Several pharmacologic agents used to induce controlled hypotension may reduce intraoperative bleeding and improved surgical field quality during endoscopic sinus surgery, with similar safety profiles across drugs, according to a systematic review and network meta-analysis.
In the study, investigators identified 52 randomized clinical trials involving 3,526 patients undergoing endoscopic sinus surgery (ESS), 43 of which were included in the network meta-analysis. The studies were identified through searches of the PubMed, Scopus, Web of Science, and Cochrane databases through May 2025. The investigators examined the safety and effectiveness of the hypotensive agents dexmedetomidine, clonidine, esmolol, labetalol, bisoprolol, metoprolol, diltiazem, nifedipine, and verapamil, compared with placebo or other agents. The primary outcomes of the study were surgical bleeding score, intraoperative mean arterial pressure (MAP), and mean intraoperative heart rate; and secondary outcomes included blood loss, surgery duration, and emergence time.
Across the included trials, several agents reduced bleeding scores compared with placebo. Diltiazem was associated with the greatest reduction, followed by esmolol, dexmedetomidine, labetalol, and clonidine. Dexmedetomidine was associated with the greatest reduction in mean arterial pressure, lowering MAP by just over 30 mmHg, followed by clonidine, esmolol, and labetalol. After a period of 60 minutes, the largest reductions in mean intraoperative heart rate came with the use of bispoprolol followed by verapamil and labetalol.
Further, esmolol and labetalol were associated with shorter emergence times of less than 4 minutes. Blood loss was lower with labetalol, dexmedetomidine, esmolol, and clonidine. Clonidine and dexmedetomidine were associated with shorter surgery duration, while dexmedetomidine prolonged time to first analgesic request. No statistically significant differences were observed across agents for bradycardia, hypotension, or postoperative nausea and vomiting.
The results varied by outcome, with different agents ranking highest for bleeding reduction, blood pressure lowering, and recovery.
The investigators noted important limitations, including the reliance on subjective bleeding scores and variation in drug dosing and administration, which contributed to heterogeneity and limited certainty of evidence.
“Controlling hypotension for enhanced surgical field quality in ESS is possible with multiple safe and effective pharmacologic options that can be tailored to the patient and surgical context,” wrote lead study author Abdelrahman Saeed, MBBS, of the Faculty of Medicine at Al-Azhar University in Egypt, and colleagues.
Full disclosures of the study authors can be found in the study.
