A systematic review and network meta-analysis of randomized clinical trials found that several pharmacologic agents used to induce controlled hypotension are effective and generally safe for reducing intraoperative bleeding during endoscopic sinus surgery. The analysis, published in JAMA Otolaryngology — Head & Neck Surgery, suggests that drug selection can be tailored to surgical priorities such as bleeding control, hemodynamic stability, and recovery time.
Endoscopic sinus surgery (ESS) is commonly performed to treat chronic inflammatory sinonasal conditions, including chronic rhinosinusitis and nasal polyposis. Excessive intraoperative bleeding can impair visualization and increase procedural complexity and complication risk. Although controlled hypotension is widely used to improve the surgical field, the comparative effectiveness of available agents has remained uncertain.
Investigators, led by Abdelrahman Saeed, MBBS, of Al-Azhar University in Damietta, Egypt, analyzed data from 52 randomized clinical trials involving 3,526 patients undergoing ESS. The trials compared multiple hypotensive agents—including alpha-2 agonists, beta-blockers, and calcium channel blockers—with placebo or with each other. Databases searched included PubMed, Scopus, Web of Science, and Cochrane from inception through May 2025. Outcomes were assessed using random-effects meta-analysis in accordance with PRISMA guidelines, and certainty of evidence was graded using the GRADE framework.
Compared with placebo, several agents were associated with significantly improved surgical field visualization, as measured by validated bleeding scores. Diltiazem demonstrated the greatest reduction in bleeding scores, followed by esmolol, dexmedetomidine, labetalol, and clonidine.
Dexmedetomidine was associated with the largest reduction in intraoperative mean arterial pressure, lowering pressure by approximately 30 mm Hg compared with placebo. Clonidine, esmolol, and labetalol also produced significant reductions. No agent demonstrated a consistent advantage in controlling mean intraoperative heart rate, and substantial heterogeneity limited confidence in those estimates.
Several secondary outcomes favored specific agents, according to the researchers. Intraoperative blood loss was reduced with labetalol, dexmedetomidine, esmolol, and clonidine. Esmolol and labetalol were associated with shorter emergence times, while clonidine and dexmedetomidine were linked to modest reductions in overall surgical duration. Esmolol and labetalol also shortened time to recovery of consciousness following anesthesia discontinuation.
Safety profiles were broadly comparable across agents, with no consistent differences in rates of bradycardia, hypotension, or postoperative nausea and vomiting. However, the researchers noted variability in dosing regimens, outcome definitions, and use of topical vasoconstrictors across trials, which may limit generalizability.
The researchers acknowledged that the study included several limitations, the most important of which was the use of subjective scores for surgical bleeding and visualization scores across the included studies.
"These [randomized clinical trials] relied on subjective measures to determine the effect of different hypotensive agents on the surgical field bleeding scores, implying that the overall evidence of our meta-analysis may be of low to moderate quality," the researchers wrote.
The findings indicate that controlled hypotension during ESS can be achieved using multiple effective pharmacologic options. According to the researchers, agent selection may be guided by patient characteristics, anesthetic strategy, and procedural goals rather than reliance on a single preferred drug.
"Future research should aim to refine these findings by standardizing the timing and dosing protocols and by placing greater emphasis on tailoring treatment to individual patient characteristics and procedural goals," the researchers concluded.
Source: JAMA Otolaryngology
