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.