Use Of Etomidate Research Articles

Comparison of effect of etomidate with propofol on hemodynamics during modified electroconvulsive therapy.

Background and Aims:Studies comparing the effect of propofol and etomidate on hemodynamic parameters during electroconvulsive therapy (ECT) have shown ambiguous results. Although some studies observed a larger increase in blood pressure and heart rate during the use of etomidate than propofol in ECT, whereas some studies have shown no difference in hemodynamic parameters with the use of etomidate or propofol. Most of the studies done to compare the hemodynamic effects of etomidate and propofol were limited by small sample size or retrospective in nature. Therefore, we conducted a prospective randomized trial to compare the effects of etomidate and propofol on hemodynamics during ECT.Material and Methods:A prospective randomized crossover study was conducted on 30 patients with American Society of Anesthesiologist physical status I and II, between age 18 and 65 years, suffering from a mental disorder as per International Classification of Diseases-10 and requiring bilateral ECT as per clinical decision of consultant psychiatrist. They were randomized to receive both the drugs for their successive ECT sessions and were subjected to evaluation after clubbing together the ECT sessions of propofol or etomidate as anesthetic agent.Results:Duration of motor seizures was significantly more in patients receiving etomidate, whereas patients receiving propofol had more stable hemodynamics.Conclusion:Though propofol maintains stable hemodynamics during MECT, yet clinical applicability of etomidate outstrips it by a reasonable margin due to its better effect on seizure parameters.

The Optimal Preoxygenation Target to Avoid Desaturation During Pediatric Rapid Sequence Intubation

<h3>Background</h3> Rapid sequence intubation (RSI) is a critical procedure in the resuscitation of critically ill and injured patients but carries an important risk of oxygen desaturation. In the adult population, a target preoxygenation threshold of >93% has been defined. However, it is not known whether this is an appropriate target for pediatric patients. <h3>Objective</h3> To define a target preoxygenation threshold for pediatric RSI. <h3>Methods</h3> Our air medical agency includes 150 bases, with a flight RN/flight paramedic crew configuration. The pediatric RSI protocol includes the use of etomidate or ketamine for induction and either succinylcholine or rocuronium for paralysis. Up to 120 data elements are entered into the Institutions Airway Database for each RSI procedure. For this analysis, all pediatric patients (age <18 years) undergoing RSI between January 2015 and September 2019 were included. Separate analysis was performed for infants (0-2 years), young children (3-8 years), and older children (9-17 years). Patients werestratified by highest pre-attempt SpO2 value, with the rate of desaturation identified as the primary outcome measure. Desaturation was defined as decrease in SpO2 to <94% or a continued decrease by at least 2% if pre-attempt SpO2 value was <94%. A graphical analysis was performed to identify an inflection point below which substantially higher desaturation rates were observed. The desaturation rate for patients with pre-attempt SpO2 values above that threshold were compared to those below that threshold using chi-square analysis, with significance was set at p<0.05. <h3>Results</h3> A total of 1,116 patients were identified over the 57-month period (infant n=247, young children n=250, older children n=619). A clear desaturation rate inflection point was observed with pre-attempt SpO2 values of 97% or greater. For patients with pre-attempt SpO2 values of <97%, the desaturation rate was 59.2% as compared to 12.8% with pre-attempt SpO2 values of 97% or greater (OR 9.8, 95% CI 6.9-14.1, p<0.0001). These results were similar across the three age groups. <h3>Conclusions</h3> These data support a higher preoxygenation target of 97% or greater with pediatric RSI. Limitations include the observational nature of the analysis and the possibility that lower pre-attempt SpO2 is a surrogate for more a difficult airway.

Comparison of Hemodynamic Effects of Intravenous Etomidate Versus Thiopentone During Induction and Intubation Using Entropy-Guided Hypnosis Levels in Coronary Artery Bypass Surgery Cases

Background: Most of the induction agents cause hypotension. Accurate assessment of the depth of anesthesia using various monitors contributes to tailor drug administration, thus maintaining anesthetic depth and improving hemodynamic stability. Aim: The aim of this study is to compare the hemodynamic responses during induction and intubation between etomidate and thiopentone and to compare their doses, using entropy-guided hypnosis levels, in patients of coronary artery bypass surgery (CABG). Methodology: After ethics committee clearance, 60 patients for CABG were randomly allocated into the etomidate or thiopentone group, based on induction agents. Anesthesia was induced using intravenous etomidate or thiopentone titrated to state entropy (SE) level of 40–60. Heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressures, response entropy, and SE were recorded before, during, and after induction of anesthesia. Statistical analysis was done using descriptive and inferential statistics using Chi-square test, Students paired and unpaired t-test. Results: Stable hemodynamics was maintained with both etomidate and thiopentone. There was 33.3% and 34% less dose requirement in the etomidate and thiopentone groups, respectively. Minimal drug side effects and lesser complications were observed with equipotent doses, using entropy to guide equivalent hypnosis levels. Conclusion: The use of etomidate and thiopentone titrated to entropy leads to reduced etomidate and thiopentone dosage translating into increased hemodynamic stability during induction with adequate anesthetic depth.

Factors associated with post-electroconvulsive therapy delirium: A retrospective chart review study.

Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions from December 2006 to July 2018 in a university hospital.Demographic and clinical characteristics of sessions involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis was applied to analyze the correlation between variables and post-ECT delirium.Post-ECT delirium developed in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was significantly different between delirium-positive and delirium-negative groups after Bonferroni correction. The regression model also indicated that etomidate use to be significantly associated with post-ECT delirium.In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an association that appeared unrelated to other possible measured variables. Practitioners should take into account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation before sufficient therapeutic gain is achieved.

Association between Etomidate Use for Rapid Sequence Intubation and Adrenal Insufficiency in Sepsis.

BackgroundThe risk of adrenal insufficiency (AI) in using single-dose etomidate for intubation among patients with sepsis remains controversial. Our aim was to assess the prevalence of AI and characterize the risk factors in patients who received etomidate for rapid sequence intubation (RSI).MethodsThis is a retrospective study of prospectively-acquired data evaluating surgical intensive care unit (SICU) patients who developed respiratory failure undergoing RSI.ResultsOf the 44 adult SICU patients who developed respiratory failure, 34 patients received etomidate. The average age for the total cohort, for the patients that received etomidate and for those who did not, was 70.91 ± 14.92, 72.82 ± 13.61 years and 64.40 ± 15.93, respectively. Twenty-four patients of the total cohort (54.55%) developed AI; 26 had septic shock (59.09%), and 16 patients had AI and septic shock (36.36%). There was no statistical significance between the incidence of AI in patients who received etomidate (47%) and those who did not (80%). However, in the subset of patients who received etomidate for RSI, there was a non-significant trend toward increased incidence of AI in those who were septic compared to those who were not (p = 0.06).ConclusionA single dose of etomidate used for RSI in SICU patients is not associated with the development of AI or mortality. However, a trend was shown, although not statistically significant, towards the development of AI in septic patients. High-quality and adequately powered randomized control trials (RCTs) are warranted.

Changes in hemodynamic parameters with the use of etomidate versus ketamine induction in the emergency department

Objectives: Etomidate is the sedative agent of choice during rapid sequence intubation (RSI) owing to its hemodynamic stability, rapid onset of action, and short duration of action. Nevertheless, ketamine is rapidly gaining popularity as an alternative agent, primarily because of its catecholamine-mediated effects. This feature has prompted clinicians to use ketamine for hemodynamically unstable patients. The aim of this study was to compare the percent change in hemodynamic parameters resulting from the use of etomidate versus ketamine during RSI in the emergency department. Methods: This cross-sectional prospective observational study conducted at an academic emergency department included patients recruited from March 2018 through May 2019 on a convenience basis when the principal investigator was scheduled to work in the emergency department. Results: Our study showed a percent reduction in all hemodynamic parameters with the use of ketamine: -13.14% in systolic blood pressure, -10.40% in diastolic blood pressure, -10.15% in mean arterial pressure, and -1.12% in heart rate. Moreover, the rate of ≥ 20% reduction in hemodynamic parameters with ketamine was 27.27% in systolic blood pressure, 18.18% in diastolic blood pressure, 18.18% in mean arterial pressure, and 27.27% in heart rate. Conclusions: Although ketamine has a sympathomimetic effect, it may cause hemodynamic instability in select patients. Therefore, caution is advised when using ketamine routinely during RSI, especially in critically ill patients in the emergency department.

Comparison of propofol and etomidate on hemodynamic characteristics and seizure duration in electroconvulsive therapy

Background: Electroconvulsive therapy (ECT) is considered to be one of the most effective and mainstay treatments in psychiatry. Anesthesia is required for the safe and effective conduct of ECT. The choice of anesthetic agent in ECT is based on its capability of stabilizing the undesirable hemodynamic changes and its impact on the seizure threshold. Although literature has good number of studies on other routinely used anesthetic agents, there has been minimal research done on the use of etomidate as an agent favorable in ECT. Aim and Objectives: The objectives of the study were as follows: (1) To compare the seizure duration between the two anesthetic agents, propofol and etomidate when used in modified ECT and (2) to compare the two anesthetic agents, propofol and etomidate in terms of hemodynamic parameters when used in modified ECT. Materials and Methods: After the Institutional Ethical Committee approval, 80 adult patients of both sexes, admitted to the Psychiatry department of Krishna Rajendra Hospital with a diagnosis of a psychiatric disorder, from October 2017 to May 2019 requiring ECT, were selected for this study. The patients after randomization assigned in Group A received intravenous propofol 2 mg/kg and those in Group B received intravenous etomidate 0.3 mg/kg as an induction agent. After administering the induction agents, the blood pressure cuff was inflated 50 mmHg above the systolic pressure, to isolate the circulation of lower limb and ensure accurate measurement of the motor seizure. Results: The seizure duration recorded in seconds showed a statistical significance with P = 0.001 being longer with etomidate. The PSRT score of Evans and Davies used to asses induction characteristics over a time period of 15 min was found to be statistically not significant between both the study groups with P = 0.286. Conclusion: Etomidate was found to produce better quality of seizure, while with propofol, there was a shortening of seizure duration. Scores used to assess hemodynamic parameters in both the groups were the same indicating similar efficacy in stabilizing the hemodynamic changes.

Etomidate Use for Rapid Sequence Intubation Is Not Associated With Nosocomial Infection

Introduction: Etomidate is commonly used for induction of anesthesia for rapid sequence intubation (RSI). It has little impact on hemodynamic status, making it a widely used agent. Due to the inhibition of cortisol production, etomidate causes adrenal suppression. The purpose of this study is to determine whether there is a correlation with etomidate use and the incidence of secondary infections. Methods: This was a retrospective cohort of hospitalized patients who received either etomidate or control (ketamine, propofol, or no agent) for RSI. The primary endpoint was the incidence of secondary infections. Secondary outcomes included number of mechanical ventilator-free days within 28 days, 30-day mortality, length of hospital stay, and length of intensive care unit stay. Results: A total of 434 patients were reviewed, of which 129 (29.7%) met the study criteria (n = 94 etomidate; n = 35 control). The incidence of secondary infection was numerically higher in the etomidate group compared with the control group, though this was not statistically significant (38.7% vs. 28.6%, p = 0.447). Also, though the secondary outcomes showed no statistically significant difference between the groups, the patients in the control group had a longer hospital stay (14.0 vs. 18.1, p = 0.20) and a longer ICU stay (11.0 vs. 14.1, p = 030). Furthermore, the etomidate group had a non-statistically significant higher incidence of bacteremia (8 vs. 0, p = 0.17) Conclusion: The use of etomidate was not associated with increased incidence of secondary infection. To fully understand the effects of etomidate use and its subsequent adrenal suppression, larger studies are needed.

Effects of etomidate use in ICU patients on ventilator therapy: a study of 12,526 patients in an open database from a single center.

BackgroundThere is a debate regarding the safety of etomidate. We evaluated the effects of etomidate on mortality in a large cohort of critical care patients.MethodsThis retrospective matched-cohort study was performed using the Medical Information Mart for Intensive Care version 3 (MIMIC-III) database. Among 12,526 adult patients who were prescribed etomidate or propofol on the first day of mechanical ventilation, 625 patients administered etomidate were statistically matched with 6,250 patients administered propofol. The primary outcome measures were all-cause in-hospital mortality, 48-hour survival, cardiovascular morbidity, and infectious morbidity. Logistic regression analysis with stepwise selection of variables was performed to examine the dose–mortality relationship of etomidate.ResultsAll-cause in-hospital mortality was 1.84 times higher in the etomidate cohort (OR: 1.84, 98.75% CI: 1.42, 2.37). Compared to the propofol cohort, the etomidate cohort showed 57% lower odds of 48-hour survival (0.43 [0.27, 0.73]), no difference in odds of cardiovascular morbidity (0.86 [0.66, 1.12]), and 1.77 times higher odds of infectious morbidity (1.77 [1.35, 2.31]). Additionally, the odds of mortality increased by 1.36 times per 0.1 mg/kg of etomidate (1.36 [95% CI: 1.23, 1.49]).ConclusionsEtomidate is a poor choice as a hypnotic drug on the first day of mechanical ventilation, as it is associated with a dose-dependent increase in all-cause mortality, and does not improve survival for the first 48 h.

Clinical observation of the combined use of propofol and etomidate in painless gastroscopy.

This study is aims to compare the anesthetic safety of propofol combined with etomidate for painless gastroscopy. Three hundred patients undergoing painless gastroscopy were randomly assigned to P, PE1, and PE2 groups. Patients were anesthetized with propofol (P group) or propofol combined with etomidate (volume ratio 1: 1, PE1 group; volume ratio 2: 1, PE2 group). The hemodynamics and adverse reactions were observed. The sleep quality satisfaction and nature of dreams were recorded. Compared with pre-anesthesia, the mean arterial pressure and heart rate of the 3 groups were significantly slower during the examination and at the end of the examination. PE1 group had a higher incidence of muscle spasm, body moving, choking, and deglutition. The incidence of hypoxemia and injection pain was higher in P group. P and PE2 group had higher sleep quality satisfaction and dream incidence after awaking. However, there was no difference in the nature of dreams among 3 groups. Our data indicate that the combination of 10 ml 1.0% propofol and 5 ml 0.2% etomidate for painless gastroscopy reduces adverse reactions while not affecting the patients respiratory function. Moreover, it is safe and effective, which is worthy of clinical application and promotion.

Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study.

ObjectiveHypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation.MethodsA multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation.ResultsPost-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension.ConclusionsA novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients.Study registrationClinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

Pericardial Effusions in Patients With Cancer: Anesthetic Management and Survival Outcomes

The objective of this study was to describe practice patterns of anesthetic management during pericardial window creation. Retrospective observational cohort study. Single tertiary cancer center. A total of 150 patients treated for cancer between 2011 and 2015 were included in the study. The primary objective was to evaluate anesthetic management in pericardial window creation. Secondary outcomes were 30-day mortality and overall survival after pericardial window creation. Thirty-day mortality was 19.3%, and median survival was 5.84 months. Higher American Society of Anesthesiologists (ASA) physical status of patients was associated with preinduction arterial line placement (51% ASA 3 v 79% ASA 4; p = 0.002) and use of etomidate for anesthetic induction (34% ASA 3 v 60% ASA 4; p = 0.003). However, there was no association between anesthetic management and presence of tamponade in these patients. Cardiac aspirate volume (per 10 mL: odds ratio [OR], 1.02 [95% CI, 1.0-1.04]; p = 0.026) and intraoperative arrhythmia (atrial fibrillation: OR, 6.76 [95% CI, 1.2-37.49]; p = 0.029; sinus tachycardia: OR, 4.59 [95% CI, 1.25-16.90]; p = 0.022) were associated independently with increased 30-day mortality. High initial heart rate (per 10 beats per minute: hazard ratio [HR], 1.18 [95% CI, 1.05-1.33]; p = 0.005) in the operating room and intraoperative sinus tachycardia (HR, 1.86 [95% CI, 1.15-3.03]; p = 0.012) were associated independently with worse overall survival. Risk of death after pericardial window creation remains high in patients with cancer. Variations in anesthetic management did not affect survival in oncologic patients with pericardial effusions.

Use of etomidate in patients with heart failure undergoing noncardiac surgery

BackgroundPatients with symptomatic and asymptomatic heart failure undergoing noncardiac surgery may benefit from the haemodynamic profile of etomidate. However, the safety of etomidate in this population is unknown. We examined anaesthesiologist variation in etomidate use and assessed its safety using an instrumental variable approach to account for differences in treatment selection. MethodsA retrospective cohort study of 19 714 patients with heart failure undergoing noncardiac surgery at two tertiary care institutions from January 2006 to December 2017 was performed. The proportion of etomidate use among 294 anaesthesiologists was examined and adjusted risk differences (aRD) for in-hospital and 30-day mortality were calculated using physician preference for etomidate as an instrumental variable. ResultsEtomidate was used in 14.3% (2821/19 714) of patients. Preference for etomidate varied substantially among individual anaesthesiologists with the lowest and highest quartile users using etomidate in 0–4.7% and 20.4–66.7% of their own heart failure patients, respectively. The adjusted instrumental variable analysis showed no significant differences in the risk of in-hospital (aRD –0.2%; 95% confidence interval, –2.4%–1.9%; P=0.83) or 30 day mortality (aRD 0.2%; 95% confidence interval, –2.5%–2.9%; P=0.90). Anaesthesiologists with higher preferences for etomidate were more experienced (greater heart failure and total case volume) than anaesthesiologists with lower preferences for etomidate. ConclusionsWe found substantial variability in anaesthesiologists' preference for etomidate for use in patients with heart failure undergoing noncardiac surgery. There was no association between etomidate use and in-hospital or 30-day mortality. Etomidate is not inferior to other currently used options for induction of general anaesthesia in patients with heart failure.

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study.

The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis. This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine. A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR]= 0.4, 95% confidence interval [CI]= 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR= 2.9, 95% CI= 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR=2.7, 95% CI=1.1 to 6.7). No difference in emergency department deaths was observed. Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis.

Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study.

The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. We analyzed ED intubation data for patients aged >14years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference=8.8%, 95% confidence interval [CI]=5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI=4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference=5.9%, 95% CI=2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference=6.5%, 95% CI=3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR=1.4, 95% CI=1.2 to 1.7) and treatment for hypotension (aOR=1.8, 95% CI=1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0mg/kg versus >1.0mg/kg or patients receiving etomidate at doses ≤0.3mg/kg versus >0.3mg/kg. Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.

Efficacy and Safety of Etomidate in Comparison with Propofol or Midazolam as Sedative for Upper Gastrointestinal Endoscopy.

Background/AimsIn this study, we compared the efficacy and safety of etomidate with those of propofol or midazolam for the maintenance of sedation during endoscopy. MethodsThe study enrolled patients who underwent sedative endoscopy in our hospital and divided them into three groups. Patients in each group were administered midazolam as induction therapy and were subsequently administered either midazolam (M + M group), propofol (M + P group), or etomidate (M + E group) as maintenance medication. The primary outcome was overall cardiovascular and respiratory adverse events. ResultsIn total, 105 patients who underwent sedative endoscopic examination were enrolled. The outcomes related to the procedure and sedation were not significantly different among the groups. Overall cardiovascular and respiratory adverse events were observed in 9 patients (25.7%) in the M + M group, 8 patients (23.5%) in the M + P group, and 10 patients (27.8%) in the M + E group. The logistic regression analysis revealed that etomidate use was not an independent risk factor for overall cardiovascular and respiratory adverse events. ConclusionsThe outcomes following the use of etomidate for maintenance after induction with midazolam for sedation in upper gastrointestinal endoscopy were not inferior to those following midazolam or propofol use from the perspectives of safety and efficacy.

THE COMPARISON OF ETOMIDATE AND PROPOFOL FOR ATTENUATION OF HAEMODYNAMIC RESPONSE TO INDUCTION AND ENDOTRACHEAL INTUBATION

Background: This study is designed to compare the degree of attenuation of hemodynamic response to induction, laryngoscopy and endotracheal intubation of etomidate with those of propofol in patients undergoing noncardiac surgical procedures.&#x0D; Methods: The present study conducted in Non Cardiac Surgeries in the Department of Anaesthesiology, Jhalawar Medical College &amp; Associated Hospitals, Jhalawar, Rajasthan.After institutional ethical committee’s approval and written informed consent from the patient’s attendant in the format as per proforma, the present study was conducted on 60 patients of ASA Grade I and II of either sex, aged 18 to 60 years, scheduled for a variety of non-cardiac surgical procedures requiring general anaesthesia.&#x0D; Results: The findings of the study suggest that use of etomidate as inducing agent provides more hemodynamic stability as compared to propofol and can be preffered in patients prone to hemodynamic instability, cardiovascular abnormalities, hypovolemia, prone to renal failure due to hypotension. Propofol may be preffered for induction where hypertension is contraindicated or hypotension is preffered and myoclonus is to be avoided.&#x0D; Conclusion: Etomidate provides a more stable hemodynamics during general anesthesia as compared to propofol.&#x0D; Keyword:- Etomidate, Propofol, Hemodynamic.

KETAMINE VS ETOMIDATE FOR RAPID SEQUENCE INTUBATION IN THE CRITICALLY ILL POPULATION

SESSION TITLE: Endotracheal Intubation: Getting In and Getting Out SESSION TYPE: Original Investigations PRESENTED ON: 10/23/2019 10:45 AM - 11:45 AM PURPOSE: Etomidate and ketamine are both used for sedation in rapid sequence intubation (RSI). Early studies reported few adverse pulmonary or cardiovascular effects with etomidate use, but recent work describes potential increased mortality secondary to adrenal suppression, and possible hypotension with etomidate use in critically ill patients. Ketamine has, thus, been suggested as an alternative agent. Few studies have compared outcomes for ketamine vs. etomidate for RSI, and results are conflicting. Given the paucity of literature, and controversy over best agent, we compared outcomes with ketamine vs. etomidate for RSI in the critical care setting. METHODS: A multi-center retrospective cohort study was conducted on patients aged 18 and older who underwent rapid sequence intubation (RSI) between 1/1/2017 and 12/31/2017. Outcomes of interest included post-RSI hypotension, hospital length of stay, ventilator days, in-hospital death, and post-RSI cardiac events (MI, CVA, or cardiac arrest). RESULTS: Of 842 identified patients, 808 were exposed to etomidate and 34 to ketamine as part of RSI. There were no differences in patient characteristics or comorbidities between groups. Post-RSI hypotension was lower in those exposed to ketamine 41.2% vs. 57.0%, p = 0.078. After controlling for concurrent medications (propofol, fentanyl, versed, levophed, vasopressin, and steroid use), ketamine was less likely to cause clinical hypotension compared to etomidate in patients with non-sepsis (OR = 0.28, 95% CI 0.10-0.79, p = 0.017) and in general overall (OR = 0.36, 95% CI 0.15-0.85, p = 0.019). However, in just the sepsis group, ketamine was insignificant (OR = 0.66, 95% CI 0.13-3.42, p = 0.619). There were no differences in length of stay, ventilator days, in-hospital death or post-RSI cardiac events between groups. CONCLUSIONS: Though ketamine was associated with less clinical hypotension when used in RSI, this did not translate to differences in patient outcomes. CLINICAL IMPLICATIONS: Concerns have been raised regarding etomidate use in RSI for patients with sepsis because of etomidate’s effect on the adrenal axis and potential to increase mortality. However, we found no meaningful difference in hospital complications, length of stay, or mortality, even in those patients who had sepsis. Given the small number of patients in our study, additional work is required to evaluate for drug superiority, specifically in patients with sepsis. DISCLOSURES: No relevant relationships by Jordan Arends, source=Web Response No relevant relationships by John Elliott, source=Web Response No relevant relationships by Kim Jordan, source=Web Response No relevant relationships by Vincent Kang, source=Web Response No relevant relationships by Gabrielle Sabino, source=Web Response No relevant relationships by Steven Wu, source=Web Response

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.

Changes in anaesthetic use for trauma patients in German HEMS \u2013 a retrospective study over a ten-year period

BackgroundAirway management and use of intravenous anaesthetics to facilitate tracheal intubation after major trauma remains controversial. Numerous agents are available and used for pre-hospital rapid-sequence induction (RSI). The aim was to investigate usage and potential changes in administration of intravenous anaesthetics for pre-hospital RSI in trauma patients over a ten-year period.MethodsBased on a large helicopter emergency medical service (HEMS) database in Germany between 2006 and 2015, a total of 9720 HEMS missions after major trauma leading to RSI on scene were analysed. Administration practice of sedatives and opioids were investigated, while neuromuscular blocking agents were not documented in the database.ResultsWith respect to administration of sedatives, independent from trauma mechanism and specific injury patterns the use of Etomidate decreased dramatically (52 to 6%) in favour of a more frequent use of Propofol (3 to 32%) and Ketamine (9 to 24%; all p < 0.001) from 2006 to 2015. The use of Benzodiazepines increased slightly, while the utilization rate of Barbiturates remained constant. In patients with Shock Index > 1 at initial contact, the administration rate of Etomidate dropped significantly as well. This decline was mainly substituted by Ketamine and particularly Propofol. In patients with GCS ≤ 8 upon initial contact, a similar distribution compared to the general trauma population could be observed.With respect to opioids, mainly Fentanyl has been administered for RSI in trauma patients (2006: 69,6% to 2015: 60.2%; p < 0.001), while the use of sufentanyl showed a significant increase (0.2 to 8.8%; p < 0.001).ConclusionsThis large study analysed prehospital administration of anaesthetics in trauma patients, showing a substantial change from 2006 to 2015 despite the lack of any high-level evidence. Etomidate has shifted from the main sedative substance to virtual absence, indicating that the recommendation of an established national guideline was transferred into clinical practice, although based on weak evidence as well. The pre-hospital use of Propofol showed a particular increase. Fentanyl has been the main opioid drug for RSI in trauma, however Sufentanyl has become increasingly popular. The mechanisms and advantages of the different substances still have to be elucidated, especially in head injury and bleeding trauma.