European Journal of Cardiovascular Medicine

Endoscopic sinus surgery (ESS) is a standard procedure for treating chronic rhinosinusitis and nasal polyposis, typically conducted under general anesthesia. Intraoperative bleeding poses a significant challenge, as it reduces endoscopic visibility, complicates instrument manipulation, and may prolong operative time or increase complication risks [1,2]. Controlled hypotension has emerged as an effective strategy to minimize bleeding, thereby improving surgical field quality, precision, and patient safety [3,4].

Dexmedetomidine, a selective α2-adrenergic agonist, induces sedation, analgesia, and sympatholysis with minimal respiratory depression, making it suitable for controlled hypotension [5]. Remifentanil, an ultra-short-acting opioid, provides rapid-onset analgesia and titratable hypotension due to its short half-life [6]. While both agents have been used in ESS to achieve hypotensive anesthesia, comparative studies on their impacts on surgical field quality, hemodynamics, and postoperative outcomes remain limited and inconsistent [7,8].

This study aimed to compare the efficacy of dexmedetomidine and remifentanil infusions in ESS, evaluating: (1) surgical field quality and surgeon satisfaction; (2) hemodynamic stability; (3) intraoperative anesthetic requirements; (4) prevention of emergence agitation; and (5) incidence of PONV. We hypothesized that dexmedetomidine would offer superior hemodynamic stability and reduced postoperative complications compared to remifentanil.

Study Design

This was a prospective, randomized, double-blinded controlled trial conducted at Department of Anesthesia, Government Erode Medical College and Hospital, Perundurai, Erode, Tamilnadu from January 2024 to march 2025. The study protocol was approved by the institutional ethics committee, and written informed consent was obtained from all participants. The trial adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines.

Participants

Sixty patients aged 18–60 years, classified as American Society of Anesthesiologists (ASA) physical status I or II, and scheduled for ESS under general anesthesia for chronic sinusitis or nasal polyposis were enrolled. Exclusion criteria included patient refusal, hemodynamic instability (e.g., baseline MAP <70 mmHg or HR >100 bpm), significant cardiovascular disease, body mass index (BMI) >30 kg/m², or contraindications to study drugs.

Randomization and Blinding

Patients were randomized (1:1 ratio) using a computer-generated list into Group D (dexmedetomidine) or Group R (remifentanil). Allocation was concealed in sealed envelopes. The anesthesiologist preparing the infusions, surgeon assessing outcomes, and patients were blinded to group assignments.

Anesthesia Protocol

Premedication followed institutional standards (e.g., oral midazolam 0.5 mg/kg if needed). Anesthesia induction involved intravenous fentanyl (2 mcg/kg) and propofol (2 mg/kg), followed by endotracheal intubation facilitated by rocuronium (0.6 mg/kg). Maintenance was with isoflurane (1–2% in oxygen/air mixture) titrated to bispectral index (BIS) values of 40–60.

Study drug infusions began at induction and continued until extubation: Group D received dexmedetomidine at 0.4 mcg/kg/h; Group R received remifentanil at 0.05 mcg/kg/min. Intraoperative fluids and vasopressors were administered as needed to maintain MAP between 55–65 mmHg.

Data Collection

Primary Outcomes: Surgical field quality was scored by the blinded surgeon using a 6-point scale (0 = no bleeding; 5 = uncontrollable bleeding) [9]. Surgeon satisfaction was rated on a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied).

Secondary Outcomes: MAP and HR were recorded at baseline (pre-induction), incision, 30, 60, 90, and 120 minutes post-incision, and 10 minutes post-infusion cessation. Intraoperative anesthetic requirements (isoflurane concentration) were noted. Emergence agitation was assessed using the Richmond Agitation-Sedation Scale (RASS) post-extubation. PONV was evaluated in the post-anesthesia care unit (PACU) using a binary scale (present/absent).

Adverse events, such as bradycardia or hypotension requiring intervention, were monitored.

Statistical Analysis

Sample size was calculated based on prior studies [7], assuming a 20% difference in surgical field scores (α=0.05, power=80%), yielding 30 patients per group. Data normality was assessed with the Shapiro-Wilk test. Continuous variables were analyzed using unpaired Student's t-test or Mann-Whitney U test; categorical data with chi-square or Fisher's exact test. Results are presented as mean ± standard deviation (SD) or percentages. Significance was set at p < 0.05. Analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY).

Sixty patients were enrolled and completed the study (Figure 1: CONSORT flow diagram).

Figure 1: CONSORT flow diagram

Baseline Characteristics

Demographic and clinical baseline data were comparable between groups (Table 1).

Table 1. Baseline Characteristics of Study Participants

Data presented as mean ± SD or counts.

Hemodynamic Parameters

Intraoperative MAP and HR were significantly lower in Group R at 30-, 60-, and 90-minutes post-incision (p < 0.05), but returned to baseline similarly post-infusion (Table 2).

Table 2. Hemodynamic Parameters at Various Time Points

Data presented as mean ± SD.

Surgical Field Quality and Other Outcomes

Surgical field quality and surgeon satisfaction were comparable, but emergence agitation was significantly lower in Group D (p < 0.05). PONV incidence did not differ significantly (Table 3). Intraoperative isoflurane requirements were lower in Group D (mean end-tidal concentration: 1.2% ± 0.2% vs. 1.5% ± 0.3%; p < 0.05).

Table 3. Surgical Field Quality, Satisfaction, and Postoperative Outcomes

Data presented as mean ± SD or percentages.

No serious adverse events were reported.

This trial demonstrates that both dexmedetomidine and remifentanil effectively facilitate controlled hypotension in ESS, leading to improved surgical field quality. However, dexmedetomidine provided more stable hemodynamics and reduced emergence agitation, consistent with its sympatholytic and sedative properties [5,10]. Remifentanil's rapid onset resulted in lower intraoperative MAP and HR, but with greater variability, aligning with previous findings [6,7].

Surgical field scores were similar, supporting meta-analyses showing comparable bleeding control [11]. Lower anesthetic requirements in Group D may reflect dexmedetomidine's propofol-sparing effects [12]. The non-significant difference in PONV contrasts some studies [13], possibly due to standardized antiemetic prophylaxis.

Limitations include single-center design and lack of long-term follow-up. Future research should explore dose optimizations and combinations with other agents.

Dexmedetomidine and remifentanil both enhance surgical field quality in ESS via controlled hypotension. Dexmedetomidine excels in hemodynamic stability and emergence agitation prevention, while remifentanil provides quicker hypotension. Agent selection should be tailored to patient needs and surgical demands.

Acknowledgments:

The authors would like to thank all of the study participants and the administration of Department of Anesthesia, Government Erode Medical College and Hospital, Perundurai, Erode, Tamilnadu, India  for granting permission to carry out the research work.

Conflicts of interest: There are no conflicts of interest.

Ethical statement:

Institutional ethical committee accepted this study. The study was approved by the institutional human ethics committee, Department of Anesthesia, Government Erode Medical College and Hospital, Perundurai, Erode, Tamilnadu. Informed written consent was obtained from all the study participants and only those participants willing to sign the informed consent were included in the study. The risks and benefits involved in the study and the voluntary nature of participation were explained to the participants before obtaining consent. The confidentiality of the study participants was maintained.

Funding: Nil.

Authors’ contributions:

Dr.Kousalya T: Conceptualization, Formal analysis, Project administration, Writing‑original draft, Validation, Investigation. Dr. Kokila T : Conceptualization, Writing‑review and editing, Formal analysis, Validation, Investigation, Visualization. Dr. Dr.Gayathri B: Conceptualization, Methodology, Writing‑review and editing, Validation, Resources.  All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript.

DATA AVAILABILITY:

All datasets generated or analysed during this study are included in the manuscript.

INFORMED CONSENT:

Written informed consent was obtained from the participants before enrolling in the study.

1. Snidvongs K, Tingthanathikul W, Aeumjaturapat S, Chusakul S. Dexmedetomidine improves the quality of the operative field for functional endoscopic sinus surgery: systematic review. J Laryngol Otol. 2015;129(S3):S8-S13. doi:10.1017/s0022215115001334
2. Shams T, Bahnasawe N, Abu-Samra M, El-Masry R. Induced hypotension for functional endoscopic sinus surgery: a comparative study of dexmedetomidine versus esmolol. Saudi J Anaesth. 2013;7(2):175. doi:10.4103/1658-354x.114073
3. Ravikumar M, Shanmugasundaram P. Comprehensive study on effectiveness and advantages of dexmedetomidine and esmolol in controlled hypotension for functional endoscopic sinus surgery. J Evol Med Dent Sci. 2017;6(34):2789-2793. doi:10.14260/jemds/2017/601
4. Damarla R, Mamidi M. Dexmedetomidine and esmolol for induced hypotension for functional endoscopic sinus surgery: a comparative study. Int J Med Anesthesiol. 2021;4(2):197-201. doi:10.33545/26643766.2021.v4.i2c.255
5. Carollo DS, Nossaman BD, Ramadhyani U. Dexmedetomidine: a review of clinical applications. Curr Opin Anaesthesiol. 2008;21:457-461. doi:10.1097/ACO.0b013e3283052fc4
6. Kishiyama Y, Tanigami H, Kagawa K, Asakura Y, et al. Remifentanil provides faster recovery and hemodynamic stability in laryngomicrosurgery anesthesia. Masui. 2010;59:989-993.
7. Grape S, Kirkham KR, Frauenknecht J, Albrecht E. Intraoperative analgesia with remifentanil versus dexmedetomidine: a systematic review and meta-analysis with trial sequential analysis. Anaesthesia. 2019;74:793-800. doi:10.1111/anae.14657
8. Huh H, Park J, Seong H, Lee S, Yoon S, Cho J. Effectiveness comparison of dexmedetomidine and remifentanil for perioperative management in patients undergoing endoscopic sinus surgery. Am J Rhinol Allergy. 2020;34(6):751-758. doi:10.1177/1945892420927291
9. Fromme GA, MacKenzie RA, Gould AB Jr, Lund BA, Offord KP. Controlled hypotension for orthognathic surgery. Anesth Analg. 1986;65(6):683-686.
10. Sahu B, Nayak L, Mohapatra P, Mishra K. Induced hypotension in functional endoscopic sinus surgery: a comparative study of dexmedetomidine and esmolol. Cureus. 2021;13(5):e15069. doi:10.7759/cureus.15069
11. Lee J, Kim Y, Park C, et al. Comparison between dexmedetomidine and remifentanil for controlled hypotension and recovery in endoscopic sinus surgery. Ann Otol Rhinol Laryngol. 2013;122(7):421-426. doi:10.1177/000348941312200702
12. Gousheh S, Olapour A, Nesioonpour S, Rashidi M, Pooyan S. The effect of intravenous infusion of dexmedetomidine to prevent bleeding during functional endoscopic sinus surgery: a clinical trial. Anesthesiol Pain Med. 2017;7(4):e12682. doi:10.5812/aapm.12682
13. Kim H, Kwak H, Lee D, Lee J, Min S, Kim J. Comparison of remifentanil concentrations with and without dexmedetomidine for the prevention of emergence cough after nasal surgery: a randomized double-blinded trial. BMC Anesthesiol. 2021;21(1):1-8. doi:10.1186/s12871-021-01314-x