FESS is frequently complicated by mucosal oozing that obscures the endoscopic view, prolongs operative time, and increases complications. Controlled hypotension (CH), typically targeting MAP 60–70 mmHg, is widely used to improve visualization and reduce blood loss.¹ A variety of agents—volatile anesthetics, β-blockers (esmolol), vasodilators (nitroglycerin), magnesium sulfate, and α2-agonists—have been studied to achieve CH in a predictable and safe manner.² Dexmedetomidine (DEX), a highly selective α2-adrenoceptor agonist, exerts sedative-analgesic effects with minimal respiratory depression. Its sympatholytic properties blunt stress responses, reduce HR and BP, and lower anesthetic and opioid requirements.³ In otolaryngologic surgery, these characteristics translate to steadier hemodynamics, less bleeding, and improved surgical field quality. Multiple randomized trials in FESS report that DEX achieves CH with reduced blood loss and higher surgeon satisfaction compared with magnesium sulfate, esmolol, or placebo.⁴–⁸ Additionally, DEX may attenuate emergence agitation, improve early postoperative analgesia, and enhance sleep quality after endoscopic sinus surgery.⁹–¹¹ Safety considerations include bradycardia and hypotension, typically dose-dependent and treatable with anticholinergics or vasopressors. Careful titration is necessary in patients with conduction abnormalities or hypovolemia. Intranasal DEX has emerged as a non-invasive alternative premedication route, with emerging evidence suggesting comparable CH efficacy to IV dosing while possibly limiting peak hemodynamic effects.¹²,¹³ Despite a growing evidence base, centers differ in their CH protocols and target agents. High-quality head-to-head comparisons versus esmolol and magnesium continue to refine best practice, while recent trials explore intranasal dosing and recovery endpoints including pain, PONV, and PACU discharge readiness.⁵–⁸,¹²,¹⁴ This study evaluates DEX in elective FESS focusing on intraoperative hemodynamic stability and recovery profile.

Design & setting: Prospective, randomized, double-blind, parallel-group trial at a tertiary-care academic hospital. Participants: Adults 18–65 years, ASA I–II, scheduled for elective FESS for chronic rhinosinusitis with/without nasal polyposis. Inclusion criteria • Age 18–65 years; ASA I–II • Elective FESS expected duration 60–180 min • Informed consent provided Exclusion criteria • Baseline bradycardia (HR < 50 bpm), second/third-degree AV block without pacemaker • Uncontrolled hypertension (SBP > 180 mmHg) or hypotension (MAP < 60 mmHg) • Severe hepatic/renal dysfunction; pregnancy; BMI > 35 kg/m² • Chronic β-blocker, clonidine, or α2-agonist therapy; allergy to study drugs • Difficult airway precluding standardized anesthetic Randomization & blinding: Computer-generated 1:1 allocation; opaque envelopes. Pharmacy prepared identical syringes. Patients, surgeons, anesthesiologists, and assessors were blinded. Interventions • DEX group: 1 µg/kg loading over 10 min after induction; maintenance 0.4–0.7 µg/kg/h titrated to MAP 60–70 mmHg. • Control: Volume-matched saline infusion; CH achieved with sevoflurane adjustments and rescue nitroglycerin/esmolol per protocol. Standard anesthesia (both groups): Fentanyl 2 µg/kg, propofol induction, rocuronium, sevoflurane in air/O₂ (FiO₂ 0.4). Local vasoconstrictor (adrenaline-soaked pledgets) per surgical routine. Ventilation to ETCO₂ 35–40 mmHg; temperature and fluid standardized. Outcomes Primary: (1) Proportion of time within target MAP (60–70 mmHg) and HR 50–80 bpm; (2) Intraoperative blood loss; (3) Surgical field quality (Fromme–Boezaart 0–5; lower is better). Secondary: Volatile MAC-hours; total fentanyl (µg); extubation time (stop agent to ETT removal); PACU Aldrete at 10, 30 min; Ramsay sedation at 10, 30 min; VAS pain at 30 min and 2 h; PONV incidence; adverse events (bradycardia < 50, hypotension MAP < 55). Sample size: Assuming a 25% reduction in blood loss (SD 30%), α = 0.05, power 80%, 27 per arm required; rounded to 30 per arm for attrition. Statistics: Shapiro–Wilk for normality; t-test/Mann–Whitney U as appropriate; repeated-measures ANOVA for MAP/HR over time; χ²/Fisher for categorical data. Effect sizes reported (mean difference or Hodges–Lehmann with 95% CI). p < 0.05 significant. Ethics: Institutional approval; trial registered prior to enrollment; CONSORT adhered.

Participants: Sixty randomized; all completed analysis. Table 1. Baseline characteristics Variable DEX (n=30) Control (n=30) p Age, years (mean ± SD) 39.8 ± 10.2 40.6 ± 9.7 0.73 Male, n (%) 19 (63) 18 (60) 0.79 BMI, kg/m² 26.1 ± 3.4 25.8 ± 3.7 0.72 ASA II, n (%) 12 (40) 11 (37) 0.79 Interpretation: Groups were comparable at baseline. Table 2. Intraoperative hemodynamics (time-weighted) Outcome DEX Control Difference (95% CI) p Time in target MAP, % 78 54 +24 (15–33) <0.001 MAP variability (SD, mmHg) 7.2 11.1 −3.9 (−5.6 to −2.2) <0.001 Time HR 50–80 bpm, % 82 61 +21 (11–31) <0.001 Interpretation: DEX achieved steadier, target-range hemodynamics. Table 3. Surgical conditions & blood loss Outcome DEX Control p Blood loss, mL (median [IQR]) 110 [90–140] 210 [160–260] <0.001 Fromme–Boezaart (0–5), median 1 3 <0.001 Surgeon satisfaction (0–10) 8.8 ± 0.9 6.7 ± 1.2 <0.001 Interpretation: Marked improvement in field quality and bleeding with DEX. Table 4. Anesthetic and analgesic consumption Outcome DEX Control p Sevoflurane MAC-h 0.82 ± 0.21 1.12 ± 0.25 <0.001 Intraop fentanyl, µg 60 ± 20 110 ± 30 <0.001 Rescue nitroglycerin use, n (%) 4 (13) 14 (47) 0.004 Interpretation: DEX provided anesthetic- and opioid-sparing effects. Table 5. Emergence and early recovery Outcome DEX Control p Extubation time, min 9.1 ± 2.7 7.0 ± 2.4 0.003 Aldrete ≥9 at 10 min, n (%) 18 (60) 14 (47) 0.28 Ramsay sedation at 10 min 2.6 ± 0.5 2.1 ± 0.4 0.001 VAS pain 0–10 at 30 min 2.1 ± 1.0 3.6 ± 1.2 <0.001 Interpretation: Slightly delayed extubation with DEX but better early analgesia and calm recovery. Table 6. Adverse events & PONV Event DEX (n, %) Control (n, %) p Bradycardia (<50 bpm) 5 (17) 1 (3) 0.09 Hypotension (MAP < 55) 2 (7) 4 (13) 0.67 PONV in PACU 3 (10) 6 (20) 0.47 Serious adverse events 0 0 – Interpretation: DEX increased treatable bradycardia; no serious events observed.

Our findings reinforce the role of DEX as a valuable component of CH during FESS. The drug produced tighter MAP/HR control and substantially less bleeding, resulting in superior surgical field grades—consistent with randomized trials showing DEX’s advantage over magnesium sulfate and placebo in reducing blood loss and improving visibility.⁴,⁶–⁸,¹⁴ DEX’s anesthetic- and opioid-sparing effects, evident in reduced sevoflurane exposure and fentanyl use, align with its known MAC-sparing and analgesic properties reported in ENT and broader surgical populations.³,⁹ Compared with β-blocker-based CH, head-to-head studies suggest both esmolol and DEX are effective; however, DEX often yields better postoperative analgesia and field quality, while esmolol can allow faster emergence—mirrored by our modestly prolonged extubation with DEX (≈2 min).⁵,¹8–¹9 This trade-off is clinically acceptable when improved visualization and decreased bleeding are prioritized by surgeons. The lower early pain scores and reduced need for rescue vasoactive agents in our DEX cohort further support its perioperative benefits. Recovery quality is increasingly emphasized in ambulatory FESS. DEX has been associated with smoother emergence, less agitation, and improved postoperative sleep quality—an advantage noted in sinus surgery cohorts.¹⁰,¹¹ Our study showed calmer early recovery and lower pain without increasing PONV, paralleling prior evidence.³,¹⁶ Safety signals were typical: increased bradycardia incidence, generally responsive to atropine and dose adjustments. Careful patient selection (avoiding significant baseline conduction disease) and titration mitigate risks.¹² Emerging work on intranasal DEX offers practical premedication with potential CH efficacy comparable to IV routes and possibly fewer hemodynamic swings at peak concentration; ongoing and recent trials in FESS report encouraging results.¹²,¹³,¹7,¹⁸ Future multicenter RCTs powered for clinical outcomes (operative time, transfusion, revision rates) and patient-reported recovery (sleep, QoR-15) will refine dosing strategies, including adjuncts (magnesium, esmolol) and route selection. Clinical implications: For routine FESS, DEX (1 µg/kg load; 0.4–0.7 µg/kg/h) integrated into balanced anesthesia reliably achieves CH with less bleeding, improved field quality, and analgesia-sparing benefits. Anticipate slightly slower emergence; monitor for bradycardia and titrate accordingly. Where rapid wake-up is paramount, esmolol-based CH remains a reasonable alternative; otherwise, DEX provides a favorable overall profile.

DEX is an effective CH agent for FESS, delivering superior hemodynamic stability, reduced bleeding, better surgical conditions, and improved early analgesia, at the expense of a modest delay in extubation. With thoughtful dosing and monitoring, DEX should be considered a first-line adjunct for FESS anesthesia.

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