title: The effect of blood pressure and cardiac output on the quality of the surgical field and middle cerebral artery blood flow during endoscopic sinus surgery.
abstract: A clear surgical field is critical during endoscopic sinus surgery (ESS). Hypotensive anesthesia and cardiac output (CO) may optimize the surgical field; however, evidence of their effect on bleeding and cerebral blood flow is conflicting. The aim of this study was to evaluate the effect of blood pressure (BP) and CO on intraoperative bleeding and middle cerebral artery blood flow velocity (Vmca ) during ESS.
  
  
  
  This was a prospective randomized controlled trial. Patients undergoing ESS for chronic rhinosinusitis at a tertiary institution in 2013 were randomized to receive BP manipulation using target-controlled noradrenaline infusion during surgery to either their left or right sinuses. The contralateral side in each patient served as control. Bleeding was scored using a 0 to 10 point bleeding assessment scale (BAS, 0-10) and Vmca was measured using transcranial Doppler ultrasonography every 10 minutes or when surgically opportune, and time-matched with BP and CO. Data was analyzed using Bland-Altman methods.
  
  
  
  A total of 105 time points were collected across a mean arterial pressure (MAP) range of 32 to 118 mmHg. Significant correlations were demonstrated between MAP and Vmca (r = 0.7, p < 0.0001), MAP and BAS (r = 0.50, p < 0.0001), CO and Vmca (r = 0.57, p < 0.0001), and CO and BAS (r = 0.42, p < 0.0001). The best surgical fields were seen at 40 to 59 mmHg MAP. However, MAP below 60 mmHg produced >50% reduction in Vmca in more than 10% of time points.
  
  
  
  Balancing surgical visibility with organ perfusion remains a challenge. The results of this study show that moderate hypotension significantly improves the surgical field; however reducing BP below 60 mmHg may risk cerebral hypoperfusion.
authors.affiliation: Department of Surgery-Otolaryngology Head and Neck Surgery, The University of Adelaide, Australia.
authors.forename: Thanh Ngoc
authors.initials: TN
authors.lastname: Ha
authors.affiliation: Wakefield Anesthetic Group, Adelaide, Australia.
authors.forename: Robert Graham
authors.initials: RG
authors.lastname: van Renen
authors.affiliation: Discipline of Acute Care Medicine, The University of Adelaide, Australia.
authors.forename: Guy L
authors.initials: GL
authors.lastname: Ludbrook
authors.affiliation: Department of Surgery-Otolaryngology Head and Neck Surgery, The University of Adelaide, Australia.
authors.forename: Peter-John
authors.initials: PJ
authors.lastname: Wormald
mesh_terms: D000328:Adult; D000368:Aged; D001783:Blood Flow Velocity; D001794:Blood Pressure; D002302:Cardiac Output; D002560:Cerebrovascular Circulation; D004724:Endoscopy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000502:physiology; D010256:Paranasal Sinuses / Q000098:blood supply / Q000601:surgery*; D055815:Young Adult
keywords: cardiac output; endoscopic sinus surgery; hypotensive anesthesia; intraoperative bleeding; surgical field