Anaesthetic dilemma of controlled hypotensive anaesthesia and systemic effects of topical adrenaline during functional endoscopic sinus surgery

Abstract

Functional endoscopic sinus surgery (FESS) frequently requires controlled hypotensive anaesthesia and topical adrenaline to minimize intraoperative bleeding and improve surgical visualization. However, the concurrent use of these techniques may result in significant haemodynamic instability due to systemic absorption of adrenaline. This case report highlights the haemodynamic challenges encountered during FESS for a 45-year-old male with bilateral nasal polyposis under general anaesthesia. Controlled hypotension was achieved using propofol infusion. Following the application of a large amount of adrenaline-soaked gauze at 1:1,000 concentrations by the surgeon bilaterally, which precipitated a haemodynamic crisis marked by profound hypotension (80/40 mmHg), rebound hypertension (180/110 mmHg), and tachycardia (150 bpm), with consequent deterioration of the surgical field leading to poor visibility. Prompt substitution with a diluted 1:10,000 preparations restored haemodynamic stability. The patient recovered uneventfully and remained symptom-free at one-year follow-up. The anaesthetic dilemma of combining controlled hypotensive anaesthesia with topical adrenaline during FESS remains a significant challenge. Topical adrenaline use may cause profound systemic cardiovascular effects; however, vigilant monitoring, prompt recognition of haemodynamic disturbances, and the use of lower adrenaline concentrations are essential to ensure patient safety.