Etomidate For Induction Of Anaesthesia Research Articles

Evaluation of safety and efficacy with propofol and etomidate for induction of Anaesthesia in dilatation and curettage

Introduction and Aims: We compared the safety, efficacy, hemodynamic variation, recovery duration and adverse effects of propofol and etomidate, with or without fentanyl, in patients undergoing dilatation and curettage for incomplete abortions. Materials and Methods: One hundred patients, ASA status I & II, aged 20-50 years, undergoing dilatation and curettage, were randomly divided into four groups of 25 patients each. Group P received propofol 2 mg/kg + normal saline 2 ml for anesthesia induction. Group PF received propofol 2 mg/kg +fentanyl 1mcg/kg to make volume 2 ml for anesthesia induction. Group E received etomidate 0.2 mg/kg + normal saline 2 ml for anesthesia induction and Group EF received etomidate 0.2 mg/kg + fentanyl 1 mcg/kg to make volume 2 ml for anesthesia induction. Heart rate, arterial pressure and SpO2 were recorded at different time intervals. The recovery time, pain on injection, myoclonus and postoperative nausea vomiting were also recorded. Results: During induction, mean arterial pressure fall significantly in both propofol groups. Amongst four groups, there was no significant difference observed in recovery time after anesthesia. The incidence of pain on injection was lower in etomidate groups. Myoclonus and Postoperative nausea and vomiting were significantly higher in etomidate groups. Conclusion: This study demonstrates that etomidate is superior in term of hemodynamic stability and less incidence of pain on injection. Etomidate combined with low dose fentanyl is more favourable than etomidate alone for attenuating myoclonus. Keywords: Etomidate, Dilatation and curettage, Propofol.

A Study Evaluating Safety, Pharmacodynamics and Pharmacokinetics of HSK3486 and Etomidate for Induction of Anesthesia in Healthy Male Subjects

A Study Evaluating Safety, Pharmacodynamics and Pharmacokinetics of HSK3486 and Etomidate for Induction of Anesthesia in Healthy Male Subjects

Pre-hospital emergent intubation in trauma patients: the influence of etomidate on mortality, morbidity and healthcare resource utilization

BackgroundDue to its favorable hemodynamic characteristics and by providing good intubation conditions etomidate is often used for induction of general anesthesia in trauma patients. It has been linked to temporary adrenal cortical dysfunction. The clinical relevance of this finding after a single-dose is still lacking appropriate evidence.MethodsThis retrospective multi-centre study is based on merged data from a German Helicopter Emergency Medical Service (HEMS) database and a large trauma patient registry. All trauma patients who were intubated prior to hospital admission with a documented Injury Severity Score ≥ 9 between 2008 and 2012 were eligible for analysis. The primary endpoint was hospital mortality. Other outcome measures were organ failures, sepsis, length of ventilation, as well as length of stay in hospital and ICU.ResultsOne thousand six hundred ninety seven patients were enrolled into the study. Seven hundred sixty two patients received etomidate and 935 patients received other induction agents. The in-hospital mortality was similar in both groups (18.9% versus 18.2%; p = 0.71). Incidences of organ failures and sepsis were not increased in the etomidate group. However, health care resource utilization parameters were prolonged (after adjusting: + 1.3 days for ICU length of stay, p = 0.062; + 0.8 days for length of ventilation, p = 0.15; + 2,7 days for hospital length of stay, p = 0.034). A multivariable logistic regression analysis did not identify etomidate as an independent predictor of hospital mortality (OR: 1.10, 95% CI: 0.77–1.57; p = 0.60).ConclusionsThis is the largest trial investigating outcome data for trauma patients who had received a single-dose of etomidate for induction of anesthesia. The use of etomidate did not affect mortality. The influence on morbidity and health care resource utilization remains unclear.

The cortisol stress response induced by surgery: A systematic review and meta-analysis.

Surgery is a stressor that can be categorized by duration and severity and induces a systemic stress response that includes increased adrenal cortisol production. However, the precise impact of surgical stress on the cortisol response remains to be defined. We performed a systematic review and meta-analysis to assess the cortisol stress response induced by surgery and to stratify this response according to different parameters. We conducted a comprehensive search in several databases from 1990 to 2016. Pairs of reviewers independently selected studies, extracted data and evaluated the risk of bias. Cortisol concentrations were standardized, pooled in meta-analysis and plotted over time. We included 71 studies reporting peri-operative serum cortisol measurements in 2953 patients. The cortisol response differed substantially between moderately/highly invasive and minimally invasive surgical procedures. Minimally invasive procedures did not show a peri-operative cortisol peak, whereas more invasive surgeries caused a cortisol surge that was more pronounced in older subjects, women and patients undergoing open surgery and general anaesthesia. The duration of the procedure and the use of etomidate for induction of anaesthesia did not affect the cortisol response. The peri-operative cortisol stress response is dynamic and influenced by patient-specific, surgical and anaesthetic features. However, the available evidence is derived from highly heterogeneous studies, with only two of 71 studies measuring cortisol by mass spectrometry, which currently prevents a precise and reproducible definition of this response.

Etomidate and General Anesthesia

Induction of general anesthesia with control of ventilation remains a routine procedure both in critically ill patients and in those undergoing elective surgery. Etomidate is considered the drug of choice for emergency intubation procedure because of a good perceived benefit/ risk ratio, including hemodynamic stability, and minor side effects such as, myoclonus. Administered in conjunction with a rapid-onset neuromuscular-blocking drug, etomidate remains the preferred drug by most emergency physicians, anesthesiologists, and intensivists for rapid sequence induction of anesthesia. Publication of observational cohort studies suggesting increased mortality with the use of etomidate in septic patients has, however, raised safety concerns. In a systematic review and meta-analysis in septic patients, including randomized controlled trials and observational studies, Chan et al. 1 reported that a single dose of etomidate for induction of anesthesia was associated with increased 28-day mortality (relative risk 1.20, 95% confidence inter val, 1.02–1.4). Similar findings were observed in a post hoc analysis of the Corticosteroid Therapy of Septic Shock (CORTICUS) trial. An increased 28-day mortality rate (43% vs 31%, P = 0.03) was noted in patients who received etomidate compared with patients who did not. 2 However, other authors did not observe such an increased risk of mortality when using etomidate in septic patients 3 and even observed a decreased mortality rate after adjustment for severity of illness. 4 Similarly, randomized controlled trials have not provided evidence for an increased risk of death following a single dose of etomidate in critically ill patients (Fig. 1). 5–8 In the largest multicenter study in the prehospi

A presumptive case of adrenal insufficiency following a single dose of etomidate for induction of anesthesia in a cardiac surgery patient.

A presumptive case of adrenal insufficiency following a single dose of etomidate for induction of anesthesia in a cardiac surgery patient.

Acute Adrenal Insufficiency After a Single Dose of Etomidate

Acute adrenocortical insufficiency is a critical care emergency characterized by hemodynamic instability, lethargy, and cardiovascular collapse. Acute adrenal insufficiency has many etiologies, from rapid withdrawal of exogenous glucocorticoids to adrenocortical destruction to poor adrenal reserve after administration of steroid synthesis inhibitors. Etomidate, a parenteral hypnotic agent, is a steroid synthesis inhibitor. Although the use of continuous etomidate infusion in the intensive care unit fell from favor secondary to reports of adrenal crisis, single-dose etomidate for induction of anesthesia is common for the hemodynamically unstable patient or in patients who may not tolerate wide variance in heart rate or blood pressure. A case is presented of acute adrenocortical insufficiency and crisis after a standard induction dose of etomidate. Acute adrenal insufficiency should be suspected in intensive care unit patients who have undergone general anesthesia with etomidate induction and present with hypotension refractory to standard vasopressor administration.

Propofol causes more hypotension than etomidate in patients with severe aortic stenosis: a double‐blind, randomized study comparing propofol and etomidate

Vasodilatation and hypotension are thought to be harmful in patients with severe aortic stenosis. Etomidate is preferred to propofol for anaesthesia induction in haemodynamically unstable patients, but may disturb cortisol synthesis. We assessed the haemodynamic effects of etomidate vs. propofol as anaesthesia induction agents, and the effects of these drugs on cortisol concentrations, in patients with severe aortic stenosis. The main end-point of the study was the incidence of hypotension. Sixty-six patients with severe aortic stenosis scheduled for elective aortic valve replacement were enrolled in the study. The patients were randomized to receive either propofol or etomidate for induction of anaesthesia. Haemodynamic parameters, i.e. mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP) and cardiac index (CI), were measured. If MAP decreased below 70 mmHg for more than 30 s, phenylephedrine was administered. Serum cortisol concentrations were also measured. MAP decreased in all patients (P < 0.001). MAP decreased to a greater extent in patients receiving propofol than in those receiving etomidate (P = 0.006). Patients receiving propofol needed phenylephedrine more often than those receiving etomidate (20/30 vs. 8/30, P = 0.002). CI and PCWP decreased in both groups (P < 0.001), with no difference between the groups. Patients receiving etomidate had a lower serum cortisol concentration immediately after the operation than those receiving propofol (P < 0.001), but no differences between the groups were observed on the first post-operative morning. Propofol is twice as likely as etomidate to evoke hypotension in anaesthesia induction of patients with severe aortic stenosis; however, etomidate transiently decreases post-operative serum cortisol concentrations.

Midazolam and etomidate for induction of anaesthesia in ophthalmic surgery

Objectives: To assess the effect of midazolam 0.02 mg/kg administered with etomidate on the incidence of myoclonus and the dose requirement for etomidate to induce general anaesthesia. Design: Double blind randomised control trial. Setting: Two urban teaching hospitals in Durban, Kwa Zulu Natal (KZN). Patients: 60 patients older than 60 years of age undergoing intraocular surgery. Outcome measures: Etomidate dose required for loss of verbal contact (dose V) and loss of eyelash reflex (dose E). Myoclonus assessed by means of a three-point scale (0-nil; 1-mild; 2-severe) 30 sec after the last dose of etomidate. Duration of recovery from cessation of anaesthesia to first response to verbal command. Results: No significant difference in myoclonus or dose requirement for etomidate could be demonstrated. There was no difference in haemodynamic variation between the groups and recovery time was not prolonged. Conclusion: Midazolam 0.02 mg/kg given with etomidate for induction of anaesthesia does not reduce myoclonus or dose requirement for etomidate. Further studies may be undertaken to assess the usefulness of larger doses of midazolam for co-induction or oral premedication with midazolam.

Etomidate and the osteocalcin response to gynaecological surgery

Circulating osteocalcin is a good marker of osteoblastic activity and decreases significantly after stressful physiological states such as major surgery. Glucocorticoids are known to inhibit osteoblastic activity and result in a decline in circulating osteocalcin. We used etomidate to inhibit the cortisol response to routine gynaecological surgery to determine if this would prevent the postoperative decline in osteocalcin. Twenty-four patients were allocated randomly to receive either thiopental or etomidate for induction of anaesthesia; all other aspects of anaesthesia and perioperative management were standardized. In the thiopental group, circulating cortisol increased significantly at 2 and 6 h after the start of surgery and plasma osteocalcin concentrations decreased significantly to almost 50% of baseline values at 48 h. Etomidate abolished the cortisol response to surgery, and circulating osteocalcin concentrations did not change after operation. There was a significant difference in osteocalcin concentration between the groups at 48 h. We conclude that the cortisol response to surgery is associated with a postoperative decrease in circulating osteocalcin.

Comparison of Infusion Rates of Three I.V. Anaesthetic Agents for Induction in Elderly Patients

BERTHOUD, M. C.; McLAUGHLAN, G. A.; BROOME, I. J.; HENDERSON, P. D.; PEACOCK, J. E.; REILLY, C. S. Author Information

COMPARISON OF INFUSION RATES OF THREE I.V. ANAESTHETIC AGENTS FOR INDUCTION IN ELDERLY PATIENTS

We have compared the effect of different rates of injection of 2.5% thiopentone, 0.5% methohexitone and 0.2% etomidate for induction of anaesthesia in 90 premedicated, elderly patients. The agents were administered by infusion pump at rates of 1200 ml h-1, 600 ml h-1 and 300 ml h-1, respectively until anaesthesia was induced as judged by loss of verbal contact with the patient. The times for induction were significantly greater with the slower infusion rates (thiopentone 41 s, 57 s and 91 s (P < 0.001); methohexitone 44 s, 62 s and 84 s (P < 0.01); etomidate 48 s, 59 s and 87 s (P < 0.001)). The doses were significantly smaller (P < 0.001) with the slower infusion rates for all three agents (thiopentone 5.0, 3.7 and 2.8 mg kg-1; methohexitone 1.00, 0.75 and 0.56 mg kg-1; etomidate 0.26, 0.15 and 0.11 mg kg-1). For each drug there was no significant difference in induction characteristics, oxygen saturation, heart rate or mean arterial pressure, at the different infusion rates.

Hormonal effects of an induction dose of etomidate for patients undergoing urgent myocardial revascularization

The use of etomidate for induction of anesthesia in patients requiring urgent coronary artery surgery provides good cardiovascular stability. However, long-term etomidate infusions may cause transient signs of adrenocortical suppression. The purpose of this study was to determine whether an induction bolus dose of etomidate would cause clinically relevant endocrine dysfunction in urgent coronary artery bypass patients. With institutional review board approval, 11 patients were prospectively randomized to a diazepam (control) or etomidate rapid sequence induction. The diazepam group (n = 6; mean, 69 years) received 0.4 mg/kg of diazepam. The etomidate group (n = 5; mean, 54 years) received 0.3 mg/kg of etomidate. Maintenance anesthesia included nitrous oxide, oxygen, pancuronium, and fentanyl in increments up to 32 μg/kg. Hemodynamics, cortisol, epinephrine, and norepinephrine were measured both intraoperatively and postoperatively. The only significant differencebetween the two groups in hemodynamic parameters was a higher heart rate in the etomidate group. Both agents adequately controlled the stress response to intubation as judged from the levels of epinephrine, norepinephrine, and cortisol. However, in both groups epinephrine and norepinephrine increased between intubation and removal of the aortic cross-clamp. Cortisol also increased from the time of cross-clamp removal to 12 and 24 hours post-bypass. During anesthesia and surgery in the pre-bypass period, there was a decrease in cortisol over time in the etomidate group, and there was an increase with diazepam. Thus, etomidate provided stable hemodynamics, possible mild intraoperative adrenocortical suppression, a depressed hormonal stress response to intubation, and a normal hormonal reaction to the later part of surgery and the postoperative period.

HORMONAL EFFECTS OF AN INDUCTION DOSE OF ETOMIDATE FOR PATIENTS UNDERGOING URGENT MYOCARDIAL REVASCULARIZATION

Abstract The use of etomidate for induction of anesthesia in patients requiring urgent coronary artery surgery provides good cardiovascular stability. However, long-term etomidate infusions may cause transient signs of adrenocortical suppression. The purpose of this study was to determine whether an induction bolus dose of etomidate would cause clinically relevant endocrine dysfunction in urgent coronary artery bypass patients. With institutional review board approval, 11 patients were prospectively randomized to a diazepam (control) or etomidate rapid sequence induction. The diazepam group (n = 6; mean, 69 years) received 0.4 mg/kg of diazepam. The etomidate group (n = 5; mean, 54 years) received 0.3 mg/kg of etomidate. Maintenance anesthesia included nitrous oxide, oxygen, pancuronium, and fentanyl in increments up to 32 μg/kg. Hemodynamics, cortisol, epinephrine, and norepinephrine were measured both intraoperatively and postoperatively. The only significant differencebetween the two groups in hemodynamic parameters was a higher heart rate in the etomidate group. Both agents adequately controlled the stress response to intubation as judged from the levels of epinephrine, norepinephrine, and cortisol. However, in both groups epinephrine and norepinephrine increased between intubation and removal of the aortic cross-clamp. Cortisol also increased from the time of cross-clamp removal to 12 and 24 hours post-bypass. During anesthesia and surgery in the pre-bypass period, there was a decrease in cortisol over time in the etomidate group, and there was an increase with diazepam. Thus, etomidate provided stable hemodynamics, possible mild intraoperative adrenocortical suppression, a depressed hormonal stress response to intubation, and a normal hormonal reaction to the later part of surgery and the postoperative period.

Malignant Hyperthermia

The safety of etomidate for induction of anesthesia in malignant hyperthermia-susceptible (MHS) pigs was evaluated in a two-phase experiment. Two litters of Purebred Poland China pigs, one MHS (n = 4) and the other malignant hyperthermia-resistant (MHR) (n = 4) were used. Phase I compared MHS vs MHR animals in terms of cardiovascular, metabolic, and skeletal muscle rigidity responses to etomidate and fentanyl anesthesia and to a subsequent malignant hyperthermia (MH) challenge with halothane-succinylcholine. When three of the four criteria for the diagnosis of MH occurred (rigidity, tachycardia, or increases in temperature or end-tidal CO2) in an animal, phase I was terminated. In phase II, only the MHS animals were used and experimental procedures were as in phase I except thiopental replaced etomidate. In phase I, evidence was inadequate to support the diagnosis of MH based upon responses of MHS pigs to the infusion of etomidate even though the infusion of etomidate in MHS pigs was associated with statistically significant increases in body temperature and plasma lactate levels above those observed in MHR pigs. Heart rate and bicarbonate levels were lower in MHS than in MHR pigs during etomidate infusion. With discontinuation of etomidate and a subsequent challenge with halothane-succinylcholine, all four pigs developed the MH syndrome within 15-30 min. Thiopental replacement of etomidate in the phase II experiment resulted in a twofold greater time (45-75 min) for halothane-succinylcholine to trigger MH in the susceptible pigs.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemodynamic effects of fentanyl or alfentanil as adjuvants to etomidate for induction of anaesthesia in cardiac patients.

This investigation was designed to study the comparative haemodynamic effects of alfentanil, 5 mg vs. fentanyl 0.5 mg when administered in combination with etomidate for induction of anaesthesia in patients undergoing cardiac surgery. Both groups manifested significant decreases in heart rate (17-22%), cardiac index (12-25%) and mean pulmonary artery pressure (4-17%). The mean arterial pressure was decreased in both groups; however, the decrease was significantly greater in the alfentanil group. In contrast to the fentanyl group, the systemic vascular resistance was transiently decreased in in the alfentanil group. In conclusion, it appears that alfentanil is associated with a greater degree of cardiovascular depression than fentanyl when used in combination with etomidate as part of an induction sequence in cardiac surgery patients.