Control of Hemodynamic Responses and Perioperative Outcomes in Transsphenoidal Pituitary Surgery: A Qualitative Systematic Review of the Available Evidence

Abstract: Transnasal transsphenoidal (TNTS) pituitary surgery is associated with short-lived but intense nociceptive stimuli which cause substantial hemodynamic perturbations that may increase blood loss and impair visualization of the surgical field. This systematic review aimed to critically appraise the clinical evi dence for the efficacy and safety of various anesthetic techniques, other pharmacological modalities, and supplementary inter ventions by assessing intraoperative systemic hemodynamics, use of adjunct medications, quality of the surgical field, intra operative blood loss, and recovery profiles in patients undergoing TNTS pituitary surgery. Relevant randomized clinical trials and observational studies were identified in a systematic literature search; 16 studies (13 randomized clinical trials, 3 observational studies) enrolling a total of 907 patients were identified for in clusion in this review. Propofol provided more potent hemody namic control compared with volatile anesthetics with a sparing effect on the need for additional drugs to blunt hemodynamic responses. Recovery profiles between propofol and sevoflurane were either equivalent or favored sevoflurane, but both agents were superior to isoflurane. Regarding intraoperative analgesia, remifentanil was associated with superior hemodynamic control and recovery profiles than fentanyl. Dexmedetomidine had beneficial effects on hemodynamics, surgical field quality, re covery characteristics, and nociceptive properties compared with placebo. Although there was no clear-cut superiority of other adjunct pharmacological modalities on hemodynamic responses during surgery, regional blocks were associated with beneficial impacts on both primary and secondary outcomes. In summary, short-acting anesthetics, analgesics and dexmedetomidine seem to improve intraoperative hemodynamics, blood loss, and re covery qualities during TNTS pituitary surgery. However, de finitive conclusions cannot be drawn because of methodological heterogeneity in the identified studies