Risks and benefits of deliberate hypotension in anaesthesia: a systematic review

doi:10.1016/j.ijom.2008.03.011

International Journal of Oral and Maxillofacial Surgery

Volume 37, Issue 8, August 2008, Pages 687-703

https://doi.org/10.1016/j.ijom.2008.03.011 Get rights and content

Abstract

This systematic review was performed to investigate and review the evidence on the risks and benefits of hypotensive anaesthesia in order to answer the following question: ‘Should deliberate hypotension be used routinely during orthognathic surgery?’ An electronic search on MEDLINE and the Cochrane Library database was carried out for all relevant articles using specific search keywords. All articles were classified by their levels of evidence. Studies with highest level of evidence and rated to have the lowest risk of bias were reviewed. Regarding the benefits of hypotensive anaesthesia, three studies reported significant decrease of blood loss in patients receiving hypotensive anaesthesia. Two studies reported a significant decrease in transfusion rate. Two studies demonstrated improved surgical field and significant reduction in operation time. In terms of risk, no significant changes in cerebral, cardiovascular, renal and hepatic functions in patients receiving hypotensive anaesthesia compared to control were reported. In conclusion, hypotensive anaesthesia appears to be effective in reducing blood loss. Serious consequences due to organ hypoperfusion are uncommon. Hypotensive anaesthesia can be justified as a routine procedure for orthognathic surgery especially bimaxillary osteotomy. Patient selection and appropriate monitoring are mandatory for this technique to be carried out safely.

Section snippets

Material and methods

A literature search regarding the risks and benefits of hypotensive anaesthesia was performed using MEDLINE with PubMed and Ovid (National Library of Medicine) and the Cochrane Library from January 1966 to June 2007. Keywords used in the search were ‘controlled hypotension’, ‘deliberate hypotension’, ‘induced hypotension’, ‘hypotensive anaesthesia’ and ‘orthognathic surgery’, ‘osteotomy’, ‘cerebral’, ‘heart’, ‘renal’, ‘liver’ or ‘skin’. Other references were obtained from citations found in the

Results

The computer search yielded 578 hits from PubMed, 662 hits from Ovid and none from the Cochrane Library. A total of 833 potentially relevant articles were retrieved and examined. After reading the abstracts and/or full texts, 314 articles were found to be relevant to the topic and sorted according to their level of evidence (Table 2). Clinical studies totaled 201 articles but only 54 of them were randomized clinical trials. These 54 articles were critically appraised and rated for their

Discussion

Hypotensive anaesthesia is advocated in order to minimize intraoperative blood loss and hence reduce haemorrhage-related morbidity. There has been ongoing debate on the value of hypotensive anaesthesia in orthognathic surgery, but in order to justify its use the benefits must outweigh the potential risks. Systematic review is defined as “an efficient scientific technique to identify and summarise evidence on the effectiveness of interventions and to allow the generalisability and consistency of

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Anesthesia provider experience impacts nausea and vomiting in other surgical specialties but its influence within orthognathic surgery remains unclear.
The study purpose was to evaluate whether anesthesiologist experience with orthognathic surgery impacts postoperative outcomes, including nausea, emesis, narcotic use, and perioperative adverse events, for patients undergoing orthognathic surgery.
This is a retrospective cohort study of subjects aged 12 to 35 years old who underwent orthognathic surgery, including Le Fort 1 osteotomy ± bilateral sagittal split osteotomy, at Boston Children's Hospital from August 2018 to January 2022. Subjects were excluded if they had incomplete medical records, a syndromic diagnosis, or a hospital stay of greater than 2 days.
The predictor variable was attending anesthesia provider experience with orthognathic surgery. Providers were classified as experienced or inexperienced, with experienced providers defined as having anesthetized ≥10 orthognathic operations during the study period.
The primary outcome variable was postoperative nausea. Secondary outcome variables were emesis, narcotic use in the hospital, and perioperative adverse events within 30 days of their operation.
Study covariates included age, sex, race, comorbidities (body mass index, history of psychiatric illness, cleft lip and/or palate, chronic pain, postoperative nausea/vomiting, gastrointestinal conditions), enhanced recovery after surgery protocol enrollment, and intraoperative factors (operation performed, anesthesia/procedure times, estimated blood loss, intravenous fluid and narcotic administration, and anesthesiologist's years in practice).
χ² and unpaired t-tests were used to compare primary predictor and covariates against outcome variables. A P-value <.05 was considered significant.
There were 118 subjects included in the study after 4 were excluded (51.7% female, mean age 19.1 ± 3.30 years). There were 71 operations performed by 5 experienced anesthesiologists (mean cases/provider 15.4 ± 5.95) and 47 cases by 22 different inexperienced providers (mean cases/provider 1.91 ± 1.16). The nausea rate was 52.1% for experienced providers and 53.2% for inexperienced providers (P = .909). There were no statistically significant associations between anesthesiologist experience and any outcome variable (P > .341).
Anesthesia providers' experience with orthognathic surgery did not significantly influence postoperative nausea, emesis, narcotic use, or perioperative adverse events.
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The objective of this mapping review was to identify, describe, and organize clinical research currently available from systematic reviews and primary studies regarding co-interventions and different surgical modalities used in orthognathic surgery (OS) and their outcomes.
Systematic reviews (SRs), randomized controlled trials, and observational studies that evaluated perioperative OS co-interventions and surgical modalities were identified in an exhaustive search of MEDLINE, EMBASE, Epistemonikos, Lilacs, Web of Science, and CENTRAL. Grey literature was also screened.
Included were 35 SRs and 253 primary studies, 103 from SRs, and another 150 identified in our search. Overall, SR quality was rated as critically low, with only two SRs rated as of high quality. 19 questions on population, interventions, comparisons, and outcomes (PICO) extracted from the SRs focused on osteosynthesis methods, surgical cutting devices, and use of antibiotics, corticosteroids, and induced hypotension. Also identified were 15 research gaps. Evidence bubble maps were created to graphically depict the available evidence.
Future high-quality research, both primary and secondary, is needed to address the knowledge gaps identified in this systematic mapping review.
Comparison of Efficacy of Dexmedetomidine and Clonidine Infusion to Produce Hypotensive Anesthesia in Patients Undergoing Orthognathic Surgery: A Randomized Controlled Trial
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The purpose of the study was to compare the efficacy of dexmedetomidine (DEX) and clonidine (CLON) infusion to produce hypotensive anesthesia in patients undergoing orthognathic surgery.
The investigators designed a randomized controlled trial on patients undergoing orthognathic surgery. Patients were randomized into 2 groups (DEX and CLON group). The DEX group patients received loading dose of 1 ug/kg DEX over 10 minutes followed by 0.2 to 0.5 ug/kg/hour as maintenance dose. Similarly, CLON group patients received 3 ug/kg loading dose followed by maintenance dose of 0.3 to 2 ug/kg/hour. Primary objectives were to compare the quality of surgical field, duration of surgery, amount of blood loss and secondary objectives were to compare total and rescue analgesia used, need for blood transfusion and associated adverse effects. The P value of <.05 was taken significant at confidence interval of 95%.
The study sample included 30 patients (15 in each group), (m:f = 1:1.1) requiring orthognathic surgery. Single jaw cases were 11 (DEX:CLON = 4:7) and bijaw cases were 19 (DEX:CLON = 11:8) in number. There was statistically insignificant difference in quality of surgical field between 2 groups (P = .15). Duration of surgery was 293.33 ± 58.75 and 247 ± 70.45 minutes in the DEX and the CLON group, respectively (P = .06). Blood loss was more in the DEX group (316.61 ± 147.19 mL) than the CLON group (263.33 ± 112.54 mL), (P = .71). Total drug used (P = .33) and rescue analgesia (P = .25) was less in the DEX group. Adverse effects were more in the CLON than the DEX group.
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Deliberate hypotension as a mechanism to decrease intraoperative surgical site blood loss in resource limited setting: A systematic review and guideline
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Intraoperative surgical site bleeding is usually common in different types of surgeries. Even though there are different prevention techniques for intraoperative bleeding disorder, now adays deliberate hypotension is highly recommended as management options. Uncontrolled intraoperative bleeding may contribute to disability and even death. It can be the initial sign, and lead to incapacitating symptoms in patients undergoing moderate to major surgery.
Electronic search strategies used the following databases: Cochrane library, Pub Med, Medline and various internet search routines, for English publications. Key search terms included in our review are: Deliberate/controlled/induced/permissive hypotension, Intraoperative blood loss, Bleeding control, Intraoperative monitoring, Complication and anesthetic management. Availability of each referenced literature database was assessed until March 15–2019. References classified by evidence levels were selected by one individual and checked by another investigator.
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Invited Review PaperSystematic ReviewRisks and benefits of deliberate hypotension in anaesthesia: a systematic review

Abstract

Section snippets

Material and methods

Results

Discussion

Br J Anaesth

Br J Anaesth

Prostaglandins Leukot Essent Fatty Acids

J Thorac Cardiovasc Surg

Br J Anaesth

Oral Surg Oral Med Oral Pathol

J Oral Maxillofac Surg

Br J Anaesth

J Clin Anesth

Lancet

J Clin Anesth

Ann Thorac Surg

Thromb Res

J Oral Maxillofac Surg

Br J Anaesth

Br J Anaesth

J Clin Anesth

Reg Anesth Pain Med

Br J Anaesth

Local cerebral blood flow with prostaglandin E1 or trimethaphan during cerebral aneurysm clip ligation

Can J Anaesth

Carbon dioxide reactivity during prostaglandin E1 induced hypotension for cerebral aneurysm surgery

Can J Anaesth

The effect of prostaglandin E1 on local cerebral blood flow during cerebral-aneurysm clip ligation

Eur J Anaesthesiol

Carbon dioxide reactivity and local cerebral blood flow during prostaglandin E1- or nitroglycerin-induced hypotension

Can J Anaesth

Local cerebral blood flow and CO2 reactivity during prostaglandin E1-induced hypotension in patients undergoing cerebral aneurysm surgery

Eur J Anaesthesiol

Deliberate hypotensive anesthesia for orthognathic surgery: controlled pharmacologic manipulation of cardiovascular physiology

Int J Adult Orthodon Orthognath Surg

Trimethaphan-induced hypotension: effect on renal function

Can Anaesth Soc J

Sodium nitroprusside-induced hypotension: effect on renal function

Anesth Analg

Haemodynamic changes during sodium nitroprusside induced hypotension and halothane/nitrous oxide anaesthesia

Acta Anaesthesiol Scand

The haemodynamic effects of sodium nitroprusside-induced hypotension during beta-adrenergic blockade and anaesthesia. A case report

Acta Anaesthesiol Scand Suppl

Thiopental loading during controlled hypotension for intracranial aneurysm surgery

Acta Anaesthesiol Scand

Deliberate hypotension with nicardipine or nitroprusside during total hip arthroplasty

Anesth Analg

Impact of surgical stress on the haemodynamic profile of isoflurane-induced hypotension

Acta Anaesthesiologica Scandinavica

Hypotensive anesthesia with isoflurane and enflurane during total hip replacement: a comparative study of catecholamine and renin angiotensin responses

Anesth Analg

Changing renal blood flow following sodium nitroprusside in patients undergoing nephrolithotomy

Anesth Analg

Esmolol is more effective than sodium nitroprusside in reducing blood loss during orthognathic surgery

Anesth Analg

Additive effects of dihydralazine during enflurane or isoflurane hypotensive anaesthesia for spinal fusion

Can J Anaesth

Cerebral blood flow and metabolism during controlled hypotension with sodium-nitroprusside and general anaesthesia for total hip replacement a.m.Charnley

Acta Anaesthesiol Scand

Cerebral blood flow and metabolism during hypotension induced with sodium nitroprusside and metoprolol

Eur J Anaesthesiol

Intrapulmonary shunting during induced hypotension

Anesth Analg

Hypotensive anesthesia and recovery of cognitive function in long-term craniofacial surgery

J Craniofac Surg

Effects of hypotensive anesthesia in anterior maxillary osteotomy

J Oral Surg

Adverse effects of limited hypotensive anesthesia on the outcome of patients with subarachnoid hemorrhage

J Neurosurg

Hepatic plasma flow during sodium nitroprusside-induced hypotension in humans

Anesthesiology

Baroreflex control of heart rate in humans during nitroprusside-induced hypotension

Am J Physiol

Resetting of baroreflex sensitivity after induced hypotension

Anesthesiology

Clinical evaluation of intravenous nitroglycerin for neurosurgery

J Neurosurg

Application of controlled arterial hypotension in endoscopic rhinosurgery

Invited Review Paper
Systematic Review
Risks and benefits of deliberate hypotension in anaesthesia: a systematic review