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Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 3  |  Page : 715-718  

Comparative study between magnesium sulfate and lidocaine for controlled hypotension during functional endoscopic sinus surgery: A randomized controlled study


Department of Anesthesiology, Faculty of Medicine, Fayoum University, Faiyum, Egypt

Date of Web Publication11-Sep-2018

Correspondence Address:
Dr. Mohamed Ahmed Hamed
Faculty of Medicine, Fayoum University, Fayoum
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_103_18

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   Abstract 

Background: Intraoperative bleeding impairs surgical field visibility during functional endoscopic sinus surgery (FESS); several methods have been used to decrease blood loss and improve surgical field, one of them is usage of hypotensive anesthetic agents. Aim: We intended to compare magnesium sulfate with lidocaine, regarding their efficiency in inducing controlled hypotension and providing a better surgical field exposure during FESS and the influence of their usage on extubation time. Settings and Design: This study design was a prospective randomized controlled double-blinded clinical study. Patients and Methods: Eighty adult patients with patients' physical status ASA Classes I and II, aged 20–50 years scheduled for FESS were randomly divided into two study groups; each group contains 40 patients: Group L received lidocaine 2 mg/kg/h with maximum of 200 mg/h starting at induction of anesthesia and continuing until the end of surgery and Group M received an iv bolus of magnesium sulfate 50mg/kg in a total of 100ml saline over 10 min followed by infusion of 15mg/kg/h until the end of surgery; patients were observed for the quality of the surgical field, blood loss, and extubation time. Statistical Analysis Used: Student's t-test or Mann–Whitney's U, Chi-square, or Fisher's exact tests were used. Results: Group L showed a significant decrease in blood loss (P = 0.01), better surgical field clarity (P = 0.002), and shorter extubation time (P = 0.001) than Group M, but there was no statistically significant difference between the two study groups as regards hemodynamics. Conclusion: We concluded that both magnesium sulfate and lidocaine successfully induced controlled hypotension in patients undergoing FEES, but lidocaine provided better surgical field clarity and shorter extubation time.

Keywords: Controlled hypotension, extubation time, functional endoscopic sinus surgery, lidocaine, magnesium sulfate, surgical field


How to cite this article:
Hamed MA. Comparative study between magnesium sulfate and lidocaine for controlled hypotension during functional endoscopic sinus surgery: A randomized controlled study. Anesth Essays Res 2018;12:715-8

How to cite this URL:
Hamed MA. Comparative study between magnesium sulfate and lidocaine for controlled hypotension during functional endoscopic sinus surgery: A randomized controlled study. Anesth Essays Res [serial online] 2018 [cited 2018 Dec 13];12:715-8. Available from: http://www.aeronline.org/text.asp?2018/12/3/715/240859


   Introduction Top


Functional endoscopic sinus surgery (FESS) is surgical management for chronic rhinosinusitis. Various methods have been used to improve the surgical field, such as patient positioning in reverse Trendelenburg, decongesting the nose, infiltrating the lateral nasal wall with lidocaine and epinephrine, or using the hypotensive anesthesia technique.[1] FESS is better to be performed under controlled hypotensive technique (mean arterial pressure [MAP] between 60 and 70 mmHg); this can improve surgical field and decrease the operation time.[2] Several medications have been used to provide controlled hypotension such as inhalational volatile agents,[3] remifentanil,[4] clonidine,[5] dexmedetomidine,[6] nitroglycerine,[7] esmolol,[8] intravenous lidocaine,[9] and magnesium sulfate.[10],[11],[12]

Lidocaine is one of the most commonly used amide anesthetics. It can be safely given systemically to treat ventricular arrhythmias [13] and blunt the pressor response to endotracheal intubation.[14] Hypotension has been observed to occur after submucosal injection of lidocaine.[15],[16] Systemic lidocaine was effective in producing controlled hypotension.[9]

Magnesium sulfate is a good drug for controlled hypotension, as it stabilizes the cell membrane and intracytoplasmic organelles by mediating the activation of Na +-K + ATPase and Ca ++ ATPase enzymes, which have important role in transmembrane ion exchange during the depolarization and repolarization phases,[4],[11],[17] and also, Mg ++ inhibits the release of norepinephrine by blocking the N-type Ca ++ channels at nerve endings which decrease the blood pressure.[18]

The aim in this study was to compare magnesium sulfate with lidocaine, regarding their efficiency in inducing controlled hypotension and providing a better surgical field exposure during FESS and the influence of their usage on extubation time.


   Patients and Methods Top


The Ethical Committee of our institute approved this randomized prospective double-blinded controlled study to be executed in Fayoum University Hospital for 2 years (from February 2016 to April 2018) on 80 patients scheduled for FESS after obtaining a written informed consent for anesthesia from each patient after explaining to them the nature of study and complications.

Inclusion criteria included patients aged 18–60 years, weighted 55–85 kg, and with physical status ASA Classes I and II scheduled for FESS.

Exclusion criteria included patients with anemia (hemoglobin concentration <10 gm/dl), systemic hypertension, significant cardiovascular diseases, renal diseases, diabetes mellitus, and hepatic diseases.

The patients were randomly divided into two equal groups, and each group contains 40 patients: Group L received lidocaine 2 mg/kg/h with maximum of 200 mg/h starting at induction of anesthesia and continuing until the end of surgery and Group M received an iv bolus of magnesium sulfate 50 mg/kg in a total of 100ml saline over 10 min followed by infusion of 15 mg/kg/h until the end of surgery.

The following parameters were measured: (i) hemodynamics: Heart rate (HR) and main arterial pressure (MAP) every 10 min interval; (ii) surgical field clarity: bleeding in the surgical field and the quality of the visibility were measured subjectively every 15 min by the surgeon who was blinded to the infused drug using 6 points by Fromme and Boezaart scale [19] [Table 1]; (iii) intraoperative blood loss: The blood aspirated from the surgical area was collected and measured, and nasal tamponades soaked with blood were counted (each tamponade used was assumed to contain approximately 4 ml of blood); and (iv) the extubation time: the time from discontinuation of isoflurane till the removal of the endotracheal tube.
Table 1: Fromme and Boezaart scale

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The primary outcomes of this prospective, randomized, and observer-blinded study were to compare the quality of the surgical field between groups. The secondary outcomes of this study were to compare the blood loss and extubation time between groups.

Statistical analysis

Sample size was calculated using G power program 3.1.9.2. Data were analyzed using IBM SPSS advanced statistics (Statistical Package for Social Sciences), version 21 (SPSS Inc., Chicago, IL, USA).

Data were collected, coded, and double entered into Microsoft Excel, and data analysis was performed using SPSS software version 21.0 (IBM Corporation, Armonk, NY, USA) statistics. Simple descriptive analysis in the form of numbers and percentages for qualitative data and arithmetic means as central tendency measurement was used. Standard deviations as measure of dispersion and inferential statistic test were used for quantitative parametric data. For quantitative parametric data, independent Student's t-test used to compare measures of two independent groups of quantitative data. For qualitative data, Chi-square test was used to compare two or more than two qualitative groups. The P < 0.05 was considered significant.


   Results Top


Eighty patients were included in our study and were randomly divided into two groups, and each group has 40 patients.

There was no statistically significant difference between the two study groups as regards the demographic data (sex, age, weight, height, and ASA) as shown in [Table 2].
Table 2: Demographic data (age, weight, height, gender, and American Society of Anesthesiologists)

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Heart rate

The baseline HR showed no significant difference between two groups. After induction, HR significantly decreased (about 25%) from the baseline measurements in the two groups and then increased again after tracheal intubation. The HR showed almost constant course throughout the intraoperative period in both groups, but Group L showed a lower decrease in HR than Group M, and the difference was statistically significant [Figure 1].
Figure 1: Heart rate changes in both groups

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Mean arterial blood pressure

MAP showed no significant difference between both groups preoperatively and after induction of anesthesia. MAP showed a significant decrease in Group L than Group M after intubation. The intraoperative MAP showed no significant difference between the two groups [Figure 2].
Figure 2: Intraoperative mean arterial blood pressure

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Operative field clarity

According to Fromme bleeding score, the operative field clarity was significantly better in Group L when compared to Group M [Table 3].
Table 3: Operative field clarity

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Blood loss

The amount of blood loss was statistically significant lower in Group L when compared to Group M as shown in [Table 4].
Table 4: Blood loss in both groups

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Extubation time

There was a statistically significant difference between the two study groups regarding extubation time being longer in the Group M [Table 5].
Table 5: Comparison of the extubation time between the two study groups

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   Discussion Top


FESS is better to be done under controlled hypotensive technique (mean arterial blood pressure [MAP] between 60 and 70 mmHg); this can improve surgical field and decrease the operation time.[2] Several medications have been used to provide controlled hypotension such as inhalational volatile agents,[3] remifentanil,[4] clonidine,[5] dexmedetomidine,[6] nitroglycerine,[7] esmolol,[8] intravenous lidocaine,[9] and magnesium sulfate.[10],[11],[12]

The current study shows the comparison between magnesium sulfate and lidocaine regarding their efficiency in inducing controlled hypotension and providing a better surgical field exposure during FESS and the influence of their usage on postoperative pain and extubation time.

In our study lidocaine provided better control in HR and blood pressure, and operative field clarity and the amount of blood loss were significantly better in the lidocaine group when compared to the magnesium sulfate group.

These results correspond with Omar [9] study that found lidocaine infusion is an effective method in producing deliberate hypotension in patients scheduled for FESS surgery and providing good surgical field.

Moreover, there is evidence that lidocaine can produce vasoconstriction in human. Jorfeldt et al.[20] found that total systemic vascular resistance increased at plasma lidocaine concentrations of 3–6 mcg/kg, and they postulated that vasoconstriction in some parts of the peripheral circulation should have happened. The doses used in our study were used in previous studies and provided serum lidocaine levels <4 mcg/ml.[21] These plasma lidocaine concentrations could have caused mucosal vasoconstriction in the nasal sinuses and consequently produced better surgical fields.

There are two mechanisms of lidocaine to induce hypotension. The first mechanism is local anesthetics ability to produce dose-dependent negative inotropic effect on the heart by affecting calcium influx.[22] This negative inotropic action of lidocaine may be aggravated by a similar effect of volatile anesthetics. The second mechanism is lidocaine ability to blunt the airway's reflexes to endotracheal tube.[23]

On the other hand, Mesbah Kiaee et al.[24] founded that the administration of magnesium sulfate might result in maintaining hemodynamic stability after endotracheal intubation in elective coronary artery bypass grafting in comparison with lidocaine.

Magnesium sulfate is a good option for controlled hypotension, as it stabilizes the cell membrane and intracytoplasmic organelles by mediating the activation of Na +-K + ATPase and Ca ++ ATPase enzymes, which have important role in transmembrane ion exchange during the depolarization and repolarization phases,[4],[11],[17], and also, Mg ++ inhibits the release of norepinephrine by blocking the N-type Ca ++ channels at nerve endings which decrease the blood pressure.[18]

Our limitation was a small sample size, and more studies with larger sample sizes will be needed to confirm our results. The second was postoperative magnesium sulfate, and calcium levels were not measured.

We recommend to study the combination of magnesium sulfate and lidocaine as a technique for hypotensive anesthesia.

Lidocaine provided good controlled hypotension, better surgical field quality, less blood loss, and also postoperative analgesia, so it is better than many drugs that provide hypotension with reflex tachycardia and drugs that provide delayed recovery.


   Conclusion Top


We concluded that both magnesium sulfate and lidocaine successfully induced controlled hypotension in patients undergoing FEES, but lidocaine provided better surgical field clarity and shorter extubation time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Yoo HS, Han JH, Park SW, Kim KS. Comparison of surgical condition in endoscopic sinus surgery using remifentanil combined with propofol, sevoflurane, or desflurane. Korean J Anesthesiol 2010;59:377-82.  Back to cited text no. 1
    
2.
Marzban S, Haddadi S, Mahmoudi Nia H, Heidarzadeh A, Nemati S, Naderi Nabi B, et al. Comparison of surgical conditions during propofol or isoflurane anesthesia for endoscopic sinus surgery. Anesth Pain Med 2013;3:234-8.  Back to cited text no. 2
    
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Dal D, Celiker V, Ozer E, Başgül E, Salman MA, Aypar U, et al. Induced hypotension for tympanoplasty: A comparison of desflurane, isoflurane and sevoflurane. Eur J Anaesthesiol 2004;21:902-6.  Back to cited text no. 3
    
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Ryu JH, Sohn IS, Do SH. Controlled hypotension for middle ear surgery: A comparison between remifentanil and magnesium sulphate. Br J Anaesth 2009;103:490-5.  Back to cited text no. 4
    
5.
Marchal JM, Gómez-Luque A, Martos-Crespo F, Sánchez De La Cuesta F, Martínez-López MC, Delgado-Martinez AD, et al. Clonidine decreases intraoperative bleeding in middle ear microsurgery. Acta Anaesthesiol Scand 2001;45:627-33.  Back to cited text no. 5
    
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Guven DG, Demiraran Y, Sezen G, Kepek O, Iskender A. Evaluation of outcomes in patients given dexmedetomidine in functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol 2011;120:586-92.  Back to cited text no. 6
    
7.
Degoute CS. Controlled hypotension: A guide to drug choice. Drugs 2007;67:1053-76.  Back to cited text no. 7
    
8.
Shen PH, Weitzel EK, Lai JT, Wormald PJ, Ho CS. Intravenous esmolol infusion improves surgical fields during sevoflurane-anesthetized endoscopic sinus surgery: A double-blind, randomized, placebo-controlled trial. Am J Rhinol Allergy 2011;25:e208-11.  Back to cited text no. 8
    
9.
Omar AM. Can systemic lidocaine be used in controlled hypotension? A double-blinded randomized controlled study in patients undergoing functional endoscopic sinus surgery. Egypt J Anaesth 2013;29:295-300.  Back to cited text no. 9
    
10.
Kalra NK, Verma A, Agarwal A, Pandey H. Comparative study of intravenously administered clonidine and magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy. J Anaesthesiol Clin Pharmacol 2011;27:344-8.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Elsharnouby NM, Elsharnouby MM. Magnesium sulphate as a technique of hypotensive anaesthesia. Br J Anaesth 2006;96:727-31.  Back to cited text no. 11
    
12.
Aboushanab OH, El-Shaarawy AM, Omar AM, Abdelwahab HH. A comparative study between magnesium sulphate and dexmedetomidine for deliberate hypotension during middle ear surgery. Egyt J Anaesth 2011;27:227-32.  Back to cited text no. 12
    
13.
Garratt KN, Holmes DR Jr., Molina-Viamonte V, Reeder GS, Hodge DO, Bailey KR, et al. Intravenous adenosine and lidocaine in patients with acute myocardial infarction. Am Heart J 1998;136:196-204.  Back to cited text no. 13
    
14.
Helfman SM, Gold MI, DeLisser EA, Herrington CA. Which drug prevents tachycardia and hypertension associated with tracheal intubation: Lidocaine, fentanyl, or esmolol? Anesth Analg 1991;72:482-6.  Back to cited text no. 14
    
15.
Enlund M, Mentell O, Krekmanov L. Unintentional hypotension from lidocaine infiltration during orthognathic surgery and general anaesthesia. Acta Anaesthesiol Scand 2001;45:294-7.  Back to cited text no. 15
    
16.
Yang JJ, Li WY, Jil Q, Wang ZY, Sun J, Wang QP, et al. Local anesthesia for functional endoscopic sinus surgery employing small volumes of epinephrine-containing solutions of lidocaine produces profound hypotension. Acta Anaesthesiol Scand 2005;49:1471-6.  Back to cited text no. 16
    
17.
Koinig H, Wallner T, Marhofer P, Andel H, Hörauf K, Mayer N, et al. Magnesium sulfate reduces intra- and postoperative analgesic requirements. Anesth Analg 1998;87:206-10.  Back to cited text no. 17
    
18.
Shimosawa T, Takano K, Ando K, Fujita T. Magnesium inhibits norepinephrine release by blocking N-type calcium channels at peripheral sympathetic nerve endings. Hypertension 2004;44:897-902.  Back to cited text no. 18
    
19.
Fromme GA, MacKenzie RA, Gould AB Jr., Lund BA, Offord KP. Controlled hypotension for orthognathic surgery. Anesth Analg 1986;65:683-6.  Back to cited text no. 19
    
20.
Jorfeldt L, Löfström B, Pernow B, Persson B, Wahren J, Widman B, et al. The effect of local anaesthetics on the central circulation and respiration in man and dog. Acta Anaesthesiol Scand 1968;12:153-69.  Back to cited text no. 20
    
21.
Koppert W, Weigand M, Neumann F, Sittl R, Schuettler J, Schmelz M, et al. Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesth Analg 2004;98:1050-5.  Back to cited text no. 21
    
22.
Chamberlain BK, Volpe P, Fleischer S. Inhibition of calcium-induced calcium release from purified cardiac sarcoplasmic reticulum vesicles. J Biol Chem 1984;259:7547-53.  Back to cited text no. 22
    
23.
Yukioka H, Yoshimoto N, Nishimura K, Fujimori M. Intravenous lidocaine as a suppressant of coughing during tracheal intubation. Anesth Analg 1985;64:1189-92.  Back to cited text no. 23
    
24.
Mesbah Kiaee M, Safari S, Movaseghi GR, Mohaghegh Dolatabadi MR, Ghorbanlo M, Etemadi M, et al. The effect of intravenous magnesium sulfate and lidocaine in hemodynamic responses to endotracheal intubation in elective coronary artery bypass grafting: A randomized controlled clinical trial. Anesth Pain Med 2014;4:e15905.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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