INTRODUCTION

METHODS

In this randomized clinical trial (RCT) held from 2010 to 2011, at least 60 ASA I (American Society of Anesthesiology physical condition classification) patients between 18 and 40 years of age who candidate to rhinoplasty operations for first time in Modarres hospital, will be included. Informed consent were btained from all patients included in the study and study was approved by university ethics committee. Patients will be randomly assigned to groups as odds number to reverse trendelenburg position and even numbers to head-up position. Exclusion criteria were patients who have symptoms that made us think of coagulation problems after routine preoperative examinations and laboratory tests, and patients not using any drug affected blood pressure and coagulation. In the reverse trendelenburg group, patients are placed in a supine position, which is inclined at 30 degree angle, so that the head is higher than the pelvis and the leg is lower than hip. In the head-up group, patients are laid down in a supine position, which is inclined at 30 degree angle, so the head and shoulder are higher than pelvis but legs are at same level of pelvis. The patients are all operated on under standard general anesthesia. Same drugs will be used in both groups, including remifentanil, propofol, atracurium, midazolm and colonidin. The systolic arteril blood pressure should be between 80-90 mmHg during oporation; otherwise, the patient will be excluded from study. Nasal packing to the nostrils and dorsal nasal splints were used in all patients at the end of the operation. CBC was done immediately before operation and 48 h after surgery. All gauzes used and the blood that accumulated in the suction bottle aspirator throughout the operation were calculated. Each used gauze was considered as 20 mL blood loss. Systolic, diastolic, mean arterial BP and heart rate were recorded at baseline and every 10 min intervals afterward and in recovery in first hour. Same anesthetic procedure was applied to both groups including induction by 1 to 3 mg/kg propofol, atracurium, and maintenance by TIVA propofol at maintenance dose. Premedication was used as midazolam 0.1 mg/kg and fentanyl 1 μg/kg. The amount of blood loss was estimate based on SF (the grading for endoscopic surgical view contaminated by intraoperative bleeding or blood clotting).

RESULTS

Patients demographic findings did not show any significant differences among two groups. The age and weight of the patients (mean ± SD) are included in Table 1. Comparing post-operative hemodynamic data in two patients group of trendelenburg position or head-tilt group [Table 2] also did not show any significant differences among two groups. We have used the same induction, maintenance and volume intake protocols between two groups. Even we used equal IV catheters for patients to adjust for any confounding in our study. The mean amount of blood loss in reverse trendelenburg was lower (77.00 ± 13.20 ml) than head-up position (83.33 ± 21.18 ml), although, there was no statistical difference between two groups. The volume received in each group was not significantly different. The differences of postop platelet amount and Hgb were statistically but not clinically significant between two groups. The duration of operation was not significantly different between Reverse trendelenburg (RT) group (1.35 ± 0.43 h) and heads-up group (1.28 ± 0.55 h). The RT group had significantly more grade I-II SF (19.3%) and grade III-IV (17.4%) than heads-up grade I-II (15.3%) and III-IV (11.7%).

Table 1. Comparing demographic data in two patients group of reverse trendelenburg position or head-tilt group

Table 2. Comparing post-operative hemodynamic data in two patients group of trendelenburg position or head-tilt group

DISCUSSION

Bleeding and throat pain are the most common pre and post-operative complaint after rhinoplasty.[12] In order to control bleeding during rhinoplasty, the patients are put in a slightly head-up position to help reduce bleeding and improve surgical access. Whether the use of head-up instead of reverse trendelenburg technique actually decreases the amount of bleeding is questionable. Although, there is still an inherent belief that heads-up position is safer for anesthesiologist, the markedly increased rate of hypotension from head-up position make that view difficult to prove. In this study, intraoperative bleeding rate of rhinoplasty is compared between patients who rest on reverse trendelenburg and head-up position.

Our study did not showed any significant differences between these two groups. Considering that our groups were adjusted for volume intake, age and sex, and other demographic findings, our results showed that patient bleeding is not increased because of positioning per se. In fact, post-operative hemorrhage is the most commonly seen problem after rhinoplasty, however, previous reports has not commented on whether position have a major effect on this or not.[13]

Reverse trndelenberg position during surgeries has become increasingly safer, especially because of the dramatically decreased incidence of severe bleeding intraoperative.

CONCLUSIONS

Perhaps in the future reverse trendelenburg will be given more often during rhinoplasry. Also, the ultimate impact of the position of patient on bleeding is not clear. Lastly, consistent with the practice of medicine overall, well designed protocols will increasingly be the basis upon which positioning patient is based.