Effect of premedication with systemic steroids on surgical field bleeding and visibility during nasosinusal endoscopic surgery. Intubation is a common, lifesaving medical procedure. 158. The conventional interventions, such as elevating the patients head 1520 degrees67,68 (reverse Trendelenburg position should be avoided to prevent intraoperative fluid shifts), topical decongestion of the nasal mucosa, and the use of injectable vasoconstrictors by the surgeon play an important role in optimizing the view of the operative field. Your healthcare provider will tell you what to expect after surgery. These injuries . Your healthcare provider will tell you about potential complications, but a few you may experience include: It can take a few months before you feel as if youre back to normal. Erdivanli B, Erdivanli , en A, et al. 88. Br J Anaesth 2017;118:95960. Tirelli G, Bigarini S, Russolo M, et al. Routine and comprehensive preoperative airway evaluation should include a careful history and an 11-point ASA bedside airway examination32. PloS One 2015;10:e0127809. Determination of EC95 of, 144. This may be a sign of infection. Minor bleeding, pain, congestion, discharge and fatigue are common after the surgery, but should go away in one to three weeks. Smoking can make your sinus symptoms worse. Comparing the reverse Trendelenburg and horizontal position for, 69. 128. Raikundalia MD, Cheng TZ, Truong T, et al. White PF, Tang J, Wender RH, et al. 3. NOSE AND THROAT SURGERIES SUCH AS TONSILLECTOMY AND RHINOPLASTY: Almost all nose and throat surgeries require an airway tube, so anesthetic gases and oxygen can be ventilated in and out through your windpipe safely during the time the surgeon is working on these breathing passages. 150. Tan T, Bhinder R, Carey M, et al. Maintaining intraoperative MAP within 6070mmHg range in otherwise healthy patients is safe during FESS, and no biomarkers of the associated cerebral ischemia could be detected77. Endoscopic Dilatation Sinus Surgery (FEDS) Versus Functional Endoscopic Sinus Surgery (FESS) For Treatment of Chronic Rhinosinusitis: A Pilot Study. Anesthesiology 2013;119:13609. Jaw surgery, also known as orthognathic (or-thog-NATH-ik) surgery, corrects irregularities of the jaw bones and realigns the jaws and teeth to improve the way they work. Kheterpal S, Martin L, Shanks AM, et al. Beule AG, Wilhelmi F, Khnel TS, et al. A retrospective study by Gengler et al10 of over 900 patients after sinonasal surgery demonstrated that the patients age (older than 50), duration of surgery (longer than 80min), and the requirement for nasal packing carried a statistically higher risk for unanticipated hospital admission. Prediction of difficult mask ventilation. Endoscopic sinus surgery is an outpatient procedure performed while the patient is asleep under general anesthesia. Most people have sinus surgery because they have severe sinus problems that medication hasnt helped. 42. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, Functional Endoscopic Sinus Surgery (FESS). Shen PH, Weitzel EK, Lai JT, et al. Range of S-100 levels during, 78. 106. 31. Oral bisoprolol improves surgical field during, 118. The trapped fluid can grow bacteria that can cause infections. Data is temporarily unavailable. People who have local anesthesia may feel pressure during surgery but typically dont feel any pain. Dexmedetomidine has been extensively studied due to its dose-dependent sedation and anxiolysis, potentiation of the opioid analgesia, absent or minimal respiratory depression, and additional antisialagogue, antitussive and sympatholytic properties102110. Efficacy of tranexamic acid on operative bleeding in, 70. You develop sinusitis when the tissue that lines your sinuses begins to swell, trapping mucus that typically flows through your sinuses and out through your nose. Theyll review your medical history, your current sinus situation and your medical history before making a recommendation. Theyll slowly inflate the balloon to unblock your sinuses. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702057/). Reduce the number and severity of sinus infections, Allow access for nasal rinses to reach the sinus cavities for cleaning and medication delivery, Aspirin and NSAIDs such as ibuprofen and naproxen, Fish oil, vitamin E and herbal medicines such as gingko biloba, ginseng and garlic tablets, St. Johns wort (may interact with anesthesia), Anti-coagulation medicines such as warfarin and clopidogrel (blood-thinning medications). Anesth Analg 2003;97:16338. Preoperative administration of systemic antibiotics or steroids to counteract active infection and decrease tissue swelling will vary depending on surgeons preference22. Soppitt AJ, Glass PS, Howell S, et al. Clin Ther 2018;40:1369.e19. Studies show between 80 % and 90% of people whove had this surgery feel it solved their sinus issues. 2. Most patients feel well enough to go home a few hours after the surgery. DeMaria S Jr, Govindaraj S, Chinosorvatana N, et al. Acta Otorhinolaryngol Ital 2004;24:13744. The results of the sphenopalatine ganglion block investigations are largely equivocal, with some studies demonstrating lower pain scores, reduced analgesic consumption, less nausea and vomiting, and faster recovery room discharge times151153,155157, and others150 failing to show significant beneficial effects. 19. Achieving effective surgical hemostasis is critical for FESS, as even a small amount of bleeding can have a significant impact on intraoperative exposure. If a deviated septum causes breathing problems, specialized instruments can straighten the septum and reduce the size of the turbinates (bony structures inside the sinuses). People who undergo the procedure might develop a sinus infection. Comparison between dexmedetomidine and, 114. The effect of beta-blocker premedication on the surgical field during, 90. Hwang PH, Sunder STJaffe RA, Samuels SI, Schmiesing CA, Golianu B. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Extubation is the process of having the endotracheal tube removed. Ask your healthcare provider to explain what kinds of complications you may have and what theyll do to help you if you do have complications from sinus surgery. Kim H, Ha SH, Kim CH, et al. Endoscopic sinus surgery is usually performed as an outpatient procedure with the patient under general anesthesia (asleep). Endoscopic sinus surgery is a procedure used to remove blockages in the sinuses that cause pain, drainage, infections, impaired breathing or loss of smell. A quick emergence from anesthesia, without associated bucking, straining, or coughing and with full return of patients protective airway reflexes is required to help prevent profuse microvascular bleeding and laryngospasm, and also minimizes postextubation hypertensive responses. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. 146. Quality of surgical field during, 92. Major anesthetic objectives and strategies for, 1. The indication for surgery may be purely cosmetic, post trauma, reconstructive after tumor resection or to improve nasal breathing. 123. Cleveland Clinic is a non-profit academic medical center. 29. Jacob SM, Chandy TT, Cherian VT. Functional endoscopic sinus surgery (FESS) is minimally invasive surgery for serious sinus conditions. Malnutrition. Nekhendzy VJaffe RA, Samuels SI, Schmiesing CA, Golianu B. Srivastava U, Dupargude AB, Kumar D, et al. Simple sinus surgery may only require a small dose such as 4mg IV dexamethasone; however, more extensive polyposis may require a dose up to 12mg to further decrease postoperative edema. Endoscopic intraoperative control of epistaxis in nasal surgery. Ebert TJ, Hall JE, Barney JA, et al. Wolters Kluwer Health Functional endoscopic sinus surgery (FESS) is the primary approach used today for the surgical treatment of chronic sinusitis. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546409/), (https://www.ncbi.nlm.nih.gov/books/NBK563202/#_NBK563202_pubdet_). Healthcare providers may also recommend surgery if you have nasal polyps. A barrier to dye placed in the pharynx. Pilot study comparing, 94. Functional endoscopic sinus surgery (FESS) is a minimally invasive technique used to clear blockages in the sinuses and make breathing easier. Kamibayashi T, Maze M. Clinical uses of alpha2-adrenergic agonists. An endotracheal tube is a flexible tube that is placed in the trachea (windpipe) through the mouth or nose. Smooth emergence in men undergoing nasal surgery: the effect site concentration of, 138. Masuki S, Dinenno FA, Joyner MJ, et al. Comparing. The incidence of PONV is reduced with TIVA and remifentanil use, as the emetogenic effect of inhalational anesthetics is avoided148. 105. Using 3 strict criteria for proper FLMA placement and function during administration of the positive pressure ventilation (PPV), such as the ability to achieve and/or maintain adequate ventilation (tidal volume, 6mL/kg), airway protection from above the cuff (airway sealing pressure, >12cmH2O), and adequate separation of the respiratory and gastrointestinal tracts (absent gastric insufflation during PPV), Nekhendzy et al58 have demonstrated a nearly 93% overall success rate of intraoperative FLMA use by experienced operators. 6. 4. Preoperative -blockade and hypertension in the first hour of. Another approach to extubation is ventilation through an extraglottic tracheal tube135. He or she guides it through your nasal and sinus passages. Local and regional anesthesia (eg, sphenopalatine ganglion block) facilitates MAC cases, and its use is widespread to supplement general anesthesia, which is performed far more frequently. Thiruvenkatarajan V, Watts R, Calvert M, et al. Nekhendzy V, Lemmens HJ, Vaughan WC, et al. 1. Cattano D, Rane M. Ventilation through an extraglottic tracheal tube: a technique for deep extubation and airway control. Before you leave, your provider will give you information about taking care of yourself as you recover. Chaaban MR, Baroody FM, Gottlieb O, et al. In some studies, no clear direct correlation between intraoperative MAP and blood loss could be demonstrated78,79,8992. Comparison of sodium nitroprusside- and esmolol-induced hypotension for, 79. They inject a numbing solution into your nose. Keyword Highlighting 39. This review article discusses state-of-the-art perioperative anesthesia care for patients presenting for functional endoscopic sinus surgery (FESS). Koga Y. Otolaryngol Clin North Am 2016;49:51729. Quijada-Manuitt MA, Escamilla Y, Vallano A, et al. An anatomic approach to local. Bhattacharyya N. Ambulatory sinus and nasal surgery in the United States: demographics and perioperative outcomes. Cho HB, Kim JY, Kim DH, et al. Most people go back to school or work in a week or so and resume their normal routine within two weeks. Thirty years of endoscopic sinus surgery: What have we learned? Endoscopic surgery may be used to remove nasal polyps and tumors, treat chronic sinus infections, and address other types of sinus problems. Effects of three different types of anaesthesia on perioperative bleeding control in, 71. Anesthesiology 2000;92:122936. Standard IV induction with propofol and opioid is used most often, and propofols beneficial antiemetic effect is facilitated if TIVA is used for maintenance59,60. In the past sinus operations were done through incisions . Boezaart AP, Van der Merwe J, Coetzee A. Prevention of perioperative and. 103. Other NG tube complications include: 4 Abdominal cramps Aspiration Diarrhea Injury to the esophagus, throat, sinuses, or stomach Swelling Diarrhea Taheri A, Hajimohamadi F, Soltanghoraee H, et al. The essential anesthesia requirements for FESS include airway management considerations for facilitating surgical access, provision of a clear and still surgical field for precision surgery, assuring quick and nonstimulating emergence from anesthesia, and fast-tracking patients for discharge (Table 1). The adult patients presenting for FESS are diverse and could be either completely healthy (American Society of Anesthesiologists [ASA] physical status I) or have controlled systemic diseases of varying severity (ASA physical status IIIII). A comparative study of dexmedetomidine with midazolam and midazolam alone for sedation during elective awake fiberoptic intubation. Please try after some time. Bhat Pai RV, Badiger S, Sachidananda R, et al. John RE, Hill S, Hughes TJ. . Comprehensive Review on Endonasal Endoscopic Sinus Surgery. 14. Sinus surgery may involve removing infected sinus tissue, bone or polyps. Propofol versus sevoflurane: bleeding in, 80. Your doctor might want to do it because you're unconscious. Society for Ambulatory. Risks and Complications NG tube feeding can cause unpleasant side effects like reflux, nausea, and vomiting in some people. Surgery may be an option if your sinusitis is due to a deviated septum, polyps, or other structural problems. Healthcare providers use this surgery to treat chronic sinusitis, remove polyps from your sinuses and treat other conditions. Some conditions that may require temporary tube feeding through a nasogastric tube include: Difficulty swallowing ; Head and neck cancers. Both the anesthesiologist and surgeon should be aware of this potential occurrence and the risks and benefits should be discussed. Predictors of unanticipated admission within 30 days of outpatient sinonasal surgery. American Academy of Otolaryngology-Head and Neck Surgery. This is the air-filled space behind your nose. 109. J Otolaryngol 2006;35:23541. Curr Opin Anaesthesiol 2009;22:40511. 2. This may be related to the complexity of nasal vascular structure and to the predominantly capillary nature of the bleeding80,89. Upon review, 260 references were identified as pertinent and 164 articles were selected for this publication. Efficacy of intraoperative dexmedetomidine infusion on visualization of the surgical field in, 115. In small prospective trials, the use of both oral and IV clonidine effectively improved the surgical field for different anesthetic techniques during FESS, compared favorably with IV remifentanil, but results in undesired carry-over patient sedation95101. During these visits, the care team will clean your nose and sinuses of fluid and blood left behind after surgery. Healthcare providers use general or local anesthesia when they do sinus surgery. Choi EM, Park WK, Choi SH, et al. Gomez-Rivera and colleagues showed that TIVA compared with a sevoflurane-remifentanil anesthetic actually increased sinonasal mucosal blood flow as measured by optical rhinometry but found no difference in blood loss or surgical field visualization93. There are, however, a couple of potential risks associated: 1 Acute bacterial sinusitis, infection of the sinuses by bacteria Excessive bleeding in the affected area Modir H, Modir A, Rezaei O, et al. Appendix 5. 131. The nonsteroidal anti-inflammatory medications (NSAIDs) and herbal supplements such as the 4 Gs (garlic, ginkgo biloba, ginseng, ginger) and certain vitamins (eg, vitamin E), may provoke microvascular bleeding and should ideally be discontinued at least 1 week before surgery when possible17,18. Advertising on our site helps support our mission. Fedok FG, Ferraro RE, Kingsley CP, et al. Vaccines & Boosters | Testing | Visitor Guidelines | Coronavirus. Rodriguez Valiente A, Roldan Fidalgo A, Laguna Ortega D. Bleeding control in. Saxena, Amit MD; Nekhendzy, Vladimir MD, FASA, Departments of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, CA. Proper anesthetic management, however, can indirectly decrease blood loss during FESS by improving the operating conditions and allowing for a more rapid surgery94. If your surgery involves general anesthesia, dont eat or drink anything after midnight the day of your surgery. J Anaesthesiol Clin Pharmacol 2017;33:17280. Obese patients have a higher incidence of adverse airway events on induction and emergence from anesthesia37. Clinical characteristics of patients with chronic rhinosinusitis with nasal polyps, asthma, and aspirin-exacerbated respiratory disease. Schraag S, Pradelli L, Alsaleh AJO, et al. Complications are rare and may include: At Another Johns Hopkins Member Hospital: Sinus Surgery for Nasal Polyps: Nici's Story. Address: Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Rm H3580 300 Pasteur Drive Stanford, CA 94305-5640. Miller DR, Martineau RJ, Wynands JE, et al. During the procedure, the healthcare provider inserts the endoscope into your nose. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Effect of infraorbital nerve block under, 154. 13. Int Forum Allergy Rhinol 2018;8:87782. 2 These include: the infundibular pattern, with inflammation of the maxillary sinus and opacification of the ipsilateral ostium and infundibulum; the ostiomeatal unit pattern, with inflammation of the ipsilateral maxillary, Higashizawa T, Koga Y. Open reduction internal fixation (ORIF) is a surgery to fix severely broken bones. Propofol for maintenance of, 85. may email you for journal alerts and information, but is committed Studies have shown that scheduled oral acetaminophen can provide effective pain control and reduced opioid requirements in the days after surgery146, and the initial investigations into the value of perioperative IV acetaminophen use for pain control after FESS seem encouraging although no definitive conclusions can be made147. 124. Comparison of, 93. Sometimes, your doctor may prescribe a nasal irrigation with topical steroids in them, which is called. Improved quality of surgical field during, 96. Focused patient assessment and preparation shall be aimed at optimizing intraoperative surgical exposure and minimizing factors that may promote bleeding in the perioperative period. They typically remove any damaged tissue or bone as part of the surgery. Esmolol prevents movement and attenuates the BIS response to orotracheal intubation. Coloma M, Chiu JW, White PF, et al. Intubation is a standard procedure that involves passing a tube into a person's airway. Desflurane versus sevoflurane for maintenance of outpatient, 67. Therefore, the dedicated airway and all the anesthesia circuit connections must be properly secured. You have a fever. Nasal saline irrigation flushes out the nasal and sinus cavities to manage polyps. Endoscopic sinus surgery can help people who experience nasal congestion, pain, drainage, difficulty breathing, loss of sense of smell (anosmia) or other symptoms due to: The goals of endoscopic sinus surgery include: Because general anesthesia will be used, you will be instructed to not eat or drink after midnight before the procedure. Most prospective studies demonstrate that, compared with balanced inhalational technique, TIVA provides superior intraoperative hemodynamic stability, quicker recovery times, faster return of cognitive function, decreased incidence of PONV, and improved patient satisfaction4,61,62. Your healthcare provider may recommend you rinse your nose and sinuses with saline. Patients with significant cardiac disease need to be evaluated by the cardiologist preoperatively. 36. True deep extubation has associated risks after FESS because of the increased risk of postextubation laryngospasm and increased need for airway support on the part of the anesthesiologist4,21. : +650-723-6412; fax: +650-725-8544. The success of endoscopic sinus surgery is greatly dependent upon properly administered anesthesia. They use an endoscope to increase the size of your maxillary sinus opening. A prospective, randomized trial of 180 patients conducted under TIVA and CH demonstrated that the blood loss during FESS may be best predicted by the severity of preexisting sinus disease and duration of surgery94. Bettelli G. High risk patients in day surgery. Healthcare providers use nasal endoscopes thin tubes with lights and lens to ease your sinus symptoms without making incisions in or around your nose. Current data indicate that EC95 of the effect site concentration of remifentanil for blunting tracheal reflexes ranges between 1.5 and 2.9ng/mL (corresponding manual infusion rate 0.051.0mcg/kg/min)136145. Prevention of this complication begins with recognition of a potentially difficult intubation and applying good practice rules. Application of deliberate hypotension for orthognathic surgeries decreases blood loss. 23. Jaw surgery may be a corrective option if you have jaw problems that can't be resolved with orthodontics alone . Functional endoscopic sinus surgery is a minimally invasive technique used to restore sinus ventilation and normal function. 49. Day-surgery patients anesthetized with propofol have less postoperative pain than those anesthetized with sevoflurane. Your healthcare provider makes an incision in your gum between your upper lip and gum tissue to get to the wall of your maxillary sinus. Some error has occurred while processing your request. J Clin Anesth 2007;19:3703. 47. But you can stay intubated (with a breathing tube in place) for days or weeks depending on your medical needs. Minimally invasive sinus surgery such as FESS and balloon sinuplasty often cures sinus issues. Lastly, the postoperative period for patients undergoing FESS is discussed with an emphasis on approaches that facilitate prompt hospital discharge with high patient satisfaction. 38. Then, theyll use the catheter to place a small balloon in your sinuses. Yu SK, Tait G, Karkouti K, et al. Grzegorzek T, Kolebacz B, Stryjewska-Makuch G, et al. Your healthcare provider will review your medical history and do a physical examination. Hanna BMN, Crump RT, Liu G, et al. You can help prevent recurring sinus problems by following your post-surgery care and giving your nose time to heal. Sieskiewicz A, Olszewska E, Rogowski M, et al. You should see your healthcare provider for follow-up visits a few weeks after your surgery so they can clean your nose and check on your progress. Skip Navigation. The effect of sphenopalatine block on the postoperative pain of. Procedure. Medicine (Baltimore) 2019;98:e17254. Once the tube is removed, the person is able to breathe on their own. Patients with diabetes mellitus and those with rheumatologic diseases may be particularly prone to bruising and delayed healing, and will require careful intraoperative positioning. Intraoperative access to the patients airway is highly restricted, as the OR table is usually turned 90 or 180 degrees away from the anesthesiologist. Although this algorithm could be useful in elective Oro-Maxillo-Facial surgery, we would like to highlight the challenges facing nasotracheal intubation during anaesthesia for patients with recent maxillo-facial injuries. PloS One 2013;8:e54807. 86. Incidence and burden of comorbid pain and depression in patients with chronic rhinosinusitis awaiting. Fleisher LA, Fleischmann KE, Auerbach AD, et al. Heres an overview of the process: This is an alternative to FESS. Several small prospective randomized trials attempted to further improve postoperative analgesia and patients recovery profile through the use of the regional nerve blocks, most commonly sphenopalatine ganglion block150157. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. The perioperative use of an oral (eg, metoprolol) and IV -blockers (eg, esmolol, labetalol) desirably elicits negative chronotropic and inotropic effects, resulting in improved operating conditions89,116121. At least 16%26% of these patients also have concomitant hypersensitivity to aspirin and cyclooxygenase 1 (COX-1) inhibitors, and a high incidence of reactive airway disease19,21. If the patients baseline functional capacity is moderate-to-excellent then additional cardiac testing should not be required. What are the risks of intubation for surgery and anesthesia? 24. Healthcare providers use nasal endoscopes thin tubes with lights and lenses to ease your sinus symptoms without making incisions in or around your nose. Many nasal procedures can successfully be performed under local anesthesia with sedation. Your healthcare provider puts decongestant medication in your nose. The effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery. Analgesic effects of intravenous acetaminophen vs placebo for, 148. Nekhendzy V, Ramaiah VK, Collins J, et al. Editorial Comment Administering a successful MAC without immediate access to the patients airway (the OR table is usually turned away from the anesthesiologist) is frequently more challenging than conducting a general anesthetic4. The tube is then gently pulled from the person's mouth or nose. Youll have gauze under your nose to catch drainage that youll need to replace as the gauze becomes wet. It is used to: 2 Protect the airway if there is a threat of an obstruction Give anesthesia for surgeries involving the mouth, head, or neck (including dental surgery) What to Expect When Intubated Intubation is a common procedure. Br J Anaesth 1997;78:24755. Under general anesthesia, either an oral tracheal intubation (endotracheal tube, ETT), or a flexible laryngeal mask airway (FLMA, Teleflex Inc., Wayne, PA) can be used to secure and maintain patients airway. Even small amounts of aspirin can increase how much you bleed during and after your surgery. 159. Shukry M, Miller JA. Even small amounts of aspirin can increase how much you bleed during and after your surgery. Anesthesiology 2000;93:13459. Ayala MA, Sanderson A, Marks R, et al. There's a greater risk of sorer throat with intubation. Sethi RKV, Miller AL, Bartholomew RA, et al. Abdelmalak B, Makary L, Hoban J, et al. Anesthesiology 2013;118:25170. Policy. your express consent. Fleisher LA, Pasternak LR, Herbert R, et al. In contrast, when the vapor-based or balanced FESS anesthesia techniques are selected, especially in conjunction with the use of direct-acting peripheral vasodilators (eg, sodium nitroprusside), heart rate (HR) increases, and a lower quality of surgical field and a clear trend toward increased blood loss is observed78,8184,86. In this surgery, providers open your maxillary sinus, which is located behind your cheek, and create a new path from your sinus to your nose. A Phase IIIb, randomized, double-blind, placebo-controlled, multicenter study evaluating the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation. 136. Comparison of cognitive, ambulatory, and psychomotor recovery profiles after day care, 66. Optimization of the pulmonary status of patients with cystic fibrosis will decrease the possibility of postoperative pulmonary complications. The patients with either known or presumed OSA should undergo outpatient surgery only if their cardiovascular and pulmonary comorbidities are optimized and will especially benefit from multimodal approach to perioperative analgesia38,41,42. 160. [5] [6] Furthermore, NT intubation is better tolerated than endotracheal intubation in the awake patient and should therefore be considered when there is a need for awake intubation. This type of surgery does not include cutting the skin because it is performed entirely through the nostrils. The doctor uses a device called an endoscope, along with other tools, to access and treat the problem area through the nostrils. Tel. 133. The safety and efficacy of the use of the flexible. A recent meta-analysis by Kim et al69 has shown that intraoperative administration of tranexamic acid IV 1015mg/kg (not to exceed 1g total dose), decreases intraoperative bleeding, operative time and improves surgical visibility without side effects. Routine intraoperative administration of IV dexamethasone also makes additional stress-dose steroids unnecessary21. A total of 1564 articles were identified and 1454 were analyzed after removing 200 duplicate papers. Dexmedetomidine improves the quality of the operative field for. You should sleep with your head elevated. Ann Allergy Asthma Immunol 2017;118:2869. Sometimes hospital patients just need additional nutrition to support their healing.