Evaluation and Comparison the Effectiveness of Remifentanil, Nitroglycerin, Esmolol, and Nitroglycerin + Esmolol on Blood Pressure And Heart Rate During Rhinoplasty Surgery

Background: Rhinoplasty is still one of the top five aesthetic surgeries performed and is considered one of the most challenging procedures in otorhinolaryngology surgery. Bleeding is one of the most important factors affecting an operation's success. The controlled hypotension method reduces bleeding; therefore, it provides a satisfying bloodless surgical field during operation. 
Objective: To evaluate and compare the effectiveness of (Remifentanil, Nitroglycerin, Esmolol, and Nitroglycerin + Esmolol) on hemodynamic parameters and the effectiveness of these drugs in providing a satisfactory bloodless surgical field during rhinoplasty surgery. 
Patients and Methods: 200 adults aged 20 to 45 years were randomly divided into four groups: Remifentanil (R), Nitroglycerin (N), Esmolol (E), Nitroglycerin + Esmolol (N+E). Systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate (SBP, DBP, MBP, and HR) were recorded before anesthesia induction until the operation's end. The bleeding score and the visibility of the surgical field were rated by the surgeon as follows: (0) No bleeding, (1) Mild bleeding - no aspiration required, (2) Mild bleeding - intermittent aspiration is required, (3) Moderate bleeding - frequent aspiration is required, (4) Severe bleeding-constant aspiration is required, (5) Severe bleeding, operation stopped because of surgical field invisibility. 
Results: As a result, during operation, decreased values of (SBP, DBP, and MBP) were statistically significant in all groups. At the same time, the value of HR showed a statistically significant decrease in the (E) and (R) groups, while there was a statistically significant increase in the (N) and (N+ E) groups. Patients in the (E) and (R) groups had a statistically significantly lower bleeding score than the patients in the (N) and (N + E) groups. 
Conclusion: Patients had better Hemodynamic stability and surgical field visibility after applying Esmolol and Remifentanil.