- Email: [email protected]
Risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery
Auris Nasus Larynx 35 (2008) 521–526 www.elsevier.com/locate/anl
Risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery ¨ zc¸akır b, Nuray Bayar Muluk a,*, Alpaslan Apan b, Sibel O a c Osman Ku¨rs¸at Arıkan , Can Koc¸ b
a ENT Department, School of Medicine, Kırıkkale University, Turkey Anesthesiology Department, School of Medicine, Kırıkkale University, Turkey c Outpatient Clinic, Turkey
Received 17 June 2007; accepted 19 December 2007 Available online 7 March 2008
Abstract Objective: This prospective study investigated the risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery; and effects of nasal packing on consciousness level while the patients were awake or asleep, measured by Bispectral Index (BIS). Methods: The study group consisted of 15 adult patients (10 male, 5 female), who were applied nasal packing at the end of nasal surgery. The control group consisted of 15 adult patients (10 male, 5 female), who received general anesthesia for various reasons. In the study and control groups, BIS index, respiratory rate, peripheral oxygen saturation, pulse per minute and blood pressure were measured at seven different times. Results: There was no statistically significant difference between BIS indexes of the study and control groups. In the fourth hour after sleep (AS-4 h), respiratory rate of the study group was significantly lower than that of the control group. In the fourth hour after the anesthesia (AA4 h), oxygen saturation value of the study group was lower than that of the control group. Conclusion: We conclude that in patients who are applied nasal packing at the end of nasal surgery; at AA-4 h and AS-4 h times, there may be risk of decrease in the oxygen saturation and respiratory rate parameters, respectively. Therefore, it is necessary to monitor non-invasive respiratory parameters and to give enriched oxygen by an oral catheter. # 2008 Published by Elsevier Ireland Ltd. Keywords: The Bispectral Index (BIS); Respiratory rate; Oxygen saturation; Nasal packing; Nasal surgery; Enriched oxygen; Anesthesia
1. Introduction The Bispectral Index (BIS) is a mathematically derived electroencephalographic (EEG) derivative that has been introduced to monitor depth of anesthesia [1] and to predict the level of sedation in patients undergoing conscious sedation [2]. BIS is a single number composed of from different EEG features, is drug independent and changes with increasing doses of hypnotics in an almost linear way [3]. * Corresponding author at: Birlik Mahallesi, Zirvekent 2, Etap Sitesi, C-3 blok, No: 62/43, 06610 C ¸ ankaya, Ankara, Turkey. Tel.: +90 312 4964073/532 7182441; fax: +90 318 2252819. E-mail addresses: [email protected], [email protected] (N.B. Muluk). 0385-8146/$ – see front matter # 2008 Published by Elsevier Ireland Ltd. doi:10.1016/j.anl.2007.12.007
The sensation of comfortable nasal breathing is a complex phenomenon. In optimal nasal respiration, air passes over the maximum amount of nasal mucosa with resulting humidification, cleansing and warming but without the sensation of dyspnea [4]. When there is a blockage in nasal breathing due to nasal packing after nasal surgeries, there may be a disturbance in patient’s sense of well-being resulting from problems with nasal respiration. In patients with nasal packing, oxygen saturation may be decreased and carbon dioxide level may be increased. In addition, nasal packing may affect patient’s sedation level while the patient is awake or asleep. In the present study, we investigated the risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery; and the effects of nasal
522
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
packing on conciousness level of the patients while the patients were awake or asleep. The measurements were based on BIS index and respiratory rate and oxygen saturation parameters. To the best of our knowledge, literature does not reveal any similar study.
2.2. Method
2. Materials and methods
2.2.1. Questionnaire form In the questionnaire form, the patients were asked for the presence of anterior and posterior nasal discharge, nasal congestion, cough, facial and dental pain, halitosis, paroxysmal nocturnal coughing spells, sore throat, fever, olfactory loss, headache and ear pain [6].
The study was conducted in the Ear Nose Throat (ENT) Department of Kirikkale University School of Medicine between April 2003 and February 2005. The Bispectral Index analysis was managed by Anesthesiology Department of Kirikkale University School of Medicine. All the steps of the study were planned and continued according to the principles outlined in the Declaration of Helsinki [5]. The written informed consents of all the patients in both groups were obtained before the study.
2.2.2. Endoscopic examination Endoscopic examination with 08 and 308 endoscopes was performed in the Endoscopy Unit of ENT Department of Kirikkale University School of Medicine. Discharge (none, clear and thin, thick, purulent), mucosal status (normoplasia, light hyperplasia with no erythema, hyperplasia) [7], anatomic anomalies (septal deviation, lateral rotation of the uncinate process, turbinate hypertrophy and other anatomic anomalies) [6] were assessed.
2.1. Subjects
2.2.3. Computed tomography By axial and coronal sections of the paranasal sinuses, chronic sinusitis patients with >4 mm mucosal thickening within paranasal sinuses, nasal polyposis, septal deviation, concha bullosa, lateral rotation of the uncinate process, prominent ethmoid bulla and other anatomic anomalies [6] were also investigated.
2.1.1. The study group The nasal surgery patients who were applied nasal packing at the end of the surgery were selected from the subjects examined in the Otolaryngology Department of Kirikkale University School of Medicine. The study group consisted of 15 adult patients (American Society of Anesthesiologist I—ASA I) (10 male, 5 female). They underwent nasal surgery for different reasons such as chronic sinusitis, nasal polyposis, nasal septal deviation and nasal deformity. Under general anesthesia, these patients were performed Functional Endoscopic Sinus Surgery (FESS), septoplasty, septorhinoplasty or rhinoplasty operations, and all of the patients were applied nasal packing bilaterally for 2 days. The mean age of the patients was 36.3 12.56 years. The patients were evaluated through a questionnaire form; ENT examination; endoscopic examination with 08 and 308 endoscopes; Waters’ graph; and if necessary, axial and coronal computerized tomography (CT) of paranasal sinuses in preoperative period. In rhinoplasty patients, four-sided photographs of the face were also taken. The patients in the study group had no coexisting medical conditions. 2.1.2. Control group The patients in the control group were selected among those who received general anesthesia for different reasons such as herniation of the lumbar disk, ureterolithiasis, abdominal dystrophia, etc. The control group consisted of 15 adult patients (ASA I) (10 male, 5 female). In this group, patients were not applied nasal packing, peroperatively or at the end of the operation. The mean age of the patients in the control group was 42.1 13.8 years. The patients in the control group had no coexisting medical conditions.
2.3. Instrumentation All the patients were hospitalized 1 day before the operation. Upon admission of the patients, the demographic data of the patients were obtained and the patients were informed on the research protocol and the operation procedure by one of the researchers. 2.3.1. Bispectral Index (BIS) In the operation room, a BIS monitor (BISTM Monitor, Model A-2000TM, System Rev. 3.21, Aspect Medical Systems, Natic, Massachusetts) was used to determine the patients’ EEG via a set of electrodes (BIS Sensor, Aspect Medical Systems) attached to the subject’s forehead as instructed by the manufacturer. Patients were instrumented with BIS leads (two-channelreferential measurement, frontotemporal application) on entry into the operation room. The electrode impedances were confirmed to be <10 kV before study drug initiation. A 10-min resting period was allowed after instrumentation and before the baseline measurements. In the 30 s averaged (bispectral smoothing), baseline BIS values were collected separated at intervals of 2 min. BIS values were obtained at every 10 min during the first hour and then at every 60 min. BIS index data, respiratory rate, peripheral oxygen saturation (Nellcor pulse oximeter Model N-100), pulse per minute, systolic and diastolic blood pressures were obtained simultaneously at the times described below:
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
1. before the operation induction, in the operation room (Basal value) without nasal packing (BO), 2. during anesthesia [while under anesthesia (the mean of five values)] without nasal packing (DA), 3. just after the anesthesia in the operation room with nasal packing (JAA), 4. in the fourth hour after the anesthesia, in the clinic, with nasal packing (AA-4 h), 5. in the second hour after sleep, in the evening, with nasal packing (AS-2 h), 6. in the fourth hour after sleep, in the evening, with nasal packing (AS-4 h), 7. in the morning when the patient awoke, with nasal packing (Aw). 2.3.2. Sedation procedure The same protocol was used in all the patients in the study: General anesthesia induction was achieved with propofol 1–1.5 mg/kg and vecuronium bromide 0.1 mg/kg. Sevoflurane 2% with N2O–O2 mixture (inspired O2 30%) was used for the maintenance of the general anesthesia. In the sixth hour after the operation, non-steroid antiinflammatory drugs were given to the patients who underwent general anesthesia. Non-steroid anti-inflammatory drugs provided sufficient levels of patient-satisfaction about postoperative pain. We did not give opioids in order to prevent respiratory inhibition. 2.3.3. Operation and procedure The patients underwent FESS, septoplasty, septorhinoplasty or rhinoplasty under general anesthesia. All of the patients were applied anterior nasal packing bilaterally for 2 days. The most commonly sterilized strip gauze with antibiotic ointment was used as an anterior nasal packing. Oxidized cellulose preparations (Surgicel) and absorbable gelatin sponge (Gelfoam) were also used for this purpose [8]. Two days after the surgery, anterior nasal packings were removed carefully. Therefore, the 1st and 2nd values of the BIS monitoring were obtained from the patients without nasal packing; and the 3rd, 4th, 5th, 6th and 7th values were obtained from the patients with nasal packing.
523
2.3.4. Statistical analysis Statistical package for SPSS (Version 10.0) was used for statistical evaluation. The difference between ages of study and control groups was analyzed by ‘‘Independent Sample T-test’’. The differences between BIS index; respiratory rate; oxygen saturation; pulse per minute; systolic blood pressure; and diastolic blood pressure of study and control groups were analyzed by ‘‘Mann–Whitney U-test’’ for each of the seven measurement times (1. before the operation induction, in the operation room (Basal value) (BO), 2. during anesthesia [While under anesthesia (the mean of five values)] (DA), 3. just after the anesthesia in the operation room (JAA), 4. in the fourth hour after the anesthesia, in the clinic (AA-4 h), 5. in the second hour after sleep, in the evening (AS-2 h), 6. in the fourth hour after sleep, in the evening (AS-4 h), 7. in the morning when the patient awoke) (Aw). p < 0.05 was considered statistically significant.
3. Results For the study and control groups; the values of BIS index (Table 1); respiratory rate (Fig. 1); oxygen saturation (Fig. 2); pulse per minute; systolic blood pressure; and diastolic blood pressure for each of the seven measurement times (BO, DA, JAA, AA-4 h, AS-2 h, AS-4 h and Aw) were evaluated. The respiratory rates of the study and control groups were demonstrated in Fig. 1. The oxygen saturation values of the study and control groups were demonstrated in Fig. 2. The difference between ages of the study and control groups was analyzed by ‘‘Independent Sample T-test’’ and no statistically significant difference was found ( p = 0.239). The difference between BIS index; respiratory rate; oxygen saturation; pulse per minute; systolic blood pressure; and diastolic blood pressure values of the study and control groups were analyzed by ‘‘Mann–Whitney U-test’’ for each of the seven times (1. BO, 2. DA, 3. JAA, 4. AA-4 h, 5. AS2 h, 6. AS-4 h and 7. Aw): For BIS index, no statistically significant difference was found between the two groups ( p > 0.05) (Table 1).
Table 1 BIS index values of the study and control groups Time
p*
BIS index values Study group
BO DA JAA AA-4 h AS-2 h AS-4 h Aw *
Control group
Median
Minimum
Maximum
Median
Minimum
Maximum
97.0 40.0 79.0 96.0 75.0 74.0 96.0
85.0 34.0 58.0 83.0 32.0 43.0 77.0
98.0 63.0 97.0 98.0 95.0 97.0 98.0
98.0 44.0 83.0 97.0 84.0 77.0 97.0
94.0 34.0 51.0 86.0 49.0 34.0 91.0
98.0 61.0 98.0 98.0 96.0 97.0 98.0
p values are the results of Mann–Whitney U-test.
0.326 0.164 0.443 0.219 0.430 0.787 0.202
524
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
Fig. 1. Respiratory rates of the study and control groups.ôNasal P: Study group: ôData is presented as mean standard deviation; *the statistically significant difference is present between the study and control groups at AS4 h by Mann Whitney U Test ( p = 0.038).
For respiratory rate, at AS-4 h, a statistically significant difference was found ( p = 0.038). The respiratory rate of the control group was higher than that of the study group (median value of the respiratory rate in the control group = 20.0 breaths per minute); median value of the respiratory rate in the study group = 18.0 breaths per minute). However, for the other measurement times, no statistically significant difference was found ( p > 0.05) (Fig. 1). For oxygen saturation, at AA-4 h, a statistically significant difference was found between the two groups ( p = 0.048). Saturation value of the study group was lower than that of the control group (the median value of the saturation in the study group = 96%; the median value of the saturation in the control group = 97%). For the other measurement times, no statistically significant difference was detected ( p > 0.05) (Fig. 2). For pulse per minute, no statistically significant difference was found ( p > 0.05). For systolic blood pressure; at BO and DA, a statistically significant difference was found [( p = 0.007) (the median
Fig. 2. Oxygen saturation values of the study and control groups.ôNasal P: Study group: ôData is presented as mean standard deviation; *the statistically significant difference is present between the study and control groups at AA-4 h by Mann Whitney U Test ( p = 0.048).
value of the systolic blood pressure in the study group = 121 mmHg and the median value of the systolic blood pressure in the control group = 136 mmHg); and ( p = 0.001) (the median value of the systolic blood pressure in the study group = 90 mmHg and the median value of the systolic blood pressure in the control group = 111 mmHg), respectively]. For diastolic blood pressure; at BO and DA, a statistically significant difference was found [( p = 0.036) (the median value of the diastolic blood pressure in the study group = 77 mmHg and the median value of the diastolic blood pressure in the control group = 81 mmHg); and ( p = 0.006) (the median value of the diastolic blood pressure in the study group = 63 mmHg and the median value of the diastolic blood pressure in the control group = 76 mmHg), respectively]. 4. Discussion A variety of direct and non-invasive monitoring techniques assessing the effects of sedatives and anesthetics on the brain have been proposed and studied. The most direct monitoring methods utilize the EEG, which allows for a non-invasive observation of cerebral electrical activity [9]. Bispectral analysis of the EEG has been shown in many situations to be fairly reliable and accurate method for monitoring the depth of anesthesia and sedation. The BIS is a numeric index ranging from a maximum of 100, indicating that the patient is fully awake, to a minimum of zero, representing a total suppression of electrical brain activity [10]. Tung et al. [11] monitored volunteers during the transition from waking to sleep. Because sleep shares electroencephalographic similarities with the anesthetized state, they hypothesized that the BIS monitor, a currently available EEG-based monitor of anesthetic depth, would detect the onset of physiologic sleep. All the subjects responded to audio stimuli at BIS values >90, and were asleep either by subjective or objective report at BIS values <80. They concluded that although variability in the BIS value marking sleep onset was noted, the BIS monitor detected all episodes of sleep onset in their testing regimen and a threshold BIS value can be defined, allowing the BIS monitor to detect sleep onset. In the present study, we investigated the risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery by measuring oxygen saturation levels and respiratory rates. Since increased carbon dioxide level and decreased oxygen level may affect patient’s sedation level in the awake state and during sleeping; we investigated the effects of nasal packing on consciousness level while the patients who underwent nasal surgery were awake or asleep by BIS index measurement. The baseline value of BIS is 96–99 in the awake state [12]; and our results were similar to the literature data; and no significant difference was found between the BIS indexes of
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
the study and control groups, indicating that nasal packing did not affect the sedation and consciousness level of the patients, as measured by BIS index. It appears that the use of BIS monitor may help titrate the level of sedation so that less amount of anesthetic drug is used to maintain the desired level of sedation [13]. In the 3rd–7th measurements while the patients were with nasal packing, the respiratory rates of the study group were lower than those of the control group and at AS-4 h, the difference was significant. At AS-4 h, the patients had nasal packing, and sleep depth might have been much more than the earlier stages of sleep. At this time, the lower respiration rate may be very important for both the patient and the responsible physician. Thus, this should be kept in mind in management of the patients with nasal packing especially during the late period of sleep. Lower respiration rates may lead to lower saturation rates. Hence, postoperatively, these patients must be monitored closely in the clinics. Patients with respiratory risks should also be monitored, and the position of their beds should be adjusted to 458 upwards on the horizontal plane. This will ensure that the base of the tongue does not move backward and airway passage is not obstructed. The another important thing is in the evening. When the medical team thinks that the patient is sleeping; the patient may have carbon dioxide narcosis. If no oxygen saturation monitoring system is available, a major mistake may be committed, leading to undesired results. While the patients were with nasal packing, the oxygen saturation rates of the study group were lower than those of the control group were, and at AA-4 h, the difference was significant. In the postoperative period, 4 h after the operation, the patients might have been affected by anesthetical agents and in the study group, nasal packing may be a contributing factor to sedation induced by anesthesia. At this time, slightly lower oxygen saturation may be important especially in patients with airway problems, such as obstructive sleep apnea and/or chronic obstructive pulmonary disease (COPD). In these patients, a choice of short acting anesthetic agents with no residual effects should be made. In addition, these patients may be observed in the intensive care units until the morning after the operation. If this is not possible, they should be closely monitored and provided with oral oxygen in the clinic. In the patients who were applied nasal packing at the end of nasal surgery, it is necessary to monitor non-invasive respiratory parameters such as end-tidal carbon dioxide, end-tidal oxygen and saturation. In addition, because of the blockage of the nasal passage with nasal packing, especially in patients with coexisting pulmonary disease and in elderly population, enriched oxygen may be given by oral catheter. In the study of Sandler [13], the Bispectral Index has been used to interpret partial EEG recordings to predict the level of sedation and loss of consciousness in patients undergoing general anesthesia. BIS index provides additional information to standard monitoring techniques that help guide the administration of sedative-hypnotic agents.
525
In patients with nasal packing due to nasal surgery, the surgeon and anesthetist must be very careful not to sedate the patient deeply or give opioids. Furthermore, patients with obstructive sleep apnea and/or COPD should receive more attention. If nasal packing must be applied in such patients because of nasal surgery, monitoring of oxygen saturation and depth of anesthesia and sedation must be performed in the postoperative period. In our study, we did not use sedatives and/or opioids that cause respiratory inhibition and aimed to demonstrate the sole effects of nasal packing on BIS and respiration and saturation values [14]. BIS aids in titrating the level of sedation; therefore, less amount of anesthetic drug is used to maintain general anesthesia. In these BIS-monitored patients, earlier return of motor function may help patients tongue tonus and may prevent the obstruction of the upper airway by the mass of the tongue base. We conclude that the patients who were applied nasal packing at the end of nasal surgery, at AA-4 h and AS-4 h times, there may be risk of decreased oxygen saturation and respiratory rate parameters respectively. Therefore, in patients with the risk of respiratory problems, such as OSA and COPD, merocell packing with airway cannule in the center should be preferred for nasal packing. In addition, these patients should be closely monitored with non-invasive respiratory parameters and be provided with enriched oxygen through an oral catheter. However, the use of opioids and heavy sedation should be avoided in these patients.
References [1] Hemmerling TM, Harvey P. Electrocardiographic electrodes provide the same results as expensive special sensors in the routine monitoring of anesthetic depth. Anesth Analg 2002;94:369–71. [2] Sandler NA, Hodges J, Sabino M. Assessment of recovery in patients undergoing intravenous conscious sedation using bispectral analysis. J Oral Maxillofac Surg 2001;59:603–11. discussion 611–612. [3] Sennholz G, Bispectral analysis technology and equipment. Minerva Anestesiol 2000;66:386–8. [4] Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, Richardson MA. 3rd ed., Otolaryngology head & neck surgery, vol. II, 3rd ed. St Louis: Mosby; 1998. [5] 52nd WMA General Assembly. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2000;284:3043–9. [6] Driscoll PV, Naclerio RM, Baroody FM. CD4+ lymphocytes are increased in the sinus mucosa of children with chronic sinusitis. Arch Otolaryngol Head Neck Surg 1996;122:1071–6. [7] Lavigne F, Nguyen CT, Cameron L, Hamid Q, Renzi PM. Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis. J Allergy Clin Immunol 2000;105:746–51. [8] Abelson TI, Epistaxis. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL, editors. Otolaryngology. vol. III: Head and neck. 3rd ed., Philadelphia: W.B. Saunders Company; 1991. p. 1831–41. [9] Barr G, jacobson JG, Owall A, Anderson RE. Nitrous oxide does not alter bispectral index: study with nitrous oxide as a sole agent and as an adjunct to i.v. anaesthesia. Br J Anaesth 1999;82:827–30. [10] Religa ZC, Wilson S, Ganzberg SI, Casamassimo PS. Association between bispectral analysis and level of conscious sedation of pediatric dental patients. Pediatr Dent 2002;24:221–6.
526
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
[11] Tung A, Lynch JP, Roizen MF. Use of the BIS monitor to detect onset of naturally occurring sleep. J Clin Monit Comput 2002;17: 37–42. [12] Renna M, Handy J, Shah A. Low baseline Bispectral Index of the electroencephalogram in patients with dementia. Anesth Analg 2003;96:1380–5.
[13] Sandler NA, The use of bispectral analysis to monitor outpatient sedation. Anesth Prog 2000;47:72–83. [14] Glass PS, Bloom M, Kearse L, Rosow C, Sebel P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997;86:836–47.
Risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery ¨ zc¸akır b, Nuray Bayar Muluk a,*, Alpaslan Apan b, Sibel O a c Osman Ku¨rs¸at Arıkan , Can Koc¸ b
a ENT Department, School of Medicine, Kırıkkale University, Turkey Anesthesiology Department, School of Medicine, Kırıkkale University, Turkey c Outpatient Clinic, Turkey
Received 17 June 2007; accepted 19 December 2007 Available online 7 March 2008
Abstract Objective: This prospective study investigated the risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery; and effects of nasal packing on consciousness level while the patients were awake or asleep, measured by Bispectral Index (BIS). Methods: The study group consisted of 15 adult patients (10 male, 5 female), who were applied nasal packing at the end of nasal surgery. The control group consisted of 15 adult patients (10 male, 5 female), who received general anesthesia for various reasons. In the study and control groups, BIS index, respiratory rate, peripheral oxygen saturation, pulse per minute and blood pressure were measured at seven different times. Results: There was no statistically significant difference between BIS indexes of the study and control groups. In the fourth hour after sleep (AS-4 h), respiratory rate of the study group was significantly lower than that of the control group. In the fourth hour after the anesthesia (AA4 h), oxygen saturation value of the study group was lower than that of the control group. Conclusion: We conclude that in patients who are applied nasal packing at the end of nasal surgery; at AA-4 h and AS-4 h times, there may be risk of decrease in the oxygen saturation and respiratory rate parameters, respectively. Therefore, it is necessary to monitor non-invasive respiratory parameters and to give enriched oxygen by an oral catheter. # 2008 Published by Elsevier Ireland Ltd. Keywords: The Bispectral Index (BIS); Respiratory rate; Oxygen saturation; Nasal packing; Nasal surgery; Enriched oxygen; Anesthesia
1. Introduction The Bispectral Index (BIS) is a mathematically derived electroencephalographic (EEG) derivative that has been introduced to monitor depth of anesthesia [1] and to predict the level of sedation in patients undergoing conscious sedation [2]. BIS is a single number composed of from different EEG features, is drug independent and changes with increasing doses of hypnotics in an almost linear way [3]. * Corresponding author at: Birlik Mahallesi, Zirvekent 2, Etap Sitesi, C-3 blok, No: 62/43, 06610 C ¸ ankaya, Ankara, Turkey. Tel.: +90 312 4964073/532 7182441; fax: +90 318 2252819. E-mail addresses: [email protected], [email protected] (N.B. Muluk). 0385-8146/$ – see front matter # 2008 Published by Elsevier Ireland Ltd. doi:10.1016/j.anl.2007.12.007
The sensation of comfortable nasal breathing is a complex phenomenon. In optimal nasal respiration, air passes over the maximum amount of nasal mucosa with resulting humidification, cleansing and warming but without the sensation of dyspnea [4]. When there is a blockage in nasal breathing due to nasal packing after nasal surgeries, there may be a disturbance in patient’s sense of well-being resulting from problems with nasal respiration. In patients with nasal packing, oxygen saturation may be decreased and carbon dioxide level may be increased. In addition, nasal packing may affect patient’s sedation level while the patient is awake or asleep. In the present study, we investigated the risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery; and the effects of nasal
522
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
packing on conciousness level of the patients while the patients were awake or asleep. The measurements were based on BIS index and respiratory rate and oxygen saturation parameters. To the best of our knowledge, literature does not reveal any similar study.
2.2. Method
2. Materials and methods
2.2.1. Questionnaire form In the questionnaire form, the patients were asked for the presence of anterior and posterior nasal discharge, nasal congestion, cough, facial and dental pain, halitosis, paroxysmal nocturnal coughing spells, sore throat, fever, olfactory loss, headache and ear pain [6].
The study was conducted in the Ear Nose Throat (ENT) Department of Kirikkale University School of Medicine between April 2003 and February 2005. The Bispectral Index analysis was managed by Anesthesiology Department of Kirikkale University School of Medicine. All the steps of the study were planned and continued according to the principles outlined in the Declaration of Helsinki [5]. The written informed consents of all the patients in both groups were obtained before the study.
2.2.2. Endoscopic examination Endoscopic examination with 08 and 308 endoscopes was performed in the Endoscopy Unit of ENT Department of Kirikkale University School of Medicine. Discharge (none, clear and thin, thick, purulent), mucosal status (normoplasia, light hyperplasia with no erythema, hyperplasia) [7], anatomic anomalies (septal deviation, lateral rotation of the uncinate process, turbinate hypertrophy and other anatomic anomalies) [6] were assessed.
2.1. Subjects
2.2.3. Computed tomography By axial and coronal sections of the paranasal sinuses, chronic sinusitis patients with >4 mm mucosal thickening within paranasal sinuses, nasal polyposis, septal deviation, concha bullosa, lateral rotation of the uncinate process, prominent ethmoid bulla and other anatomic anomalies [6] were also investigated.
2.1.1. The study group The nasal surgery patients who were applied nasal packing at the end of the surgery were selected from the subjects examined in the Otolaryngology Department of Kirikkale University School of Medicine. The study group consisted of 15 adult patients (American Society of Anesthesiologist I—ASA I) (10 male, 5 female). They underwent nasal surgery for different reasons such as chronic sinusitis, nasal polyposis, nasal septal deviation and nasal deformity. Under general anesthesia, these patients were performed Functional Endoscopic Sinus Surgery (FESS), septoplasty, septorhinoplasty or rhinoplasty operations, and all of the patients were applied nasal packing bilaterally for 2 days. The mean age of the patients was 36.3 12.56 years. The patients were evaluated through a questionnaire form; ENT examination; endoscopic examination with 08 and 308 endoscopes; Waters’ graph; and if necessary, axial and coronal computerized tomography (CT) of paranasal sinuses in preoperative period. In rhinoplasty patients, four-sided photographs of the face were also taken. The patients in the study group had no coexisting medical conditions. 2.1.2. Control group The patients in the control group were selected among those who received general anesthesia for different reasons such as herniation of the lumbar disk, ureterolithiasis, abdominal dystrophia, etc. The control group consisted of 15 adult patients (ASA I) (10 male, 5 female). In this group, patients were not applied nasal packing, peroperatively or at the end of the operation. The mean age of the patients in the control group was 42.1 13.8 years. The patients in the control group had no coexisting medical conditions.
2.3. Instrumentation All the patients were hospitalized 1 day before the operation. Upon admission of the patients, the demographic data of the patients were obtained and the patients were informed on the research protocol and the operation procedure by one of the researchers. 2.3.1. Bispectral Index (BIS) In the operation room, a BIS monitor (BISTM Monitor, Model A-2000TM, System Rev. 3.21, Aspect Medical Systems, Natic, Massachusetts) was used to determine the patients’ EEG via a set of electrodes (BIS Sensor, Aspect Medical Systems) attached to the subject’s forehead as instructed by the manufacturer. Patients were instrumented with BIS leads (two-channelreferential measurement, frontotemporal application) on entry into the operation room. The electrode impedances were confirmed to be <10 kV before study drug initiation. A 10-min resting period was allowed after instrumentation and before the baseline measurements. In the 30 s averaged (bispectral smoothing), baseline BIS values were collected separated at intervals of 2 min. BIS values were obtained at every 10 min during the first hour and then at every 60 min. BIS index data, respiratory rate, peripheral oxygen saturation (Nellcor pulse oximeter Model N-100), pulse per minute, systolic and diastolic blood pressures were obtained simultaneously at the times described below:
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
1. before the operation induction, in the operation room (Basal value) without nasal packing (BO), 2. during anesthesia [while under anesthesia (the mean of five values)] without nasal packing (DA), 3. just after the anesthesia in the operation room with nasal packing (JAA), 4. in the fourth hour after the anesthesia, in the clinic, with nasal packing (AA-4 h), 5. in the second hour after sleep, in the evening, with nasal packing (AS-2 h), 6. in the fourth hour after sleep, in the evening, with nasal packing (AS-4 h), 7. in the morning when the patient awoke, with nasal packing (Aw). 2.3.2. Sedation procedure The same protocol was used in all the patients in the study: General anesthesia induction was achieved with propofol 1–1.5 mg/kg and vecuronium bromide 0.1 mg/kg. Sevoflurane 2% with N2O–O2 mixture (inspired O2 30%) was used for the maintenance of the general anesthesia. In the sixth hour after the operation, non-steroid antiinflammatory drugs were given to the patients who underwent general anesthesia. Non-steroid anti-inflammatory drugs provided sufficient levels of patient-satisfaction about postoperative pain. We did not give opioids in order to prevent respiratory inhibition. 2.3.3. Operation and procedure The patients underwent FESS, septoplasty, septorhinoplasty or rhinoplasty under general anesthesia. All of the patients were applied anterior nasal packing bilaterally for 2 days. The most commonly sterilized strip gauze with antibiotic ointment was used as an anterior nasal packing. Oxidized cellulose preparations (Surgicel) and absorbable gelatin sponge (Gelfoam) were also used for this purpose [8]. Two days after the surgery, anterior nasal packings were removed carefully. Therefore, the 1st and 2nd values of the BIS monitoring were obtained from the patients without nasal packing; and the 3rd, 4th, 5th, 6th and 7th values were obtained from the patients with nasal packing.
523
2.3.4. Statistical analysis Statistical package for SPSS (Version 10.0) was used for statistical evaluation. The difference between ages of study and control groups was analyzed by ‘‘Independent Sample T-test’’. The differences between BIS index; respiratory rate; oxygen saturation; pulse per minute; systolic blood pressure; and diastolic blood pressure of study and control groups were analyzed by ‘‘Mann–Whitney U-test’’ for each of the seven measurement times (1. before the operation induction, in the operation room (Basal value) (BO), 2. during anesthesia [While under anesthesia (the mean of five values)] (DA), 3. just after the anesthesia in the operation room (JAA), 4. in the fourth hour after the anesthesia, in the clinic (AA-4 h), 5. in the second hour after sleep, in the evening (AS-2 h), 6. in the fourth hour after sleep, in the evening (AS-4 h), 7. in the morning when the patient awoke) (Aw). p < 0.05 was considered statistically significant.
3. Results For the study and control groups; the values of BIS index (Table 1); respiratory rate (Fig. 1); oxygen saturation (Fig. 2); pulse per minute; systolic blood pressure; and diastolic blood pressure for each of the seven measurement times (BO, DA, JAA, AA-4 h, AS-2 h, AS-4 h and Aw) were evaluated. The respiratory rates of the study and control groups were demonstrated in Fig. 1. The oxygen saturation values of the study and control groups were demonstrated in Fig. 2. The difference between ages of the study and control groups was analyzed by ‘‘Independent Sample T-test’’ and no statistically significant difference was found ( p = 0.239). The difference between BIS index; respiratory rate; oxygen saturation; pulse per minute; systolic blood pressure; and diastolic blood pressure values of the study and control groups were analyzed by ‘‘Mann–Whitney U-test’’ for each of the seven times (1. BO, 2. DA, 3. JAA, 4. AA-4 h, 5. AS2 h, 6. AS-4 h and 7. Aw): For BIS index, no statistically significant difference was found between the two groups ( p > 0.05) (Table 1).
Table 1 BIS index values of the study and control groups Time
p*
BIS index values Study group
BO DA JAA AA-4 h AS-2 h AS-4 h Aw *
Control group
Median
Minimum
Maximum
Median
Minimum
Maximum
97.0 40.0 79.0 96.0 75.0 74.0 96.0
85.0 34.0 58.0 83.0 32.0 43.0 77.0
98.0 63.0 97.0 98.0 95.0 97.0 98.0
98.0 44.0 83.0 97.0 84.0 77.0 97.0
94.0 34.0 51.0 86.0 49.0 34.0 91.0
98.0 61.0 98.0 98.0 96.0 97.0 98.0
p values are the results of Mann–Whitney U-test.
0.326 0.164 0.443 0.219 0.430 0.787 0.202
524
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
Fig. 1. Respiratory rates of the study and control groups.ôNasal P: Study group: ôData is presented as mean standard deviation; *the statistically significant difference is present between the study and control groups at AS4 h by Mann Whitney U Test ( p = 0.038).
For respiratory rate, at AS-4 h, a statistically significant difference was found ( p = 0.038). The respiratory rate of the control group was higher than that of the study group (median value of the respiratory rate in the control group = 20.0 breaths per minute); median value of the respiratory rate in the study group = 18.0 breaths per minute). However, for the other measurement times, no statistically significant difference was found ( p > 0.05) (Fig. 1). For oxygen saturation, at AA-4 h, a statistically significant difference was found between the two groups ( p = 0.048). Saturation value of the study group was lower than that of the control group (the median value of the saturation in the study group = 96%; the median value of the saturation in the control group = 97%). For the other measurement times, no statistically significant difference was detected ( p > 0.05) (Fig. 2). For pulse per minute, no statistically significant difference was found ( p > 0.05). For systolic blood pressure; at BO and DA, a statistically significant difference was found [( p = 0.007) (the median
Fig. 2. Oxygen saturation values of the study and control groups.ôNasal P: Study group: ôData is presented as mean standard deviation; *the statistically significant difference is present between the study and control groups at AA-4 h by Mann Whitney U Test ( p = 0.048).
value of the systolic blood pressure in the study group = 121 mmHg and the median value of the systolic blood pressure in the control group = 136 mmHg); and ( p = 0.001) (the median value of the systolic blood pressure in the study group = 90 mmHg and the median value of the systolic blood pressure in the control group = 111 mmHg), respectively]. For diastolic blood pressure; at BO and DA, a statistically significant difference was found [( p = 0.036) (the median value of the diastolic blood pressure in the study group = 77 mmHg and the median value of the diastolic blood pressure in the control group = 81 mmHg); and ( p = 0.006) (the median value of the diastolic blood pressure in the study group = 63 mmHg and the median value of the diastolic blood pressure in the control group = 76 mmHg), respectively]. 4. Discussion A variety of direct and non-invasive monitoring techniques assessing the effects of sedatives and anesthetics on the brain have been proposed and studied. The most direct monitoring methods utilize the EEG, which allows for a non-invasive observation of cerebral electrical activity [9]. Bispectral analysis of the EEG has been shown in many situations to be fairly reliable and accurate method for monitoring the depth of anesthesia and sedation. The BIS is a numeric index ranging from a maximum of 100, indicating that the patient is fully awake, to a minimum of zero, representing a total suppression of electrical brain activity [10]. Tung et al. [11] monitored volunteers during the transition from waking to sleep. Because sleep shares electroencephalographic similarities with the anesthetized state, they hypothesized that the BIS monitor, a currently available EEG-based monitor of anesthetic depth, would detect the onset of physiologic sleep. All the subjects responded to audio stimuli at BIS values >90, and were asleep either by subjective or objective report at BIS values <80. They concluded that although variability in the BIS value marking sleep onset was noted, the BIS monitor detected all episodes of sleep onset in their testing regimen and a threshold BIS value can be defined, allowing the BIS monitor to detect sleep onset. In the present study, we investigated the risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery by measuring oxygen saturation levels and respiratory rates. Since increased carbon dioxide level and decreased oxygen level may affect patient’s sedation level in the awake state and during sleeping; we investigated the effects of nasal packing on consciousness level while the patients who underwent nasal surgery were awake or asleep by BIS index measurement. The baseline value of BIS is 96–99 in the awake state [12]; and our results were similar to the literature data; and no significant difference was found between the BIS indexes of
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
the study and control groups, indicating that nasal packing did not affect the sedation and consciousness level of the patients, as measured by BIS index. It appears that the use of BIS monitor may help titrate the level of sedation so that less amount of anesthetic drug is used to maintain the desired level of sedation [13]. In the 3rd–7th measurements while the patients were with nasal packing, the respiratory rates of the study group were lower than those of the control group and at AS-4 h, the difference was significant. At AS-4 h, the patients had nasal packing, and sleep depth might have been much more than the earlier stages of sleep. At this time, the lower respiration rate may be very important for both the patient and the responsible physician. Thus, this should be kept in mind in management of the patients with nasal packing especially during the late period of sleep. Lower respiration rates may lead to lower saturation rates. Hence, postoperatively, these patients must be monitored closely in the clinics. Patients with respiratory risks should also be monitored, and the position of their beds should be adjusted to 458 upwards on the horizontal plane. This will ensure that the base of the tongue does not move backward and airway passage is not obstructed. The another important thing is in the evening. When the medical team thinks that the patient is sleeping; the patient may have carbon dioxide narcosis. If no oxygen saturation monitoring system is available, a major mistake may be committed, leading to undesired results. While the patients were with nasal packing, the oxygen saturation rates of the study group were lower than those of the control group were, and at AA-4 h, the difference was significant. In the postoperative period, 4 h after the operation, the patients might have been affected by anesthetical agents and in the study group, nasal packing may be a contributing factor to sedation induced by anesthesia. At this time, slightly lower oxygen saturation may be important especially in patients with airway problems, such as obstructive sleep apnea and/or chronic obstructive pulmonary disease (COPD). In these patients, a choice of short acting anesthetic agents with no residual effects should be made. In addition, these patients may be observed in the intensive care units until the morning after the operation. If this is not possible, they should be closely monitored and provided with oral oxygen in the clinic. In the patients who were applied nasal packing at the end of nasal surgery, it is necessary to monitor non-invasive respiratory parameters such as end-tidal carbon dioxide, end-tidal oxygen and saturation. In addition, because of the blockage of the nasal passage with nasal packing, especially in patients with coexisting pulmonary disease and in elderly population, enriched oxygen may be given by oral catheter. In the study of Sandler [13], the Bispectral Index has been used to interpret partial EEG recordings to predict the level of sedation and loss of consciousness in patients undergoing general anesthesia. BIS index provides additional information to standard monitoring techniques that help guide the administration of sedative-hypnotic agents.
525
In patients with nasal packing due to nasal surgery, the surgeon and anesthetist must be very careful not to sedate the patient deeply or give opioids. Furthermore, patients with obstructive sleep apnea and/or COPD should receive more attention. If nasal packing must be applied in such patients because of nasal surgery, monitoring of oxygen saturation and depth of anesthesia and sedation must be performed in the postoperative period. In our study, we did not use sedatives and/or opioids that cause respiratory inhibition and aimed to demonstrate the sole effects of nasal packing on BIS and respiration and saturation values [14]. BIS aids in titrating the level of sedation; therefore, less amount of anesthetic drug is used to maintain general anesthesia. In these BIS-monitored patients, earlier return of motor function may help patients tongue tonus and may prevent the obstruction of the upper airway by the mass of the tongue base. We conclude that the patients who were applied nasal packing at the end of nasal surgery, at AA-4 h and AS-4 h times, there may be risk of decreased oxygen saturation and respiratory rate parameters respectively. Therefore, in patients with the risk of respiratory problems, such as OSA and COPD, merocell packing with airway cannule in the center should be preferred for nasal packing. In addition, these patients should be closely monitored with non-invasive respiratory parameters and be provided with enriched oxygen through an oral catheter. However, the use of opioids and heavy sedation should be avoided in these patients.
References [1] Hemmerling TM, Harvey P. Electrocardiographic electrodes provide the same results as expensive special sensors in the routine monitoring of anesthetic depth. Anesth Analg 2002;94:369–71. [2] Sandler NA, Hodges J, Sabino M. Assessment of recovery in patients undergoing intravenous conscious sedation using bispectral analysis. J Oral Maxillofac Surg 2001;59:603–11. discussion 611–612. [3] Sennholz G, Bispectral analysis technology and equipment. Minerva Anestesiol 2000;66:386–8. [4] Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, Richardson MA. 3rd ed., Otolaryngology head & neck surgery, vol. II, 3rd ed. St Louis: Mosby; 1998. [5] 52nd WMA General Assembly. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2000;284:3043–9. [6] Driscoll PV, Naclerio RM, Baroody FM. CD4+ lymphocytes are increased in the sinus mucosa of children with chronic sinusitis. Arch Otolaryngol Head Neck Surg 1996;122:1071–6. [7] Lavigne F, Nguyen CT, Cameron L, Hamid Q, Renzi PM. Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis. J Allergy Clin Immunol 2000;105:746–51. [8] Abelson TI, Epistaxis. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL, editors. Otolaryngology. vol. III: Head and neck. 3rd ed., Philadelphia: W.B. Saunders Company; 1991. p. 1831–41. [9] Barr G, jacobson JG, Owall A, Anderson RE. Nitrous oxide does not alter bispectral index: study with nitrous oxide as a sole agent and as an adjunct to i.v. anaesthesia. Br J Anaesth 1999;82:827–30. [10] Religa ZC, Wilson S, Ganzberg SI, Casamassimo PS. Association between bispectral analysis and level of conscious sedation of pediatric dental patients. Pediatr Dent 2002;24:221–6.
526
N.B. Muluk et al. / Auris Nasus Larynx 35 (2008) 521–526
[11] Tung A, Lynch JP, Roizen MF. Use of the BIS monitor to detect onset of naturally occurring sleep. J Clin Monit Comput 2002;17: 37–42. [12] Renna M, Handy J, Shah A. Low baseline Bispectral Index of the electroencephalogram in patients with dementia. Anesth Analg 2003;96:1380–5.
[13] Sandler NA, The use of bispectral analysis to monitor outpatient sedation. Anesth Prog 2000;47:72–83. [14] Glass PS, Bloom M, Kearse L, Rosow C, Sebel P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997;86:836–47.