Comparison of different concentrations of adrenaline nasal packs in endoscopic sinus surgery: A prospective randomized double-blind study

Comparison of different concentrations of adrenaline nasal packs in endoscopic sinus surgery: A prospective randomized double-blind study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of different concentrations of adrenaline nasal packs in endoscopic sinus surgery: A prospective randomized double-blind study Sunakshi Seigell, Surinder Singhal, Nitin Gupta, Lakesh Anand, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6709918/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Endoscopic sinus surgery has become a prevalent procedure in rhinology, aimed at treating various sinonasal conditions. A critical factor affecting surgical outcomes is the haemostasis achieved during the operation, as adequate control of bleeding can significantly influence both visibility and overall success. Aims and Objectives: This study aims to compare the effects of two concentrations of adrenaline (epinephrine) 1:1000 and 1:2000 on intraoperative visibility and systemic physiological parameters. The objective was to assess whether different concentrations provide distinct advantages in terms of local vasoconstriction and potential systemic effects. Materials & Methods : Adrenaline was administered via soaked pledgets to achieve local vasoconstriction. Local Effects: Visibility of the surgical field, which was quantified based on bleeding control and Systemic effects: Heart rate, systolic and diastolic blood pressure, mean arterial pressure, and evidence of systemic absorption of adrenaline were measured. Data were collected and analysed to compare the outcomes between the two groups receiving different concentrations. Conclusion: Our findings indicate that both concentrations of adrenaline (1:1000 and 1:2000) were equally effective in achieving a bloodless surgical field, facilitating optimal visibility during the procedure. Furthermore, there were no significant alterations in the haemodynamic parameters for either concentration, suggesting a similar safety profile. No systemic complications were observed, confirming that both concentrations are safe for use in endoscopic sinus surgery. Thus, clinicians may choose either concentration depending on their preference, without concern for differing outcomes in efficacy or safety. Adrenaline local vasoconstriction Endoscopic sinus surgery BACKGROUND Endoscopic sinus surgery (ESS) has emerged as a preferred approach over traditional surgical techniques, significantly reducing the need for external interventions and aiding in the preservation of normal anatomical structures. 1 The use of endoscopes provides excellent illumination, magnification, and angulation, making ESS a key surgical procedure for various conditions, including chronic rhinosinusitis, benign and malignant nasal tumours, mucoceles, and epistaxis. It is also utilized for intricate procedures such as the repair of cerebrospinal fluid (CSF) leaks, blow-out fractures, orbital and optic nerve decompression, and hypophysectomy. 2 Endoscopic tools enhance the quality of pathological evaluation, facilitate the diagnostic process, and grant safer operative access to the paranasal sinuses (PNS) and skull base. 3 Furthermore, ESS has catalysed the shift towards minimally invasive surgical methods within the field of otorhinolaryngology. 4 The high vascularity of the nasal and paranasal regions, coupled with the vasodilatory effects of general anaesthesia, complicates the visualization of anatomical landmarks during surgery and underscores the necessity for effective haemostatic strategies. 5 Reliable grading scales, such as the New Wormald grading scale and Boezaart’s surgical field grading scale, are employed to objectively assess intraoperative bleeding, considering variables like total blood loss (TBL) and operative time (OT). 6 Adrenaline has gained prominence as a haemostatic agent in ESS, used either topically or via infiltration, due to its affordability and widespread availability.7 The concentrations of adrenaline can vary significantly between different surgeries and institutions, typically ranging from 1:200,000 to 1:1,000 for topical application and from 1:200,000 to 1:50,000 for infiltration. 7 By engaging both alpha and beta adrenergic receptors, adrenaline induces local and systemic vasoconstriction as well as increased heart rate, cardiac output, and contractility. 8 However, these physiological effects also carry risks of complications including hypertension, coronary ischemia, ventricular dysrhythmias, and cerebral hemorrhage. 8 Furthermore, topical adrenaline can lead to adverse events such as catecholamine-induced cardiac arrhythmia, cardiomyopathy, cardiac arrest, central retinal artery occlusion, and pulmonary edema. 9 Immediate absorption of topical adrenaline into systemic circulation exacerbates the potential for cardiovascular complications. Consequently, there is a pressing need to evaluate and quantify the absorption of adrenaline into the systemic circulation following topical application at varying concentrations during ESS, alongside investigating its impacts on both the local nasal mucosa and systemic health. Aims and objectives : Studying the Effects of Different Concentrations of Adrenaline on Visibility of the Surgical Field To estimate the concentration of adrenaline absorbed into systemic circulation after nasal packing with adrenaline soaked pledgets To monitor the Haemodynamic Parameters intra operatively. MATERIALS & METHODS Setting: The study was conducted at a tertiary care hospital and medical college, involving the Department of Otorhinolaryngology, Head and Neck Surgery, in collaboration with the Department of Anaesthesiology and the Department of Biochemistry. The study was approved by Institutional Ethics Committee of the institute (IEC Regd no ECR/658/Inst/PB/2014/RR-2017) Study Design : A prospective randomized double-blind study with a duration of 18 months. The sample included 44 patients in the two arms of 22 each, aged between 10 – 60 yrs of both genders. Patients outside the age range (younger than 10 years or older than 60 years), patients who had undergone previous endoscopic sinus surgery and those who were having uncontrolled hypertension, coronary artery disease, or history of cerebrovascular accidents were excluded from the study. All patients were admitted prior to surgery in the ENT ward. Informed and written consent was obtained from the patients/parents/guardians. Patients were premedicated with tablet alprazolam 0.25 mg and ranitidine 150 mg PO, night before surgery and 6.30 AM on the day of surgery and were kept fasting during this time. Conduct of Anaesthesia On arrival in the operation room (OR), standard leads were applied and connected to the monitor. Baseline parameters that include heart rate (HR), continuous electrocardiogram (ECG) and non-invasive blood pressure (NIBP) were monitored and recorded. All the patients were intubated via orotracheal route and general anaesthesia was given. After induction of general anesthesia, patient’s venous sample was taken in a chilled lithium heparin vial, to check for the baseline plasma adrenaline level. The patients were randomly divided into 2 groups and randomisation was done by a computer-generated table. The allotted numbers were secured in a coded opaque sealed envelope which was opened before the conduct of anaesthesia to allocate the patient in one of the two groups. Nasal packing was done by placing 4 small pledgets in the following areas- one near uncinate process, one in middle meatus, one in sphenoethmoidal recess (SER) and the last one along the floor of nasal cavity. Similar procedure was done on the opposite side. Group I- Nasal cavity was packed by using pledgets soaked in 4ml, 1:1000 concentration of adrenaline and in Group II- the nasal cavity was packed with pledgets soaked in 4ml, 1:2000 concentration of adrenaline. Haemodynamic parameters including systolic blood pressure (SBP), diastolic BP (DBP), mean arterial pressure (MAP) and heart rate (HR) at following time points: T0-Baseline, T1- 4 minutes after nasal packing, T2- 8 minutes after nasal packing and T3- 15 minutes after nasal packing, were recorded for each patient. Venous samples were also collected at the above-mentioned time intervals for assessing the plasma adrenaline concentration. All the 44 cases included, were operated by the same surgeon (SKS). The visibility of surgical field was assessed by the surgeon during the procedure and was scored at the end of the procedure, based on Wormald surgical field grading scale. The venous samples collected were immediately cold centrifuged and the plasma was stored at -80 degrees. For the measurement of plasma adrenaline using ELISA (enzyme linked immunosorbent assay) technique. Finally, a correlation was made between the systemic parameters mentioned above, the visibility of surgical field and the adrenaline concentration in plasma at various time intervals, between the two groups, at the end of the study. Here is a refined version of the text you provided: OBSERVATION AND RESULTS The patients were categorized into the following age groups for easier data analysis: under 20 years, 21–30 years, 31–40 years, 41–50 years, and 50–60 years. The youngest patient enrolled was 14 years old, while the oldest was 60 years. Most patients fell into the 41–50 age group (17 patients). Of the total patients, 28 were male (63.6%) and 16 were female (36.4%). The distribution of patients based on diagnosis is presented in Table 1 . Table 1 Diagnosis Frequency Percentage 95% CI Mucormycosis 18 40.9% 26.7% − 56.7% Allergic Fungal Rhinosinusitis 7 15.9% 7.2% − 30.7% Pituitary Macroadenoma 5 11.4% 4.3% − 25.4% Polyp 5 11.4% 4.3% − 25.4% Juvenile Nasopharyngeal Angiofibroma 3 6.8% 1.8% − 19.7% Chronic Rhinosinusitis + Polyposis 2 4.5% 0.8% − 16.7% Inverted Papilloma 2 4.5% 0.8% − 16.7% CSF Rhinorrhoea 1 2.3% 0.1% − 13.5% Orbital Floor Fracture 1 2.3% 0.1% − 13.5% The mean operative time in Group I was 127.27 ± 35.18 minutes, and in Group II was 144.55 ± 51.96 minutes, with no statistically significant difference found between the two groups. The mean Surgical Field Score in Group I was 2.09 ± 0.97, and in Group II was 3.09 ± 2.27. The Surgical Field Score ranged from 1 to 4 in Group I and from 1 to 10 in Group II. There was no significant difference between the groups in terms of the Surgical Field Score (p = 0.097). HEART RATE AND BLOOD PRESSURE ANALYSIS The mean (SD) of Heart Rate (BPM) at T0 was 90.32 (18.41) for Group I and 81.55 (18.91) for Group II. At T1, the mean (SD) Heart Rate for Group I was 85.59 (18.76) and for Group II was 85.32 (18.07). Moving on to T2, the mean (SD) Heart Rate for Group I was 84.36, while for Group II, it was 83.36 (18.70). At T3, the mean (SD) Heart Rate in Group I was 86.36 (19.21) and in Group II was 79.95 (15.92). There were no significant differences between the groups in terms of Heart Rate at T0 (p = 0.169), T1 (p = 1.000), T2 (p = 0.879), and T3 (p = 0.347). Table 2 Comparison of Systolic Blood Pressure between Groups at Different Time Intervals Systolic BP (mmHg) Groups P-value for Comparison of Groups at Each Timepoint (Wilcoxon-Mann-Whitney Test I II Mean (SD) Mean (SD) Mean (SD T0 120.27 (19.86) 107.77 (12.54) 0.038 T1 106.36 (11.75) 106.55 (17.08) 0.725 T2 105.77 (18.01) 107.32 (15.66) 0.549 T3 108.91 (20.07) 107.41 (17.85) 0.833 P-Value for Change in Systolic BP (mmHg) over Time within Each Group (Friedman Test): 0.058 for Group I, 0.779 for Group II The changes in systolic blood pressure, diastolic blood pressure, and mean arterial pressure are presented in Tables 2 , 3 , and 4 , respectively. A statistically significant difference between the groups was observed only at T0 for all three parameters. Table 3 Comparison of diastolic blood pressure between two groups at different time intervals Diastolic BP (mmHg) Group P value for comparison of the two groups at each of the timepoints (Wilcoxon-Mann-Whitney Test) I II Mean (SD) Mean (SD) T0 73.41 (14.93) 63.91 (9.29) 0.020 T1 64.14 (10.26) 65.18 (10.39) 0.573 T2 61.18 (14.52) 63.59 (12.71) 0.280 T3 61.27 (12.26) 67.55 (13.81) 0.169 P Value for change in Diastolic BP (mmHg) over time within each group (Friedman Test) 0.006 0.687 Overall P Value for comparison of change in Diastolic BP (mmHg) over time between the two groups (Generalized Estimating Equations) 0.029 Table 4 Comparison of mean arterial pressure between two groups at different time intervals MAP (mmHg) Group P value for comparison of the two groups at each of the timepoints (Wilcoxon-Mann-Whitney Test) I II Mean (SD) Mean (SD) T0 93.27 (15.26) 81.86 (8.86) 0.016 T1 81.00 (8.60) 82.14 (12.77) 0.769 T2 80.59 (14.60) 82.00 (11.68) 0.466 T3 81.36 (13.52) 82.50 (11.82) 0.638 P Value for change in MAP (mmHg) over time within each group (Friedman Test) 0.002 0.804 Overall P Value for comparison of change in MAP (mmHg) over time between the two groups (Generalized Estimating Equations) 0.006 DISCUSSION In our study involving a total of 44 patients, a gender distribution analysis revealed that 28 patients (63.6%) were male, while 16 patients (36.4%) were female. A notable difference in gender composition was observed between the two study groups, with Group I exhibiting a higher proportion of male patients, whereas Group II consisted predominantly of female patients. This variance in gender distribution could potentially influence the study outcomes and treatment responses. The age range of the patients included in our study varied from a minimum of 14 years to a maximum of 60 years. Upon analysing the data, we determined that the mean age at presentation for medical evaluation and treatment was calculated to be approximately 41.23 years. Understanding the age demographics of the study participants provides valuable insights into the prevalence and impact of the diseases under investigation across different age groups. Our study encompassed a diverse spectrum of diagnoses, with patients undergoing endoscopic nasal procedures to address a total of nine distinct medical conditions. Among these conditions, mucormycosis emerged as the most prevalent, with 18 out of the 44 patients (40.9%) requiring surgical intervention for this particular ailment. The prominence of mucormycosis cases in our study cohort underscores the significance of this fungal infection and its association with other underlying health conditions, such as COVID-19. Recent research, including a systematic review conducted by Singh et al 10 in 2021, has shed light on the concerning link between the rise in mucormycosis infections and the COVID-19 pandemic, particularly during the second wave of the outbreak. This association underscores the importance of understanding and managing fungal infections in the context of evolving public health challenges. 10 Furthermore, a study by Moshaver et al. 11 involving 140 patients undergoing Functional Endoscopic Sinus Surgery (FESS) for recurrent acute sinusitis, nasal polyposis, or chronic sinusitis provides additional context for our findings. The impact of the COVID-19 pandemic on surgical practices and the prioritization of cases is evident in our study, where a significant proportion of patients required surgical intervention for mucormycosis due to the postponement of elective surgeries. Escamilla et al 12 in 2019 evaluated clonidine and dexmedetomidine for hypotensive anesthesia in Functional endoscopic sinus surgery (FESS). Both the drugs were found to be good adjuvants in decreasing surgical bleeding with comparable results in terms of variables of bleeding like duration of surgery and associated complications. Considering the better safety profile and equivalent efficacy of adrenaline with respect to cocaine, we used adrenaline as the vasoconstrictor of choice in our study. 13 We chose two different concentrations of adrenaline for comparison, namely- 1:1000 and 1: 2000. Topical as well as infiltration of vasoconstrictor agents have been described to achieve a conducive operative field. Due to the higher incidence of systemic side effects described in literature for the infiltration route, we used adrenaline topically by soaking pledgets with the adrenaline solution. ADRENALINE CONCENTARION & OPERATIVE TIME The two groups in our study were correlated with operative time. The mean operative time in group I was 127.27 minutes and that in group II was 144.55 minutes. Although this difference was not significant statistically (p = 0.474), the mean operative time was lower for group I, that received a more concentrated formulation of adrenaline. In a study by Krishnamurti et al, 7 3 different concentrations of adrenaline were used (1:2000, 1:10,000 and 1:50,000), and the mean operative time was found to be minimum in the group receiving 1:2000 adrenaline. This indicated that a more concentrated formulation of topical adrenaline was associated with lower operative time, which though not statistically significant, was in concordance with our study. Lee et al 9 compared 2 groups, one receiving topical adrenaline and the other receiving infiltration of adrenaline. They concluded that there was no difference in operative time while using either of the two formulations, but the infiltration of adrenaline was associated with higher risk of cardiac dysrhythmias. The mean operative time was found to be highest in juvenile nasopharyngeal angiofibroma which was 160 minutes. This was followed by 159.44 minutes in mucormycosis. The patients of juvenile nasopharyngeal angiofibroma in our study had an extensive disease, stage IIb/IIc by Radkowski staging, which could be the reason for a longer operative time. Another reason for mean operative time to be higher in juvenile nasal angiofibroma could be due to fewer patients compared to mucormycosis i.e., 3 vs 18 respectively. Since some patients of mucormycosis had a limited disease, their lower individual operative time could have decreased the mean operative time, in turn placing it second to that of juvenile nasal angiofibroma. In a study by Thomas et al, 14 the mean operating time during endoscopic surgery was studied. They found that the average time taken for total ethmoidectomy was 59.5 minutes, while the mean duration of full ESS including maxillary and sphenoid tissue removal was 147.1 minutes. In our study the mean operative time for FESS was 127.5 minutes in bilateral chronic rhinosinusitis with nasal polyposis and 118.57 minutes in allergic fungal rhinosinusitis. In a study by Krishnamurti et al, 7 3 different concentrations of adrenaline were used (1:2000, 1:10,000 and 1:50,000), and the mean operative time was found to be minimum in the group receiving 1:2000 adrenaline. This indicated that a more concentrated formulation of topical adrenaline was associated with lower operative time, which though not statistically significant, was in concordance with our study. Lee et al 9 compared 2 groups, one receiving topical adrenaline and the other receiving infiltration of adrenaline. They concluded that there was no difference in operative time while using either of the two formulations, but the infiltration of adrenaline was associated with higher risk of cardiac dysrhythmias. ADRENAINE CONCENTERATION & SURGICAL FIELD Bleeding in the surgical field was graded by the operating surgeon based on New Wormald Surgical Field Score. The mean surgical field score was 2.59. The surgical field score ranged from 1 in 10 patients to a score of 10 in 1 patient. There was no significant association found between the surgical field scores across the different diagnoses (p = 0.363). On further subgroup analysis, we found that the mean surgical field score in Group I was lower than Group II which suggested a better local field during the surgery. The Surgical field scores were 2.09 and 3.09 in Group I and II respectively. However, the difference was not found to be statistically significant (p = 0.09). This could be attributed to the small sample size for this study. Krishnamurti et al, 7 used a visual analogue scale to assess the surgical field score unlike the Wormald scale used in our study. They found a significantly higher difference in the 1:50,000 adrenaline group in terms of surgical field score than 1:10,000 and 1:2000 concentration groups, indicating that the higher concentration of adrenaline helped produce a better visual field. Tangbumrungtham et al 15 did a study in 2019 to compare topical 1:1000 adrenaline and infiltration of 1.1% lidocaine and 1:100,000 adrenaline in addition to the topical preparation. The surgical field graded by Wormald Scale showed no added advantage of infiltrating epinephrine to the topical 1:1000 preparation. The hemodynamic parameters included in our study were heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) are depicted Table 2 , 3 & 4 . Patients were observed for any adverse cardiovascular events. Orlandi et al 8 described a case of a female patient who developed ST elevation on electrocardiogram and was associated with coronary artery spasm and temporary blockage of marginal artery. We did not encounter any patient with episodes of arrhythmia or any other adverse cardiovascular event. HEART RATE RESPONSE TO TOPICAL ADRENALINE AND ANESTHETIC AGENTS Upon initial assessment, the mean baseline heart rate (bpm) for Group I was recorded at 90.32, while for Group II, it was slightly lower at 81.55. Following the administration of topical adrenaline, a second heart rate reading was taken at 4 minutes (T1), revealing mean heart rates of 85.59 for Group I and 85.32 for Group II. Interestingly, while Group I exhibited a decrease in heart rate values from T0 to T1, Group II showed a slight increase during the same period. The observed decline in heart rate in Group I post-adrenaline administration could be attributed to the pharmacological effects of adrenaline. The rapid systemic absorption of adrenaline at higher concentrations can lead to a swift elevation in heart rate. However, the subsequent action of anesthetic agents likely counteracted this initial rise, resulting in a controlled heart rate by the time the T1 reading was taken, effectively showing a decrement from the baseline at T0. Subsequent measurements at T2 and T3 indicated a slight increase in mean heart rate (bpm) for Group I, with values of 84.36 and 86.36, respectively. Conversely, Group II exhibited a decrease in mean heart rate at T2 (83.36) and T3 (79.95). Statistical analysis revealed no significant differences (p = 0.076) between the two groups concerning heart rate at any time point. Our findings regarding heart rate dynamics align with the results of a study by Krishnamurti et al., where no significant variations in heart rate were observed at different time intervals following the use of various concentrations of topical adrenaline. Similarly, in the study by Gunaratne et al., the application of topical adrenaline in a 1:1000 concentration did not elicit significant changes in heart rate, consistent with the outcomes of our investigation. The influence of different concentrations of topical adrenaline on heart rate regulation remains a subject of ongoing research, and our study contributes to the existing body of knowledge in this area. Further investigations may provide additional insights into the cardiovascular effects of adrenaline and its interactions with anesthetic agents in clinical settings. BLOOD PRESSURE RESPONSE TO HYPOTENSIVE ANESTHESIA TECHNIQUES In our study, the Systolic Blood Pressure (SBP) values exhibited a wide range, spanning from 83 mmHg to 170 mmHg in Group I and from 84 mmHg to 149 mmHg in Group II. At the baseline measurement (T0), the mean SBP was 120.27 mmHg for Group I and 107.77 mmHg for Group II, demonstrating a statistically significant difference between the two groups (p = 0.038). Similarly, the Diastolic Blood Pressure (DBP) values ranged from 39 mmHg to 112 mmHg in Group I and from 40 mmHg to 87 mmHg in Group II. The mean DBP at T0 was 73.41 mmHg in Group I and 63.91 mmHg in Group II, with a statistically significant difference (p = 0.016) observed between the two groups at this time point. Subsequent readings at T1, T2, and T3 did not reveal any significant variations in DBP between the groups (p = 0.573, p = 0.28, p = 0.169, respectively). When analysing the overall trend of blood pressure over time, a notable decrease was noted in both SBP (p = 0.02) and DBP (p = 0.029) between the two groups. This decreasing trend was attributed to the utilization of hypotensive anesthesia techniques during the surgical procedures, highlighting the efficacy of these approaches in managing blood pressure levels. The Mean Arterial Pressure (MAP) values ranged from 63 mmHg to 118 mmHg in Group I and from 60 mmHg to 112 mmHg in Group II. Consistent with SBP and DBP findings, a significant difference in MAP was observed between the two groups at T0 (p = 0.005). At T0, the mean MAP was 93.27 mmHg in Group I and 81.86 mmHg in Group II. While there were no significant discrepancies in MAP at T1, T2, and T3 (p = 0.769, p = 0.466, p = 0.638, respectively), the comparison of MAP trends over time revealed a significant decrease between the groups (p = 0.006). Previous research by Krishnamurti et al. demonstrated a gradual increase in SBP and DBP over time when utilizing adrenaline concentrations of 1:2000 and 1:10,000. Their findings provide additional context for understanding the hemodynamic responses to varying concentrations of adrenaline and underline the importance of tailored anesthesia protocols in managing blood pressure dynamics during surgical procedures. PLASMA ADRENALINE LEVELS AND HEMODYNAMIC RESPONSES Add table showing concentration of Adr Our study focused on evaluating the systemic absorption of adrenaline, measured in picograms per milliliter (pg/ml), and identified varying concentrations of adrenaline in each individual within both study groups. In Group I, the baseline plasma adrenaline concentrations ranged from 6.21 pg/ml to 366.54 pg/ml, while in Group II, the range was from 6.6 pg/ml to 434.8 pg/ml. Notably, the highest recorded plasma adrenaline concentration in Group II surpassed the typical reference range for plasma adrenaline levels during stress (150–420 pg/ml), potentially attributable to patient-specific factors such as pre-surgery apprehension and stress induced by intubation. A rising trend in plasma adrenaline levels from baseline (T0) to the subsequent time point (T1) was observed in most patients in both groups, with 14 patients (63.6%) in Group I and 15 patients (68.2%) in Group II exhibiting this trend. This pattern of adrenaline absorption aligns with the findings of Krishnamurti et al., where a gradual increase in plasma adrenaline levels was noted across groups administered with different adrenaline concentrations (1:2000, 1:10,000, and 1:50,000). Importantly, no significant differences were detected between the two groups at any given time point (p = 0.316), indicating that the absorbed adrenaline levels were not substantial enough to induce sustained alterations in hemodynamic parameters or cardiovascular side effects. Our study findings are consistent with the results of a study by Cohen et al., where a comparison was made between a group receiving adrenaline injections and another group receiving saline injections. Despite the observed rapid surge in plasma adrenaline levels post-administration, the absence of significant differences in hemodynamic responses between the groups suggests that the systemic absorption of adrenaline did not lead to prolonged cardiovascular effects in our cohort. These observations underscore the complex interplay between systemic adrenaline absorption and physiological responses, emphasizing the need for tailored anesthesia and monitoring protocols to ensure patient safety and optimal surgical outcomes. CONCLUSION The primary objective of our study was to evaluate the effectiveness of topical adrenaline at different concentrations (1:1000 and 1:2000) in enhancing the surgical field of view during endoscopic procedures. Additionally, we aimed to assess the systemic absorption of adrenaline and its safety profile in this context. Our findings indicate that both concentrations of topical adrenaline (1:1000 and 1:2000) demonstrated satisfactory decongestion and vasoconstriction, leading to an optimal visualization of the surgical field. Despite utilizing varying concentrations of adrenaline, our study revealed no statistically significant differences between the two groups concerning the surgical field score and operative time. This suggests that both concentrations were equally effective in achieving the desired surgical outcome. Importantly, our investigation also highlighted the safety profile of topical adrenaline, with no significant variations observed in hemodynamic parameters or incidence of cardiovascular adverse events across both concentration groups. While a minor amount of adrenaline was absorbed systemically, the levels did not significantly differ between the two groups and were not substantial enough to elicit cardiovascular side effects. Based on our comprehensive analysis, we conclude that concentrated topical adrenaline solutions at 1:1000 and 1:2000 can be safely utilized to achieve vasoconstriction and optimize the surgical field during endoscopic sinus surgery. These findings underscore the practical utility and safety of topical adrenaline in enhancing surgical visualization without compromising patient safety or triggering adverse cardiovascular effects. Declarations Consent for publication: Has been taken from patient/guardians Availability of data and material: Available from authors on request Competing interest: None Acknowledgements: Nil Ethics approval and consent to participate: The study was approved by Institutional Ethics Committee of the institute (IEC Regd no ECR/658/Inst/PB/2014/RR-2017) and consent was taken from the patients/guardians. Funding: Nil Author Contribution Sunakshi Seigill: Principal investigator and data collectionSurinder K Singhal: Drafted the workNitin Gupta: Agree to be accountable for all aspects of workLakesh Anand: Anaethesiologist in the surgeries and edited the manuscriptJasbinder Kaur: Biochemist in the group and edited the manuscriptSeema Gupta: Biochemist in the group and edited the final manuscript References Palmer O, Moche JA, Matthews S. Endoscopic surgery of the nose and paranasal sinus. Oral Maxillofac Surg Clin North Am 2012;24:275-83. Carney AS, Raymond S. Surgical management of rhinosinusitis. In: Michael Gleeson, editor. Scott-Brown’s otorhinolaryngology, head and neck surgery, 7 th Ed. Great Britain: Hodder Arnold 2008. P. 1481-2 Maran AG. Endoscopic sinus surgery. Eur arch otorhinolaryngol 1994;251(6):309-18. Alsaleh S, Manji J, Javer A. Optimization of the Surgical Field in Endoscopic Sinus Surgery: an Evidence-Based Approach. Curr Allergy Asthma Rep 2019;1:19:8. Benjamin E, Wong DK, Choa D. ‘Moffett's’ solution: a review of the evidence and scientific basis for the topical preparation of the nose. Clin Otolaryngol Allied Sci 2004;29:582-7. Athanasiadis T, Beule A, Embate J, Steinmeier E, Field J, Wormald PJ. Standardized video endoscopy and surgical field grading scale for endoscopic sinus surgery: a multicentre study. Laryngoscope 2008;118:314-9. Junior KM, Tomita S, de Ávila Kós AO. Topical use of adrenaline in different concentrations for endoscopic sinus surgery. Braz J Otorhinolaryngol 2009;1:75:280-9. Orlandi RR, Warrier S, Sato S, Han JK. Concentrated topical epinephrine is safe in endoscopic sinus surgery. Am J Rhinol Allergy 2010;24:140-2. Lee TJ, Huang CC, Chang PH, Chang CJ, Chen YW. Hemostasis during functional endoscopic sinus surgery: the effect of local infiltration with adrenaline. Otolaryngol Head Neck Surg 2009;140:209-14. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev 2021. Moshaver A, Lin D, Pinto R, Witterick IJ. The hemostatic and hemodynamic effects of epinephrine during endoscopic sinus surgery: a randomized clinical trial. Arch Otolaryngol Head Neck Surg 2009;135:1005-9. Escamilla Y, Cardesín A, Samara L, López S, Izquierdo A, Fradera M et al. Randomized clinical trial to compare the efficacy to improve the quality of surgical field of hypotensive anesthesia with clonidine or dexmedetomidine during functional endoscopic sinus surgery. Eur Arch Otorhinolaryngol 2019;276:3095-104. Long H, Greller H, Mercurio-Zappala M, Nelson LS, Hoffman RS. Medicinal use of cocaine: a shifting paradigm over 25 years. Laryngoscope 2004;114:1625–9. Thomas AJ, Smith KA, Newberry CI, Cardon B, Davis B, Ou Z et al. Operative time and cost variability for functional endoscopic sinus surgery. Int Forum Allergy Rhinol 2019;9:23-9. Tangbumrungtham N., Hwang P.H., Maul X., Borchard N.A., Dholakia S.S., Patel Z.M et al. The effect of topical epinephrine 1: 1000 with and without infiltration of 1% lidocaine with epinephrine 1: 100,000 on endoscopic surgical field visualization: a double blind randomized controlled study. Int Forum Allergy Rhinol 2019;00:1-6. Gunaratne DA, Barham HP, Christensen JM, Bhatia DD, Stamm AC, Harvey RJ. Topical concentrated epinephrine (1: 1000) does not cause acute cardiovascular changes during endoscopic sinus surgery. Int Forum Allergy Rhinol 2016;6:2:135-9. Yim MT, Ahmed OG, Takashima M. Evaluating real‐time effects of topical 1: 1000 epinephrine in endoscopic sinus and skull‐base surgery on hemodynamic parameters through intraoperative arterial line monitoring. Int Forum Allergy Rhinol 2017;7:1065-9. John G, Low JM, Tan PE, Van Hasselt CA. Plasma catecholamine levels during functional endoscopic sinus surgery. Clin Otolaryngol Allied Sci 1995;20:213-5. Cohen Kerem R, Brown S, Villasenor LV, Witterick I. Epinephrine/lidocaine injection vs. saline during endoscopic sinus surgery. Laryngoscope 2008;118:1275-81. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6709918","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475569098,"identity":"65911bb5-bfb5-423f-a89f-a09552f3e677","order_by":0,"name":"Sunakshi Seigell","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Sunakshi","middleName":"","lastName":"Seigell","suffix":""},{"id":475569099,"identity":"6d41cc87-6557-4ea8-af1f-8295735bec9c","order_by":1,"name":"Surinder Singhal","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Surinder","middleName":"","lastName":"Singhal","suffix":""},{"id":475569100,"identity":"14e208fb-70b0-4679-9284-a6b6162f5018","order_by":2,"name":"Nitin Gupta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACZgaGAyCajb394AMgzcNHWAszWIsEH8+ZZAOQFjairAFpkZNIMJMAW0dIgzk7/8HDBRV36tgYEtIqv+bYybAxMD98dAOPFstmZobDM848k2BjOHjstuy2ZKDD2IyNc/BoMTgM1MLbdliCjbEh7bbkNmagFh42acJa/gG1MDOYFUtuqydWSwNQCxuDGePHbYeJ0mJwmOfYYck2Hp5kacZtx3nYmAn55fzBx595ag7zy89/fvDjz23V9vzszQ8f49OCAph5wCSxykGA8QcpqkfBKBgFo2DEAABBMEF1AJ0MlgAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Nitin","middleName":"","lastName":"Gupta","suffix":""},{"id":475569101,"identity":"38f6ee74-995d-4297-8e1c-9b029c81b8b3","order_by":3,"name":"Lakesh Anand","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Lakesh","middleName":"","lastName":"Anand","suffix":""},{"id":475569102,"identity":"20ddf5f8-ec42-45bb-9e6b-50d0de0a2646","order_by":4,"name":"Jasbinder Kaur","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jasbinder","middleName":"","lastName":"Kaur","suffix":""},{"id":475569103,"identity":"8d4696eb-5c71-4b7f-9bae-e37050ea56ac","order_by":5,"name":"Seema Gupta","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Seema","middleName":"","lastName":"Gupta","suffix":""}],"badges":[],"createdAt":"2025-05-20 17:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6709918/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6709918/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93770288,"identity":"37acf69d-698f-4ee7-8a9d-b797c7187a2d","added_by":"auto","created_at":"2025-10-17 11:47:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":928447,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6709918/v1/4087d02c-00d8-4e47-b4a0-94a767868531.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of different concentrations of adrenaline nasal packs in endoscopic sinus surgery: A prospective randomized double-blind study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eEndoscopic sinus surgery (ESS) has emerged as a preferred approach over traditional surgical techniques, significantly reducing the need for external interventions and aiding in the preservation of normal anatomical structures.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The use of endoscopes provides excellent illumination, magnification, and angulation, making ESS a key surgical procedure for various conditions, including chronic rhinosinusitis, benign and malignant nasal tumours, mucoceles, and epistaxis. It is also utilized for intricate procedures such as the repair of cerebrospinal fluid (CSF) leaks, blow-out fractures, orbital and optic nerve decompression, and hypophysectomy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEndoscopic tools enhance the quality of pathological evaluation, facilitate the diagnostic process, and grant safer operative access to the paranasal sinuses (PNS) and skull base.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Furthermore, ESS has catalysed the shift towards minimally invasive surgical methods within the field of otorhinolaryngology.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe high vascularity of the nasal and paranasal regions, coupled with the vasodilatory effects of general anaesthesia, complicates the visualization of anatomical landmarks during surgery and underscores the necessity for effective haemostatic strategies.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Reliable grading scales, such as the New Wormald grading scale and Boezaart\u0026rsquo;s surgical field grading scale, are employed to objectively assess intraoperative bleeding, considering variables like total blood loss (TBL) and operative time (OT).\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdrenaline has gained prominence as a haemostatic agent in ESS, used either topically or via infiltration, due to its affordability and widespread availability.7 The concentrations of adrenaline can vary significantly between different surgeries and institutions, typically ranging from 1:200,000 to 1:1,000 for topical application and from 1:200,000 to 1:50,000 for infiltration.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBy engaging both alpha and beta adrenergic receptors, adrenaline induces local and systemic vasoconstriction as well as increased heart rate, cardiac output, and contractility.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, these physiological effects also carry risks of complications including hypertension, coronary ischemia, ventricular dysrhythmias, and cerebral hemorrhage.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Furthermore, topical adrenaline can lead to adverse events such as catecholamine-induced cardiac arrhythmia, cardiomyopathy, cardiac arrest, central retinal artery occlusion, and pulmonary edema.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Immediate absorption of topical adrenaline into systemic circulation exacerbates the potential for cardiovascular complications. Consequently, there is a pressing need to evaluate and quantify the absorption of adrenaline into the systemic circulation following topical application at varying concentrations during ESS, alongside investigating its impacts on both the local nasal mucosa and systemic health.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAims and objectives\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudying the Effects of Different Concentrations of Adrenaline on Visibility of the Surgical Field\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo estimate the concentration of adrenaline absorbed into systemic circulation after nasal packing with adrenaline soaked pledgets\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo monitor the Haemodynamic Parameters intra operatively.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"MATERIALS \u0026 METHODS","content":"\u003cp\u003eSetting: The study was conducted at a tertiary care hospital and medical college, involving the Department of Otorhinolaryngology, Head and Neck Surgery, in collaboration with the Department of Anaesthesiology and the Department of Biochemistry. The study was approved by Institutional Ethics Committee of the institute (IEC Regd no ECR/658/Inst/PB/2014/RR-2017)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e: A prospective randomized double-blind study with a duration of 18 months.\u003c/p\u003e\n\u003cp\u003eThe sample included 44 patients in the two arms of 22 each, aged between 10 – 60 yrs of both genders. Patients outside the age range (younger than 10 years or older than 60 years), patients who had undergone previous endoscopic sinus surgery and those who were having uncontrolled hypertension, coronary artery disease, or history of cerebrovascular accidents were excluded from the study.\u003c/p\u003e\n\u003cp\u003eAll patients were admitted prior to surgery in the ENT ward. Informed and written consent was obtained from the patients/parents/guardians.\u0026nbsp;Patients were premedicated with tablet alprazolam 0.25 mg and ranitidine 150 mg PO, night\u0026nbsp;before surgery and 6.30 AM on the day of surgery and were kept fasting during this time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConduct of Anaesthesia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn arrival in the operation room (OR), standard leads were applied and connected to the monitor. Baseline parameters that include heart rate (HR), continuous electrocardiogram (ECG) and non-invasive blood pressure (NIBP) were monitored and recorded. All the patients were intubated via orotracheal route and general anaesthesia was given. After induction of general anesthesia, patient’s venous sample was taken in a chilled lithium heparin vial, to check for the baseline plasma adrenaline level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patients were randomly divided into 2 groups and randomisation was done by a computer-generated table. The allotted numbers were secured in a coded opaque sealed envelope which was opened before the conduct of anaesthesia to allocate the patient in one of the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNasal packing was done by placing 4 small pledgets in the following areas- one near uncinate process, one in middle meatus, one in sphenoethmoidal recess (SER) and the last one along the floor of nasal cavity. Similar procedure was done on the opposite side.\u003c/p\u003e\n\u003cp\u003eGroup I- Nasal cavity was packed by using pledgets soaked in 4ml, 1:1000 concentration of adrenaline and in Group II- the nasal cavity was packed with pledgets soaked in 4ml, 1:2000 concentration of adrenaline.\u003c/p\u003e\n\u003cp\u003eHaemodynamic parameters including systolic blood pressure (SBP), diastolic BP (DBP), mean arterial pressure (MAP) and heart rate (HR)\u0026nbsp;at following time points: T0-Baseline, T1- 4 minutes after nasal packing, T2- 8 minutes after nasal packing and T3- 15 minutes after nasal packing, were recorded for each patient.\u003c/p\u003e\n\u003cp\u003eVenous samples were also collected at the above-mentioned time intervals for assessing the plasma adrenaline concentration.\u003c/p\u003e\n\u003cp\u003eAll the 44 cases included, were operated by the same surgeon (SKS). The visibility of surgical field was assessed by the surgeon during the procedure and was scored at the end of the procedure, based on Wormald surgical field grading scale.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe venous samples collected were immediately cold centrifuged and the plasma was stored at -80 degrees. For the measurement of plasma adrenaline using ELISA (enzyme linked immunosorbent assay) technique.\u003c/p\u003e\n\u003cp\u003eFinally, a correlation was made between the systemic parameters mentioned above, the visibility of surgical field and the adrenaline concentration in plasma at various time intervals, between the two groups, at the end of the study.\u003c/p\u003e\n\u003cp\u003eHere is a refined version of the text you provided:\u003c/p\u003e"},{"header":"OBSERVATION AND RESULTS","content":"\u003cp\u003eThe patients were categorized into the following age groups for easier data analysis: under 20 years, 21\u0026ndash;30 years, 31\u0026ndash;40 years, 41\u0026ndash;50 years, and 50\u0026ndash;60 years. The youngest patient enrolled was 14 years old, while the oldest was 60 years. Most patients fell into the 41\u0026ndash;50 age group (17 patients). Of the total patients, 28 were male (63.6%) and 16 were female (36.4%). The distribution of patients based on diagnosis is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucormycosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e26.7% \u0026minus;\u0026thinsp;56.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllergic Fungal Rhinosinusitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e7.2% \u0026minus;\u0026thinsp;30.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePituitary Macroadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e4.3% \u0026minus;\u0026thinsp;25.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolyp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e4.3% \u0026minus;\u0026thinsp;25.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJuvenile Nasopharyngeal Angiofibroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e1.8% \u0026minus;\u0026thinsp;19.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic Rhinosinusitis\u0026thinsp;+\u0026thinsp;Polyposis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.8% \u0026minus;\u0026thinsp;16.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInverted Papilloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.8% \u0026minus;\u0026thinsp;16.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSF Rhinorrhoea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.1% \u0026minus;\u0026thinsp;13.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrbital Floor Fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.1% \u0026minus;\u0026thinsp;13.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean operative time in Group I was 127.27\u0026thinsp;\u0026plusmn;\u0026thinsp;35.18 minutes, and in Group II was 144.55\u0026thinsp;\u0026plusmn;\u0026thinsp;51.96 minutes, with no statistically significant difference found between the two groups. The mean Surgical Field Score in Group I was 2.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97, and in Group II was 3.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27. The Surgical Field Score ranged from 1 to 4 in Group I and from 1 to 10 in Group II. There was no significant difference between the groups in terms of the Surgical Field Score (p\u0026thinsp;=\u0026thinsp;0.097).\u003c/p\u003e\n\u003ch3\u003eHEART RATE AND BLOOD PRESSURE ANALYSIS\u003c/h3\u003e\n\u003cp\u003eThe mean (SD) of Heart Rate (BPM) at T0 was 90.32 (18.41) for Group I and 81.55 (18.91) for Group II. At T1, the mean (SD) Heart Rate for Group I was 85.59 (18.76) and for Group II was 85.32 (18.07). Moving on to T2, the mean (SD) Heart Rate for Group I was 84.36, while for Group II, it was 83.36 (18.70). At T3, the mean (SD) Heart Rate in Group I was 86.36 (19.21) and in Group II was 79.95 (15.92). There were no significant differences between the groups in terms of Heart Rate at T0 (p\u0026thinsp;=\u0026thinsp;0.169), T1 (p\u0026thinsp;=\u0026thinsp;1.000), T2 (p\u0026thinsp;=\u0026thinsp;0.879), and T3 (p\u0026thinsp;=\u0026thinsp;0.347).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Systolic Blood Pressure between Groups at Different Time Intervals\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic BP (mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value for Comparison\u003c/p\u003e \u003cp\u003eof Groups at Each Timepoint\u003c/p\u003e \u003cp\u003e(Wilcoxon-Mann-Whitney Test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120.27 (19.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107.77 (12.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106.36 (11.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106.55 (17.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105.77 (18.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107.32 (15.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.549\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108.91 (20.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107.41 (17.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eP-Value for Change in Systolic BP (mmHg) over Time within Each Group (Friedman Test): 0.058 for Group I, 0.779 for Group II\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe changes in systolic blood pressure, diastolic blood pressure, and mean arterial pressure are presented in Tables \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, respectively. A statistically significant difference between the groups was observed only at T0 for all three parameters.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of diastolic blood pressure between two groups at different time intervals\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDiastolic BP (mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eP value for comparison of the two groups at each of the timepoints (Wilcoxon-Mann-Whitney Test)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.41 (14.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.91 (9.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.14 (10.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.18 (10.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.18 (14.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.59 (12.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.27 (12.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.55 (13.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP Value for change in Diastolic BP (mmHg) over time within each group (Friedman Test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall P Value for comparison of change in Diastolic BP (mmHg) over time between the two groups (Generalized Estimating Equations)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean arterial pressure between two groups at different time intervals\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMAP (mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eP value for comparison of the two groups at each of the timepoints (Wilcoxon-Mann-Whitney Test)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.27 (15.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.86 (8.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.00 (8.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.14 (12.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.59 (14.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.00 (11.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.466\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.36 (13.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.50 (11.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP Value for change in MAP (mmHg) over time within each group (Friedman Test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall P Value for comparison of change in MAP (mmHg) over time between the two groups (Generalized Estimating Equations)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn our study involving a total of 44 patients, a gender distribution analysis revealed that 28 patients (63.6%) were male, while 16 patients (36.4%) were female. A notable difference in gender composition was observed between the two study groups, with Group I exhibiting a higher proportion of male patients, whereas Group II consisted predominantly of female patients. This variance in gender distribution could potentially influence the study outcomes and treatment responses.\u003c/p\u003e \u003cp\u003eThe age range of the patients included in our study varied from a minimum of 14 years to a maximum of 60 years. Upon analysing the data, we determined that the mean age at presentation for medical evaluation and treatment was calculated to be approximately 41.23 years. Understanding the age demographics of the study participants provides valuable insights into the prevalence and impact of the diseases under investigation across different age groups.\u003c/p\u003e \u003cp\u003eOur study encompassed a diverse spectrum of diagnoses, with patients undergoing endoscopic nasal procedures to address a total of nine distinct medical conditions. Among these conditions, mucormycosis emerged as the most prevalent, with 18 out of the 44 patients (40.9%) requiring surgical intervention for this particular ailment. The prominence of mucormycosis cases in our study cohort underscores the significance of this fungal infection and its association with other underlying health conditions, such as COVID-19.\u003c/p\u003e \u003cp\u003eRecent research, including a systematic review conducted by Singh et al\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e in 2021, has shed light on the concerning link between the rise in mucormycosis infections and the COVID-19 pandemic, particularly during the second wave of the outbreak. This association underscores the importance of understanding and managing fungal infections in the context of evolving public health challenges.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, a study by Moshaver et al.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e involving 140 patients undergoing Functional Endoscopic Sinus Surgery (FESS) for recurrent acute sinusitis, nasal polyposis, or chronic sinusitis provides additional context for our findings. The impact of the COVID-19 pandemic on surgical practices and the prioritization of cases is evident in our study, where a significant proportion of patients required surgical intervention for mucormycosis due to the postponement of elective surgeries.\u003c/p\u003e \u003cp\u003eEscamilla et al\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e in 2019 evaluated clonidine and dexmedetomidine for hypotensive anesthesia in Functional endoscopic sinus surgery (FESS). Both the drugs were found to be good adjuvants in decreasing surgical bleeding with comparable results in terms of variables of bleeding like duration of surgery and associated complications.\u003c/p\u003e \u003cp\u003eConsidering the better safety profile and equivalent efficacy of adrenaline with respect to cocaine, we used adrenaline as the vasoconstrictor of choice in our study.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e We chose two different concentrations of adrenaline for comparison, namely- 1:1000 and 1: 2000.\u003c/p\u003e \u003cp\u003eTopical as well as infiltration of vasoconstrictor agents have been described to achieve a conducive operative field. Due to the higher incidence of systemic side effects described in literature for the infiltration route, we used adrenaline topically by soaking pledgets with the adrenaline solution.\u003c/p\u003e\n\u003ch3\u003eADRENALINE CONCENTARION \u0026 OPERATIVE TIME\u003c/h3\u003e\n\u003cp\u003eThe two groups in our study were correlated with operative time. The mean operative time in group I was 127.27 minutes and that in group II was 144.55 minutes. Although this difference was not significant statistically (p\u0026thinsp;=\u0026thinsp;0.474), the mean operative time was lower for group I, that received a more concentrated formulation of adrenaline. In a study by Krishnamurti et al,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e 3 different concentrations of adrenaline were used (1:2000, 1:10,000 and 1:50,000), and the mean operative time was found to be minimum in the group receiving 1:2000 adrenaline. This indicated that a more concentrated formulation of topical adrenaline was associated with lower operative time, which though not statistically significant, was in concordance with our study. Lee et al\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e compared 2 groups, one receiving topical adrenaline and the other receiving infiltration of adrenaline. They concluded that there was no difference in operative time while using either of the two formulations, but the infiltration of adrenaline was associated with higher risk of cardiac dysrhythmias.\u003c/p\u003e \u003cp\u003eThe mean operative time was found to be highest in juvenile nasopharyngeal angiofibroma which was 160 minutes. This was followed by 159.44 minutes in mucormycosis. The patients of juvenile nasopharyngeal angiofibroma in our study had an extensive disease, stage IIb/IIc by Radkowski staging, which could be the reason for a longer operative time. Another reason for mean operative time to be higher in juvenile nasal angiofibroma could be due to fewer patients compared to mucormycosis i.e., 3 vs 18 respectively. Since some patients of mucormycosis had a limited disease, their lower individual operative time could have decreased the mean operative time, in turn placing it second to that of juvenile nasal angiofibroma.\u003c/p\u003e \u003cp\u003eIn a study by Thomas et al,\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e the mean operating time during endoscopic surgery was studied. They found that the average time taken for total ethmoidectomy was 59.5 minutes, while the mean duration of full ESS including maxillary and sphenoid tissue removal was 147.1 minutes. In our study the mean operative time for FESS was 127.5 minutes in bilateral chronic rhinosinusitis with nasal polyposis and 118.57 minutes in allergic fungal rhinosinusitis.\u003c/p\u003e \u003cp\u003eIn a study by Krishnamurti et al,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e 3 different concentrations of adrenaline were used (1:2000, 1:10,000 and 1:50,000), and the mean operative time was found to be minimum in the group receiving 1:2000 adrenaline. This indicated that a more concentrated formulation of topical adrenaline was associated with lower operative time, which though not statistically significant, was in concordance with our study. Lee et al\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e compared 2 groups, one receiving topical adrenaline and the other receiving infiltration of adrenaline. They concluded that there was no difference in operative time while using either of the two formulations, but the infiltration of adrenaline was associated with higher risk of cardiac dysrhythmias.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eADRENAINE CONCENTERATION \u0026amp; SURGICAL FIELD\u003c/h2\u003e \u003cp\u003eBleeding in the surgical field was graded by the operating surgeon based on New Wormald Surgical Field Score. The mean surgical field score was 2.59. The surgical field score ranged from 1 in 10 patients to a score of 10 in 1 patient. There was no significant association found between the surgical field scores across the different diagnoses (p\u0026thinsp;=\u0026thinsp;0.363). On further subgroup analysis, we found that the mean surgical field score in Group I was lower than Group II which suggested a better local field during the surgery. The Surgical field scores were 2.09 and 3.09 in Group I and II respectively. However, the difference was not found to be statistically significant (p\u0026thinsp;=\u0026thinsp;0.09). This could be attributed to the small sample size for this study.\u003c/p\u003e \u003cp\u003eKrishnamurti et al,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e used a visual analogue scale to assess the surgical field score unlike the Wormald scale used in our study. They found a significantly higher difference in the 1:50,000 adrenaline group in terms of surgical field score than 1:10,000 and 1:2000 concentration groups, indicating that the higher concentration of adrenaline helped produce a better visual field.\u003c/p\u003e \u003cp\u003eTangbumrungtham et al\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e did a study in 2019 to compare topical 1:1000 adrenaline and infiltration of 1.1% lidocaine and 1:100,000 adrenaline in addition to the topical preparation. The surgical field graded by Wormald Scale showed no added advantage of infiltrating epinephrine to the topical 1:1000 preparation.\u003c/p\u003e \u003cp\u003eThe hemodynamic parameters included in our study were heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) are depicted Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e,\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026amp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Patients were observed for any adverse cardiovascular events. Orlandi et al\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e described a case of a female patient who developed ST elevation on electrocardiogram and was associated with coronary artery spasm and temporary blockage of marginal artery. We did not encounter any patient with episodes of arrhythmia or any other adverse cardiovascular event.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHEART RATE RESPONSE TO TOPICAL ADRENALINE AND ANESTHETIC AGENTS\u003c/h3\u003e\n\u003cp\u003eUpon initial assessment, the mean baseline heart rate (bpm) for Group I was recorded at 90.32, while for Group II, it was slightly lower at 81.55. Following the administration of topical adrenaline, a second heart rate reading was taken at 4 minutes (T1), revealing mean heart rates of 85.59 for Group I and 85.32 for Group II. Interestingly, while Group I exhibited a decrease in heart rate values from T0 to T1, Group II showed a slight increase during the same period.\u003c/p\u003e \u003cp\u003eThe observed decline in heart rate in Group I post-adrenaline administration could be attributed to the pharmacological effects of adrenaline. The rapid systemic absorption of adrenaline at higher concentrations can lead to a swift elevation in heart rate. However, the subsequent action of anesthetic agents likely counteracted this initial rise, resulting in a controlled heart rate by the time the T1 reading was taken, effectively showing a decrement from the baseline at T0.\u003c/p\u003e \u003cp\u003eSubsequent measurements at T2 and T3 indicated a slight increase in mean heart rate (bpm) for Group I, with values of 84.36 and 86.36, respectively. Conversely, Group II exhibited a decrease in mean heart rate at T2 (83.36) and T3 (79.95). Statistical analysis revealed no significant differences (p\u0026thinsp;=\u0026thinsp;0.076) between the two groups concerning heart rate at any time point.\u003c/p\u003e \u003cp\u003eOur findings regarding heart rate dynamics align with the results of a study by Krishnamurti et al., where no significant variations in heart rate were observed at different time intervals following the use of various concentrations of topical adrenaline. Similarly, in the study by Gunaratne et al., the application of topical adrenaline in a 1:1000 concentration did not elicit significant changes in heart rate, consistent with the outcomes of our investigation.\u003c/p\u003e \u003cp\u003eThe influence of different concentrations of topical adrenaline on heart rate regulation remains a subject of ongoing research, and our study contributes to the existing body of knowledge in this area. Further investigations may provide additional insights into the cardiovascular effects of adrenaline and its interactions with anesthetic agents in clinical settings.\u003c/p\u003e\n\u003ch3\u003eBLOOD PRESSURE RESPONSE TO HYPOTENSIVE ANESTHESIA TECHNIQUES\u003c/h3\u003e\n\u003cp\u003eIn our study, the Systolic Blood Pressure (SBP) values exhibited a wide range, spanning from 83 mmHg to 170 mmHg in Group I and from 84 mmHg to 149 mmHg in Group II. At the baseline measurement (T0), the mean SBP was 120.27 mmHg for Group I and 107.77 mmHg for Group II, demonstrating a statistically significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.038).\u003c/p\u003e \u003cp\u003eSimilarly, the Diastolic Blood Pressure (DBP) values ranged from 39 mmHg to 112 mmHg in Group I and from 40 mmHg to 87 mmHg in Group II. The mean DBP at T0 was 73.41 mmHg in Group I and 63.91 mmHg in Group II, with a statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.016) observed between the two groups at this time point. Subsequent readings at T1, T2, and T3 did not reveal any significant variations in DBP between the groups (p\u0026thinsp;=\u0026thinsp;0.573, p\u0026thinsp;=\u0026thinsp;0.28, p\u0026thinsp;=\u0026thinsp;0.169, respectively).\u003c/p\u003e \u003cp\u003eWhen analysing the overall trend of blood pressure over time, a notable decrease was noted in both SBP (p\u0026thinsp;=\u0026thinsp;0.02) and DBP (p\u0026thinsp;=\u0026thinsp;0.029) between the two groups. This decreasing trend was attributed to the utilization of hypotensive anesthesia techniques during the surgical procedures, highlighting the efficacy of these approaches in managing blood pressure levels.\u003c/p\u003e \u003cp\u003eThe Mean Arterial Pressure (MAP) values ranged from 63 mmHg to 118 mmHg in Group I and from 60 mmHg to 112 mmHg in Group II. Consistent with SBP and DBP findings, a significant difference in MAP was observed between the two groups at T0 (p\u0026thinsp;=\u0026thinsp;0.005). At T0, the mean MAP was 93.27 mmHg in Group I and 81.86 mmHg in Group II. While there were no significant discrepancies in MAP at T1, T2, and T3 (p\u0026thinsp;=\u0026thinsp;0.769, p\u0026thinsp;=\u0026thinsp;0.466, p\u0026thinsp;=\u0026thinsp;0.638, respectively), the comparison of MAP trends over time revealed a significant decrease between the groups (p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e \u003cp\u003ePrevious research by Krishnamurti et al. demonstrated a gradual increase in SBP and DBP over time when utilizing adrenaline concentrations of 1:2000 and 1:10,000. Their findings provide additional context for understanding the hemodynamic responses to varying concentrations of adrenaline and underline the importance of tailored anesthesia protocols in managing blood pressure dynamics during surgical procedures.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePLASMA ADRENALINE LEVELS AND HEMODYNAMIC RESPONSES\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eAdd table showing concentration of Adr\u003c/h2\u003e \u003cp\u003eOur study focused on evaluating the systemic absorption of adrenaline, measured in picograms per milliliter (pg/ml), and identified varying concentrations of adrenaline in each individual within both study groups. In Group I, the baseline plasma adrenaline concentrations ranged from 6.21 pg/ml to 366.54 pg/ml, while in Group II, the range was from 6.6 pg/ml to 434.8 pg/ml. Notably, the highest recorded plasma adrenaline concentration in Group II surpassed the typical reference range for plasma adrenaline levels during stress (150\u0026ndash;420 pg/ml), potentially attributable to patient-specific factors such as pre-surgery apprehension and stress induced by intubation.\u003c/p\u003e \u003cp\u003eA rising trend in plasma adrenaline levels from baseline (T0) to the subsequent time point (T1) was observed in most patients in both groups, with 14 patients (63.6%) in Group I and 15 patients (68.2%) in Group II exhibiting this trend. This pattern of adrenaline absorption aligns with the findings of Krishnamurti et al., where a gradual increase in plasma adrenaline levels was noted across groups administered with different adrenaline concentrations (1:2000, 1:10,000, and 1:50,000). Importantly, no significant differences were detected between the two groups at any given time point (p\u0026thinsp;=\u0026thinsp;0.316), indicating that the absorbed adrenaline levels were not substantial enough to induce sustained alterations in hemodynamic parameters or cardiovascular side effects.\u003c/p\u003e \u003cp\u003eOur study findings are consistent with the results of a study by Cohen et al., where a comparison was made between a group receiving adrenaline injections and another group receiving saline injections. Despite the observed rapid surge in plasma adrenaline levels post-administration, the absence of significant differences in hemodynamic responses between the groups suggests that the systemic absorption of adrenaline did not lead to prolonged cardiovascular effects in our cohort.\u003c/p\u003e \u003cp\u003eThese observations underscore the complex interplay between systemic adrenaline absorption and physiological responses, emphasizing the need for tailored anesthesia and monitoring protocols to ensure patient safety and optimal surgical outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe primary objective of our study was to evaluate the effectiveness of topical adrenaline at different concentrations (1:1000 and 1:2000) in enhancing the surgical field of view during endoscopic procedures. Additionally, we aimed to assess the systemic absorption of adrenaline and its safety profile in this context.\u003c/p\u003e \u003cp\u003eOur findings indicate that both concentrations of topical adrenaline (1:1000 and 1:2000) demonstrated satisfactory decongestion and vasoconstriction, leading to an optimal visualization of the surgical field. Despite utilizing varying concentrations of adrenaline, our study revealed no statistically significant differences between the two groups concerning the surgical field score and operative time. This suggests that both concentrations were equally effective in achieving the desired surgical outcome.\u003c/p\u003e \u003cp\u003eImportantly, our investigation also highlighted the safety profile of topical adrenaline, with no significant variations observed in hemodynamic parameters or incidence of cardiovascular adverse events across both concentration groups. While a minor amount of adrenaline was absorbed systemically, the levels did not significantly differ between the two groups and were not substantial enough to elicit cardiovascular side effects.\u003c/p\u003e \u003cp\u003eBased on our comprehensive analysis, we conclude that concentrated topical adrenaline solutions at 1:1000 and 1:2000 can be safely utilized to achieve vasoconstriction and optimize the surgical field during endoscopic sinus surgery. These findings underscore the practical utility and safety of topical adrenaline in enhancing surgical visualization without compromising patient safety or triggering adverse cardiovascular effects.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Has been taken from patient/guardians\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material: \u003c/strong\u003eAvailable from authors on request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e None\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Nil\u003c/p\u003e\u003cp\u003eEthics approval and consent to participate:\u0026nbsp;The study was approved by Institutional Ethics Committee of the institute (IEC Regd no ECR/658/Inst/PB/2014/RR-2017) and consent was taken from the patients/guardians.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding: Nil\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSunakshi Seigill: Principal investigator and data collectionSurinder K Singhal: Drafted the workNitin Gupta: Agree to be accountable for all aspects of workLakesh Anand: Anaethesiologist in the surgeries and edited the manuscriptJasbinder Kaur: Biochemist in the group and edited the manuscriptSeema Gupta: Biochemist in the group and edited the final manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePalmer O, Moche JA, Matthews S. Endoscopic surgery of the nose and paranasal sinus. Oral Maxillofac Surg Clin North Am 2012;24:275-83.\u003c/li\u003e\n\u003cli\u003eCarney AS, Raymond S. Surgical management of rhinosinusitis. In: Michael Gleeson, editor. Scott-Brown\u0026rsquo;s otorhinolaryngology, head and neck surgery, 7\u003csup\u003eth\u003c/sup\u003e Ed. Great Britain: Hodder Arnold 2008. P. 1481-2\u003c/li\u003e\n\u003cli\u003eMaran AG. Endoscopic sinus surgery. Eur arch otorhinolaryngol 1994;251(6):309-18.\u003c/li\u003e\n\u003cli\u003eAlsaleh S, Manji J, Javer A. Optimization of the Surgical Field in Endoscopic Sinus Surgery: an Evidence-Based Approach. Curr Allergy Asthma Rep 2019;1:19:8.\u003c/li\u003e\n\u003cli\u003eBenjamin E, Wong DK, Choa D. \u0026lsquo;Moffett\u0026apos;s\u0026rsquo; solution: a review of the evidence and scientific basis for the topical preparation of the nose. Clin Otolaryngol Allied Sci 2004;29:582-7. \u003c/li\u003e\n\u003cli\u003eAthanasiadis T, Beule A, Embate J, Steinmeier E, Field J, Wormald PJ. Standardized video endoscopy and surgical field grading scale for endoscopic sinus surgery: a multicentre study. Laryngoscope 2008;118:314-9. \u003c/li\u003e\n\u003cli\u003eJunior KM, Tomita S, de \u0026Aacute;vila K\u0026oacute;s AO. Topical use of adrenaline in different concentrations for endoscopic sinus surgery. Braz J Otorhinolaryngol 2009;1:75:280-9. \u003c/li\u003e\n\u003cli\u003eOrlandi RR, Warrier S, Sato S, Han JK. Concentrated topical epinephrine is safe in endoscopic sinus surgery. Am J Rhinol Allergy 2010;24:140-2. \u003c/li\u003e\n\u003cli\u003eLee TJ, Huang CC, Chang PH, Chang CJ, Chen YW. Hemostasis during functional endoscopic sinus surgery: the effect of local infiltration with adrenaline. Otolaryngol Head Neck Surg 2009;140:209-14. \u003c/li\u003e\n\u003cli\u003eSingh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev 2021. \u003c/li\u003e\n\u003cli\u003eMoshaver A, Lin D, Pinto R, Witterick IJ. The hemostatic and hemodynamic effects of epinephrine during endoscopic sinus surgery: a randomized clinical trial. Arch Otolaryngol Head Neck Surg 2009;135:1005-9. \u003c/li\u003e\n\u003cli\u003eEscamilla Y, Cardes\u0026iacute;n A, Samara L, L\u0026oacute;pez S, Izquierdo A, Fradera M et al. Randomized clinical trial to compare the efficacy to improve the quality of surgical field of hypotensive anesthesia with clonidine or dexmedetomidine during functional endoscopic sinus surgery. Eur Arch Otorhinolaryngol 2019;276:3095-104. \u003c/li\u003e\n\u003cli\u003eLong H, Greller H, Mercurio-Zappala M, Nelson LS, Hoffman RS. Medicinal use of cocaine: a shifting paradigm over 25 years. Laryngoscope 2004;114:1625\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eThomas AJ, Smith KA, Newberry CI, Cardon B, Davis B, Ou Z et al. Operative time and cost variability for functional endoscopic sinus surgery. Int Forum Allergy Rhinol 2019;9:23-9. \u003c/li\u003e\n\u003cli\u003eTangbumrungtham N., Hwang P.H., Maul X., Borchard N.A., Dholakia S.S., Patel Z.M et al. The effect of topical epinephrine 1: 1000 with and without infiltration of 1% lidocaine with epinephrine 1: 100,000 on endoscopic surgical field visualization: a double blind randomized controlled study. Int Forum Allergy Rhinol 2019;00:1-6. \u003c/li\u003e\n\u003cli\u003eGunaratne DA, Barham HP, Christensen JM, Bhatia DD, Stamm AC, Harvey RJ. Topical concentrated epinephrine (1: 1000) does not cause acute cardiovascular changes during endoscopic sinus surgery. Int Forum Allergy Rhinol 2016;6:2:135-9. \u003c/li\u003e\n\u003cli\u003eYim MT, Ahmed OG, Takashima M. Evaluating real‐time effects of topical 1: 1000 epinephrine in endoscopic sinus and skull‐base surgery on hemodynamic parameters through intraoperative arterial line monitoring. Int Forum Allergy Rhinol 2017;7:1065-9. \u003c/li\u003e\n\u003cli\u003eJohn G, Low JM, Tan PE, Van Hasselt CA. Plasma catecholamine levels during functional endoscopic sinus surgery. Clin Otolaryngol Allied Sci 1995;20:213-5. \u003c/li\u003e\n\u003cli\u003eCohen Kerem R, Brown S, Villasenor LV, Witterick I. Epinephrine/lidocaine injection vs. saline during endoscopic sinus surgery. Laryngoscope 2008;118:1275-81.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adrenaline, local vasoconstriction, Endoscopic sinus surgery","lastPublishedDoi":"10.21203/rs.3.rs-6709918/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6709918/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Endoscopic sinus surgery has become a prevalent procedure in rhinology, aimed at treating various sinonasal conditions. A critical factor affecting surgical outcomes is the haemostasis achieved during the operation, as adequate control of bleeding can significantly influence both visibility and overall success.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims and Objectives:\u003c/strong\u003e This study aims to compare the effects of two concentrations of adrenaline (epinephrine) 1:1000 and 1:2000 on intraoperative visibility and systemic physiological parameters. The objective was to assess whether different concentrations provide distinct advantages in terms of local vasoconstriction and potential systemic effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials \u0026amp; Methods\u003c/strong\u003e: Adrenaline was administered via soaked pledgets to achieve local vasoconstriction. Local Effects: Visibility of the surgical field, which was quantified based on bleeding control and Systemic effects: Heart rate, systolic and diastolic blood pressure, mean arterial pressure, and evidence of systemic absorption of adrenaline were measured. Data were collected and analysed to compare the outcomes between the two groups receiving different concentrations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Our findings indicate that both concentrations of adrenaline (1:1000 and 1:2000) were equally effective in achieving a bloodless surgical field, facilitating optimal visibility during the procedure. Furthermore, there were no significant alterations in the haemodynamic parameters for either concentration, suggesting a similar safety profile. No systemic complications were observed, confirming that both concentrations are safe for use in endoscopic sinus surgery. Thus, clinicians may choose either concentration depending on their preference, without concern for differing outcomes in efficacy or safety.\u003c/p\u003e","manuscriptTitle":"Comparison of different concentrations of adrenaline nasal packs in endoscopic sinus surgery: A prospective randomized double-blind study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 16:10:29","doi":"10.21203/rs.3.rs-6709918/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e3468632-3180-4e48-8f7d-66301d8a10b3","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-17T11:38:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-25 16:10:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6709918","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6709918","identity":"rs-6709918","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}