Hypotensive Agents for Controlled Hypotension in Endoscopic Sinus Surgery

Importance Excessive bleeding during endoscopic sinus surgery (ESS) impairs visualization and increases complications. Controlled hypotension is widely used; however, comparative effectiveness of available pharmacological agents remains uncertain. Objective To compare the effectiveness and safety of hypotensive drugs for reduced bleeding in ESS. Data Sources PubMed, Scopus, Web of Science, and Cochrane databases were searched from inception to December 2024, and updated to include studies up to May 2025. Study Selection Randomized clinical trials of patients undergoing ESS and receiving dexmedetomidine, clonidine, esmolol, labetalol, bisoprolol, metoprolol, diltiazem, nifedipine, or verapamil vs placebo. A total of 1258 records were screened. Data Extraction and Synthesis Data were extracted and assessed using the Cochrane risk of bias tool. Certainty was rated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework. A random-effects meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines. Main Outcomes and Measures Surgical bleeding score, intraoperative mean arterial pressure (MAP), and mean intraoperative heart rate. Secondary outcomes included blood loss, surgery duration, and emergence time. Results The analysis included 52 randomized clinical trials involving 3526 participants; of these, 43 studies contributed to the network analysis. Several agents were associated with reduced bleeding vs placebo: diltiazem (mean difference MD, −1.25; 95% CI, −2.13 to −0.37), esmolol (MD, −1.16; 95% CI, −1.80 to −0.51), dexmedetomidine (MD, −1.09; 95% CI, −1.48 to −0.70), labetalol (MD, −1.00; 95% CI, −1.58 to −0.42), and clonidine (MD, −0.69; 95% CI, −1.23 to −0.16). Dexmedetomidine was associated with the most reduced MAP (MD, −30.30 mm Hg; 95% CI, −47.91 to −12.69), followed by clonidine (MD, −28.61; 95% CI, −53.11 to −4.11), esmolol (MD, −27.62; 95% CI, −49.73 to −5.51), and labetalol (MD, −26.54; 95% CI, −47.20 to −5.87). At 60 minutes, bisoprolol (MD, −58.30; 95% CI, −67.50 to −49.10 beats per minute bpm), verapamil (MD, −49.90; 95% CI, −58.98 to −40.82 bpm), and labetalol (MD, −43.89; 95% CI, −54.59 to −33.18 bpm) produced the largest heart rate reductions. Esmolol (MD, −3.67; 95% CI, −4.21 to −3.13 minutes) and labetalol (MD, −3.64; 95% CI, −4.79 to −2.49 minutes) shortened emergence time. Conclusions and Relevance In this systematic review and network meta-analysis, controlled hypotension improved surgical field quality in ESS with comparable safety. Diltiazem, esmolol, dexmedetomidine, labetalol, and clonidine were effective; dexmedetomidine was associated with reduced MAP the most, and esmolol favored recovery.