, vol. 13, no. 72, pp. 375–383, 2012.

A. P. Boezaart, J. Van der Merwe, and A. Coetzee, “Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional endoscopic sinus surgery,” Canadian Journal of Anaesthesia, vol. 42, no. 5 I, pp. 373–376, 1995.

K. E. Jacobi, B. E. Böhm, A. J. Rickauer, C. Jacobi, and T. M. Hemmerling, “Moderate controlled hypotension with sodium nitroprusside does not improve surgical conditions or decrease blood loss in endoscopic sinus surgery,” Journal of Clinical Anesthesia, vol. 12, no. 3, pp. 202–207, 2000.

A. M. Mengistu, M. W. Wolf, J. Boldt, K. D. Röhm, S. W. Suttner, and S. N. Piper, “Influence of controlled hypotension using esmolol and sodium nitroprusside on natriuretic peptides in patients undergoing endonasal sinus surgery,” European Journal of Anaesthesiology, vol. 24, no. 6, pp. 529–534, 2007.

G. A. Fromme, R. A. MacKenzie, A. B. Gould Jr., B. A. Lund, and K. P. Offord, “Controlled hypotension for orthognathic surgery,” Anesthesia and Analgesia, vol. 65, no. 6, pp. 683–686, 1986.

A. Sieśkiewicz, A. Drozdowski, and M. Rogowski, “The assessment of correlation between mean arterial pressure and intraoperative bleeding during endoscopic sinus surgery in patients with low heart rate,” Otolaryngologia Polska, vol. 64, no. 4, pp. 225–228, 2010.

R. Hugosson and S. Högström, “Factors disposing to morbidity in surgery of intracranial aneurysms with special regard to deep controlled hypotension,” Journal of Neurosurgery, vol. 38, no. 5, pp. 561–567, 1973.

A. Kassam, C. H. Snyderman, R. L. Carrau, P. Gardner, and A. Mintz, “Endoneurosurgical hemostasis techniques: lessons learned from 400 cases,” Neurosurgical focus, vol. 19, no. 1, article E7, 2005.

R. Cohen-Kerem, S. Brown, L. V. Villaseñor, and I. Witterick, “Epinephrine/lidocaine injection vs. saline during endoscopic sinus surgery,” Laryngoscope, vol. 118, no. 7, pp. 1275–1281, 2008.

P.-J. Wormald, T. Athanasiadis, G. Rees, and S. Robinson, “An evaluation of effect of pterygopalatine fossa injection with local anesthetic and adrenalin in the control of nasal bleeding during endoscopic sinus surgery,” The American Journal of Rhinology, vol. 19, no. 3, pp. 288–292, 2005.

A. R. Javer, H. Gheriani, B. Mechor, D. Flamer, K. Genoway, and W. K. Yunker, “Effect of intraoperative injection of 0.25% bupivacaine with 1:200,000 epinephrine on intraoperative blood loss in FESS,” The American Journal of Rhinology and Allergy, vol. 23, no. 4, pp. 437–441, 2009.

T. Athanasiadis, A. G. Beule, and P. J. Wormald, “Effects of topical antifibrinolytics in endoscopic sinus surgery: a pilot randomized controlled trial,” The American Journal of Rhinology, vol. 21, no. 6, pp. 737–742, 2007.

R. M. Gall, I. J. Witterick, N. S. Shargill, and M. Hawke, “Control of bleeding in endoscopic sinus surgery: use of a novel gelatin-based hemostatic agent,” Journal of Otolaryngology, vol. 31, no. 5, pp. 271–274, 2002.

E. H. Kim, J. Y. Ahn, J. H. Chang, and S. H. Kim, “Management strategies of intercavernous sinus bleeding during transsphenoidal surgery,” Acta Neurochirurgica, vol. 151, no. 7, pp. 803–808, 2009.

A. D. Bedi, S. A. Toms, and A. R. Dehdashti, “Use of hemostatic matrix for hemostasis of the cavernous sinus during endoscopic endonasal pituitary and suprasellar tumor surgery,” Skull Base, vol. 21, no. 3, pp. 189–192, 2011.

J. L. Antisdel, C. G. Janney, J. P. Long, and R. Sindwani, “Hemostatic agent Microporous Polysaccharide Hemospheres (MPH) does not affect healing or intact sinus mucosa,” Laryngoscope, vol. 118, no. 7, pp. 1265–1269, 2008.

R. K. Chandra, D. B. Conley, and R. C. Kern, “The effect of FloSeal on mucosal healing after endoscopic sinus surgery: a comparison with thrombin-soaked gelatin foam,” The American Journal of Rhinology, vol. 17, no. 1, pp. 51–55, 2003.

M. G. Shrime, A. Tabaee, A. K. Hsu, S. Rickert, and L. G. Close, “Synechia formation after endoscopic sinus surgery and middle turbinate medialization with and without FloSeal,” The American Journal of Rhinology, vol. 21, no. 2, pp. 174–179, 2007.

B. A. Woodworth, R. K. Chandra, J. D. LeBenger, B. Ilie, and R. J. Schlosser, “A gelatin-thrombin matrix for hemostasis after endoscopic sinus surgery,” The American Journal of Otolaryngology, vol. 30, no. 1, pp. 49–53, 2009.

R. Sindwani, “Use of novel hemostatic powder MPH for endoscopic sinus surgery: initial impressions,” Otolaryngology, vol. 140, no. 2, pp. 262–263, 2009.

J. L. Antisdel, J. L. Matijasec, J. Y. Ting, and R. Sindwani, “Microporous polysaccharide hemospheres do not increase synechiae after sinus surgery: randomized controlled study,” The American Journal of Rhinology and Allergy, vol. 25, no. 4, pp. 268–271, 2011.

G. Phookan, A. T. Davis, and B. Holmes, “Hemangioendothelioma of the cavernous sinus: case report,” Neurosurgery, vol. 42, no. 5, pp. 1153–1156, 1998.

L. N. Sekhar, S. K. Natarajan, T. Manning, and D. Bhagawati, “The use of fibrin glue to stop venous bleeding in the epidural space, vertebral venous plexus, and anterior cavernous sinus: technical note,” Neurosurgery, vol. 61, no. 3, article E51, 2007.

J. F. Fraser, A. Y. Mass, S. Brown, V. K. Anand, and T. H. Schwartz, “Transnasal endoscopic resection of a cavernous sinus hemangioma: technical note and review of the literature,” Skull Base, vol. 18, no. 5, pp. 309–315, 2008.

S.-E. Stangerup, H. O. Dommerby, and T. Lau, “Hot water irrigation in the treatment of posterior epistaxis,” Ugeskrift for Laeger, vol. 158, no. 27, pp. 3932–3934, 1996.

S.-E. Stangerup and H. K. Thomsen, “Histological changes in the nasal mucosa after hot-water irrigation: an animal experimental study,” Rhinology, vol. 34, no. 1, pp. 14–17, 1996.

S. E. Stangerup, H. Dommerby, C. Siim, L. Kemp, and J. Stage, “New modification of hot-water irrigation in the treatment of posterior epistaxis,” Archives of Otolaryngology, vol. 125, no. 6, pp. 686–690, 1999.

C. H. Snyderman, H. Pant, R. L. Carrau, D. Prevedello, P. Gardner, and A. B. Kassam, “What are the limits of endoscopic sinus surgery? The expanded endonasal approach to the skull base,” Keio Journal of Medicine, vol. 58, no. 3, pp. 152–160, 2009.

J. T. Lee, D. B. Keschner, and D. W. Kennedy, “Endoscopic resection of juvenile nasopharyngeal angiofibroma,” Operative Techniques in Otolaryngology, vol. 21, no. 1, pp. 56–65, 2010.

J. W. Ruiz, S. Saint-Victor, B. Tessema, J. A. Eloy, and A. Anstead, “Coblation assisted endoscopic juvenile nasopharyngeal angiofibroma resection,” International Journal of Pediatric Otorhinolaryngology, vol. 76, no. 3, pp. 439–442, 2012.

L. Ye, X. Zhou, J. Li, and J. Jin, “Coblation-assisted endonasal endoscopic resection of juvenile nasopharyngeal angiofibroma,” Journal of Laryngology and Otology, vol. 125, no. 9, pp. 940–944, 2011.