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Feng Y, Zhang M, Jia SY, Guo YX, Jia X. Dexamethasone alleviates etomidate-induced myoclonus by reversing the inhibition of excitatory amino acid transporters. Front Neurosci 2024; 18:1399653. [PMID: 38979126 PMCID: PMC11228700 DOI: 10.3389/fnins.2024.1399653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/27/2024] [Indexed: 07/10/2024] Open
Abstract
Background Etomidate can induce myoclonus with an incidence of 50 ~ 85% during anesthesia induction. Dexamethasone, as a long-acting synthetic glucocorticoid, has neuroprotective effects. However, the effects of dexamethasone on the etomidate-induced myoclonus remain uncertain. Methods Adult male Sprague-Dawley rats were randomly assigned to receive etomidate (1.5 mg/kg) plus dexamethasone (4 mg/kg) (etomidate plus dexamethasone group) or etomidate (1.5 mg/kg) plus the same volume of normal saline (NS) (etomidate plus NS group). The mean behavioral scores, local field potentials and muscular tension were recorded to explore the effects of dexamethasone on etomidate-induced myoclonus. Liquid chromatography coupled with tandem mass spectrometric system (LC-MS/MS), quantitative real-time polymerase chain reaction (qRT-PCR), and western blotting were applied to analyze the levels of glutamate and γ-aminobutyric acid (GABA), the mRNA and protein expression of excitatory amino acid transporters (EAATs), and plasma corticosterone levels at different time points after anesthesia. Results Compared with the etomidate plus NS treatment, the etomidate plus dexamethasone treatment significantly decreased the mean behavioral score at 1, 3, 4, and 5 min after administration; the peak power spectral density (PSD) (p = 0.0197) in the analysis of ripple waves; and the glutamate level (p = 0.0139) in the neocortex. However, compared with etomidate plus NS, etomidate plus dexamethasone increased the expression of the neocortical proteins of EAAT1 (p = 0.0207) and EAAT2 (p = 0.0022) and aggravated the inhibition of corticosterone at 4 h (p = 0.0019), 5 h (p = 0.0041), and 6 h (p = 0.0009) after administration. Conclusion Dexamethasone can attenuate the myoclonus, inhibit the glutamate accumulation, and reverse the suppression of EAATs in the neocortex induced by etomidate following myoclonus, while conversely aggravating etomidate-induced adrenal suppression.
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Affiliation(s)
- Yan Feng
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- Department of Anesthesiology, Sichuan Integrative Medicine Hospital, Chengdu, China
| | - Min Zhang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Shuai-Ying Jia
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yan-Xia Guo
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xue Jia
- Department of Anesthesiology, Sichuan Integrative Medicine Hospital, Chengdu, China
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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2
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Detomas M, Deutschbein T, Altieri B. Medical Therapy of Endogenous Cushing's Syndrome with Steroidogenesis Inhibitors: Treatment Rationale, Available Drugs, and Therapeutic Effects. Exp Clin Endocrinol Diabetes 2024. [PMID: 38688315 DOI: 10.1055/a-2317-0801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Endogenous Cushing's syndrome (CS) is a rare disease characterized by a glucocorticoid excess. If inadequately treated, hypercortisolism can lead to increased morbidity and mortality. Surgical removal of the underlying tumor is the first-line treatment but is sometimes not feasible or even contraindicated. Additionally, in cases with severe CS, rapid control of hypercortisolism may be required. In these scenarios, steroidogenesis inhibitors represent a therapeutic alternative to surgery. Over the last years, the knowledge of the broad therapeutic effects of steroidogenesis inhibitors per se and the number of available drugs have increased. However, large comparative studies are still lacking. Accordingly, the decision on which drug to be used in a certain patient or clinical setting may be difficult. This review aims to summarize the main characteristics of steroidogenesis inhibitors.
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Affiliation(s)
- Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
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3
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Feng Y, Chang P, Liu J, Zhang WS. Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review. J Clin Anesth 2024; 94:111367. [PMID: 38232466 DOI: 10.1016/j.jclinane.2023.111367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024]
Abstract
The adrenal gland is a vital endocrine organ, and adrenal steroid synthesis and secretion are closely regulated by the hypothalamic-pituitary-adrenal (HPA) axis in response to various stimuli. Surgery or trauma can activate the HPA axis and induce the secretion of cortisol. Different cortisol responses vary with the grade of surgery. Perioperative medications have the potential to decrease the cortisol level in the body, and both excessive and insufficient cortisol levels after surgery are disadvantageous. The effect of perioperative medications on the HPA response to surgery can be divided into three levels: "adrenal insufficiency (AI)", "stress response inhibition", and "uncertainty". The clinical presentation of AI includes fatigue, nausea, vomiting, abdominal pain, muscle cramps, hypotension, hypovolemic shock and prerenal failure, which may result in fatal consequences. Stress response inhibition can reduce postoperative complications, such as pain and cognitive dysfunction. This is protective to patients during perioperative and postoperative periods. The aim of the present review is to shed light on current evidence regarding the exact effects and mechanisms of perioperative medications on the HPA response to surgical injury and provide the applicable guidance on clinical anesthesia.
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Affiliation(s)
- Yan Feng
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, China; Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Pan Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Wen-Sheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China.
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4
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Valenzuela-Sánchez F, Valenzuela-Méndez B, Rodríguez-Gutiérrez JF, Estella Á. Latest developments in early diagnosis and specific treatment of severe influenza infection. JOURNAL OF INTENSIVE MEDICINE 2024; 4:160-174. [PMID: 38681787 PMCID: PMC11043645 DOI: 10.1016/j.jointm.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Influenza pandemics are unpredictable recurrent events with global health, economic, and social consequences. The objective of this review is to provide an update on the latest developments in early diagnosis and specific treatment of the disease and its complications, particularly with regard to respiratory organ failure. Despite advances in treatment, the rate of mortality in the intensive care unit remains approximately 30%. Therefore, early identification of potentially severe viral pneumonia is extremely important to optimize treatment in these patients. The pathogenesis of influenza virus infection depends on viral virulence and host response. Thus, in some patients, it is associated with an excessive systemic response mediated by an authentic cytokine storm. This process leads to severe primary pneumonia and acute respiratory distress syndrome. Initial prognostication in the emergency department based on comorbidities, vital signs, and biomarkers (e.g., procalcitonin, ferritin, human leukocyte antigen-DR, mid-regional proadrenomedullin, and lactate) is important. Identification of these biomarkers on admission may facilitate clinical decision-making to determine early admission to the hospital or the intensive care unit. These decisions are reached considering pathophysiological circumstances that are associated with a poor prognosis (e.g., bacterial co-infection, hyperinflammation, immune paralysis, severe endothelial damage, organ dysfunction, and septic shock). Moreover, early implementation is important to increase treatment efficacy. Based on a limited level of evidence, all current guidelines recommend using oseltamivir in this setting. The possibility of drug resistance should also be considered. Alternative options include other antiviral drugs and combination therapies with monoclonal antibodies. Importantly, it is not recommended to use corticosteroids in the initial treatment of these patients. Furthermore, the implementation of supportive measures for respiratory failure is essential. Current recommendations are limited, heterogeneous, and not regularly updated. Early intubation and mechanical ventilation is the basic treatment for patients with severe respiratory failure. Prone ventilation should be promptly performed in patients with acute respiratory distress syndrome, while early tracheostomy should be considered in case of planned prolonged mechanical ventilation. Clinical trials on antiviral treatment and respiratory support measures specifically for these patients, as well as specific recommendations for different at-risk populations, are necessary to improve outcomes.
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Affiliation(s)
- Francisco Valenzuela-Sánchez
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Haematology Department, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Centro de Investigación Biomédica en Red, Enfermedades respiratorias, CIBERES, Instituto de Salud Carlos III, Av. de Monforte de Lemos, Madrid, Spain
| | - Blanca Valenzuela-Méndez
- Department of Oncological Surgery, Institut du Cancer de Montpellier (ICM), Parc Euromédecine, 208 Av. des Apothicaires,Montpellier, France
| | | | - Ángel Estella
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Department of Medicine, Faculty of Medicine, University of Cádiz, Calle Doctor Marañón, Cádiz, Spain
- Instituto de Investigación e Innovación Biomédica de Cádiz (INIBiCA), Avenida Ana de Viya 21, Cádiz, Spain
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Leou K, Mendez D, Horani G, Papagiannakis N, Jiménez Sánchez R, Mazzei D, Mora I, Manickam R, Tourlakopoulos K, Garrido Peñalver JF, Jiménez Medina D, Rodríguez Mulero MD, Annousis K, Laou E, García de Guadiana-Romualdo L, Pantazopoulos I, Kaur K, Chalkias A. Effects of Etomidate on Postintubation Hypotension, Inflammatory Markers, and Mortality in Critically Ill Patients with COVID-19: An International, Multicenter, Retrospective Study. J Intensive Care Med 2023; 38:922-930. [PMID: 37151026 PMCID: PMC10170262 DOI: 10.1177/08850666231173847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE To evaluate the association of etomidate with postintubation hypotension, inflammation, and mortality in critically ill patients with COVID-19. DESIGN International, multicenter, retrospective study. PARTICIPANTS Critically ill patients hospitalized specifically for COVID-19 from three major academic institutions in the US and Europe. MAIN OUTCOME AND MEASURES Patients were allocated into the etomidate (ET) group or another induction agent (OA) group. The primary outcome was postintubation hypotension. Secondary outcomes included postintubation inflammatory status, in-hospital mortality, and mortality at 30 days. RESULTS 171 patients with a median age of 68 (IQR 58-73) years were included (ET, n = 98; OA, n = 73). Etomidate was associated with lower postintubation mean arterial pressure [74.33 (64-85) mm Hg versus 81.84 (69.75-94.25) mm Hg, p = 0.005] compared to other agents. No statistically significant differences were generally observed in inflammatory markers between the two groups at 7- and 14-days after admission to the intensive care unit. In-hospital mortality [77 (79%) versus 41 (56%), p = 0.003] and mortality at 30-days [78 (80%) versus 43 (59%), p = 0.006] were higher in the ET group. In multivariate logistic regression analysis, only etomidate (p = 0.009) and postintubation mean arterial pressure (p < 0.001) had a statistically significant effect on mortality, in contrast to stress-dose steroids (p = 0.301), after adjusting for creatinine (p = 0.695), blood urea nitrogen (p = 0.153), age (p = 0.055), oxygen saturation of hemoglobin (SpO2) (p = 0.941), and fraction of inspired oxygen (FiO2) (p = 0.712). CONCLUSIONS Administration of a single-bolus dose of etomidate in critically ill patients with COVID-19 is associated with lower postintubation mean arterial pressure and higher in-hospital and 30-day mortality compared to other induction agents.
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Affiliation(s)
- Konstantinos Leou
- Department of Critical Care Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Dianelys Mendez
- Department of Critical Care Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - George Horani
- Department of Critical Care Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Diana Mazzei
- Department of Critical Care Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Isabel Mora
- Department of Critical Care Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Rajapriya Manickam
- Department of Critical Care Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | | | | | | | | | | | - Eleni Laou
- Department of Anesthesiology, Agia Sophia Children's Hospital, Athens, Greece
| | | | - Ioannis Pantazopoulos
- Department of Emergency Medicine, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Kunwar Kaur
- Department of Critical Care Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH, USA
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6
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Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med 2023; 51:1411-1430. [PMID: 37707379 DOI: 10.1097/ccm.0000000000006000] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
RATIONALE Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division or Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
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7
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Ahmadi A, Sehat M. Accidental Intrathecal Injection of Etomidate During Spinal Anesthesia: A Case Report. Anesth Pain Med 2023; 13:e128396. [PMID: 37529347 PMCID: PMC10389035 DOI: 10.5812/aapm-128396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 08/03/2023] Open
Abstract
Etomidate is an ultra-short-acting anesthetic agent derived from imidazole that can only be administered intravenously. Etomidate has excellent hemodynamic properties in inducing anesthesia, making it an ideal choice for patients with shock, hypovolemia, or significant cardiovascular disease, with minimal reduction in blood pressure. We report a case of a female patient who was given accidental etomidate intrathecally instead of ropivacaine because of its similar appearance, which led to a slight decrease in blood pressure and no change in the pulse rate. The patient had stable vital signs and no neurological complications.
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Affiliation(s)
- Abbas Ahmadi
- Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
| | - Malihe Sehat
- Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
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8
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Lu Z, Zheng H, Chen Z, Xu S, Chen S, Mi W, Wang T, Chai X, Guo Q, Zhou H, Yu Y, Zheng X, Zhang J, Ai Y, Yu B, Bao H, Zheng H, Huang W, Wu A, Deng X, Ma H, Ma W, Tao L, Yang X, Zhang J, Liu T, Ma HP, Liang W, Wang X, Zhang Y, Du W, Ma T, Xie Y, Xie Y, Li N, Yang Y, Zheng T, Zhang C, Zhao Y, Dong R, Zhang C, Zhang G, Liu K, Wu Y, Fan X, Tan W, Li N, Dong H, Xiong L. Effect of Etomidate vs Propofol for Total Intravenous Anesthesia on Major Postoperative Complications in Older Patients: A Randomized Clinical Trial. JAMA Surg 2022; 157:888-895. [PMID: 35947398 PMCID: PMC9366659 DOI: 10.1001/jamasurg.2022.3338] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Question Does etomidate compared with propofol provide a noninferior effect on in-hospital morbidity when used for induction and maintenance of general anesthesia in older patients undergoing abdominal surgery? Findings In this randomized clinical trial involving 1944 older patients who underwent elective abdominal surgery, the rate of major in-hospital complications was noninferior between patients who received etomidate and those who received propofol for general anesthesia (9.3% vs 8.7%). Meaning Findings of this trial indicate that etomidate anesthesia does not increase postoperative morbidity in older patients compared with propofol. Importance Older patients may benefit from the hemodynamic stability of etomidate for general anesthesia. However, it remains uncertain whether the potential for adrenocortical suppression with etomidate may increase morbidity. Objective To test the primary hypothesis that etomidate vs propofol for anesthesia does not increase in-hospital morbidity after abdominal surgery in older patients. Design, Setting, and Participants This multicenter, parallel-group, noninferiority randomized clinical trial (Etomidate vs Propofol for In-hospital Complications [EPIC]) was conducted between August 15, 2017, and November 20, 2020, at 22 tertiary hospitals in China. Participants were aged 65 to 80 years and were scheduled for elective abdominal surgery. Patients and outcome assessors were blinded to group allocation. Data analysis followed a modified intention-to-treat principle. Interventions Patients were randomized 1:1 to receive either etomidate or propofol for general anesthesia by target-controlled infusion. Main Outcomes and Measures Primary outcome was a composite of major in-hospital postoperative complications (with a noninferiority margin of 3%). Secondary outcomes included intraoperative hemodynamic measurements; postoperative adrenocortical hormone levels; self-reported postoperative pain, nausea, and vomiting; and mortality at postoperative months 6 and 12. Results A total of 1944 participants were randomized, of whom 1917 (98.6%) completed the trial. Patients were randomized to the etomidate group (n = 967; mean [SD] age, 70.3 [4.0] years; 578 men [59.8%]) or propofol group (n = 950; mean [SD] age, 70.6 [4.2] years; 533 men [56.1%]). The primary end point occurred in 90 of 967 patients (9.3%) in the etomidate group and 83 of 950 patients (8.7%) in the propofol group, which met the noninferiority criterion (risk difference [RD], 0.6%; 95% CI, –1.6% to 2.7%; P = .66). In the etomidate group, mean (SD) cortisol levels were lower at the end of surgery (4.8 [2.7] μg/dL vs 6.1 [3.4] μg/dL; P < .001), and mean (SD) aldosterone levels were lower at the end of surgery (0.13 [0.05] ng/dL vs 0.15 [0.07] ng/dL; P = .02) and on postoperative day 1 (0.14 [0.04] ng/dL vs 0.16 [0.06] ng/dL; P = .001) compared with the propofol group. No difference in mortality was observed between the etomidate and propofol groups at postoperative month 6 (2.2% vs 3.0%; RD, –0.8%; 95% CI, –2.2% to 0.7%) and 12 (3.3% vs 3.9%; RD, –0.6%; 95% CI, –2.3% to 1.0%). More patients had pneumonia in the etomidate group than in the propofol group (2.0% vs 0.3%; RD, 1.7%; 95% CI, 0.7% to 2.8%; P = .001). Results were consistent in the per-protocol population. Conclusions and Relevance Results of this trial showed that, compared with propofol, etomidate anesthesia did not increase overall major in-hospital morbidity after abdominal surgery in older patients, although it induced transient adrenocortical suppression. Trial Registration ClinicalTrials.gov Identifier: NCT02910206
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Affiliation(s)
- Zhihong Lu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hong Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumuqi, Xinjiang, China
| | - Zhijun Chen
- Department of Anesthesiology, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Shiyuan Xu
- Department of Anesthesiology, ZhuJiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Shibiao Chen
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weidong Mi
- Department of Anesthesiology, Chinese PLA General Hospital, Peking, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Peking, China
| | - Xiaoqing Chai
- Department of Anesthesiology, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, China
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Hai Zhou
- Department of Anesthesiology, Xuzhou Central Hospital, Southeast University, Xuzhou, Jiangsu, China
| | - Yonghao Yu
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaochun Zheng
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yanqiu Ai
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Buwei Yu
- Department of Anesthesiology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hongguang Bao
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hui Zheng
- Department of Anesthesiology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Anshi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Peking, China
| | - Xiaoming Deng
- Department of Anesthesiology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Hong Ma
- Department of Anesthesiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Weiqing Ma
- Department of Anesthesiology, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Peking, China
| | - Xue Yang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Junbao Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Tingting Liu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hai-Ping Ma
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumuqi, Xinjiang, China
| | - Wei Liang
- Department of Anesthesiology, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Xiang Wang
- Department of Anesthesiology, ZhuJiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wei Du
- Department of Anesthesiology, Chinese PLA General Hospital, Peking, China
| | - Ting Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Peking, China
| | - Yanhu Xie
- Department of Anesthesiology, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, China
| | - Yongqiu Xie
- Department of Anesthesiology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Na Li
- Department of Anesthesiology, Xuzhou Central Hospital, Southeast University, Xuzhou, Jiangsu, China
| | - Yong Yang
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ting Zheng
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Chunyan Zhang
- Department of Anesthesiology and Perioperative Medicine, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yanling Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Rong Dong
- Department of Anesthesiology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chen Zhang
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Guohua Zhang
- Department of Anesthesiology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking, China
| | - Kuanzhi Liu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yan Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Peking, China
| | - Xiaohua Fan
- Department of Anesthesiology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Wenfei Tan
- Department of Anesthesiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Na Li
- Department of Anesthesiology, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Lize Xiong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China.,Translational Research Institute of Brain and Brain-Like Intelligence and Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
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Pansiritanachot W, Ruangsomboon O, Limsuwat C, Chakorn T. Independent risk factors of mortality in patients with sepsis receiving single-dose etomidate as an induction agent during rapid sequence intubation in a large tertiary emergency department in Thailand. BMC Emerg Med 2022; 22:94. [PMID: 35659186 PMCID: PMC9164430 DOI: 10.1186/s12873-022-00658-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/27/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is limited evidence regarding factors associated with mortality in septic patients receiving etomidate. This study aimed to determine independent pre-intubation factors predicting 28-day mortality in septic patients receiving single-dose etomidate as an induction agent during rapid sequence intubation (RSI). METHODS This single-center retrospective cohort study included intubated septic patients receiving etomidate as an induction agent during RSI in the emergency department of Siriraj hospital, Bangkok, Thailand, between January 1st, 2016 and June 30th, 2020. Pre-intubation characteristics were compared between survivors and non-survivors. Independent risk factors associated with 28-day mortality were identified using the Cox proportional hazards regression model. Association between etomidate dosage and mortality was also determined. RESULTS A total of 344 patients, 238 (69%) survivors and 106 (31%) non-survivors, were included in the analyses. The initial Cox hazards model identified a pre-intubation lactate level ≥ 4 mmol/L as an independent factor associated with mortality (adjusted Hazards ratio [aHR] 2.66, 95% confidence interval [CI] 1.55-4.56). After removing lactate level from the model due to limited lactate values in the data, cancer was also predictive of 28-day mortality (aHR 1.83, 95%CI 1.10-3.04), while patients with respiratory infections and underlying chronic lung disease were associated with lower mortality (aHR 0.54, 95%CI 0.37-0.80 and aHR 0.57, 0.33-0.96, respectively). Etomidate dosage was not associated with mortality in our study. CONCLUSION In septic patients who received a single dose of etomidate, a pre-intubation lactate level ≥ 4 mmol/L and cancer were associated with increased 28-day mortality, while respiratory infection and underlying chronic lung disease were associated with lower mortality. Physicians may take these factors into consideration when selecting induction agents for septic patients.
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Affiliation(s)
- Wasin Pansiritanachot
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Onlak Ruangsomboon
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Chok Limsuwat
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
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Yao YT, He LX, Fang NX, Ma J. Anesthetic Induction With Etomidate in Cardiac Surgical Patients: A PRISMA-Compliant Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2020; 35:1073-1085. [PMID: 33384231 DOI: 10.1053/j.jvca.2020.11.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This meta-analysis aimed to systematically review the effects of etomidate (ETM) during anesthetic induction on patients undergoing cardiac surgery. DESIGN Systematic review and meta-analysis. SETTING Operating room. PARTICIPANTS Patients undergoing cardiac surgery. INTERVENTIONS ETM or control drugs. MEASUREMENTS AND MAIN RESULTS PubMed, Cochrane Library, OVID, and EMBASE were searched through August 31, 2020. Primary outcomes included hemodynamic profiles and stress responses. Secondary outcomes included morbidity, mortality, and postoperative recovery. For continuous/dichotomous variables, treatment effects were calculated as weighted mean difference (WMD)/odds ratio (OR) and 95% confidence interval (CI). A database search yielded 18 randomized controlled trials including 1,241 patients. The present meta-analysis demonstrated that ETM-anesthetized patients had lower heart rates (WMD, -3.31; 95% CI -5.43 to -1.19; p = 0.002), higher blood pressures (systolic blood pressure: WMD, 12.02; 95% CI 6.24 to 17.80; p < 0.0001; diastolic blood pressure: WMD, 5.23; 95% CI 2.39 to 8.08; p = 0.0003; mean arterial pressure (MAP): WMD, 8.64; 95% CI 5.85 to 11.43; p < 0.00001), less requirement for vasopressor (OR, 0.26; 95% CI 0.15 to 0.44; p < 0.00001), and more nitroglycerin usage (OR, 14.89; 95% CI 4.92 to 45.08; p < 0.00001) during anesthetic induction. Current meta-analysis also demonstrated that single-dose ETM lowered cortisol levels transiently and did not have a significant effect on endogenous norepinephrine and epinephrine levels and was not associated with increased postoperative inotrope and/or vasopressor requirement. Additionally, the meta-analysis suggested that ETM anesthesia was associated with neither increased mortality nor morbidity, except a higher incidence of transient adrenal insufficiency in ETM recipients. CONCLUSION The present meta-analysis suggested that single-dose ETM during anesthetic induction could be associated with more stable hemodynamics, transient and reversible lower cortisol levels, and a higher adrenal insufficiency incidence, but not worse outcomes in cardiac surgical patients.
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Affiliation(s)
- Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Neng-Xin Fang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Ma
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Albert SG, Sitaula S. Etomidate, Adrenal Insufficiency and Mortality Associated With Severity of Illness: A Meta-Analysis. J Intensive Care Med 2020; 36:1124-1129. [PMID: 32912050 DOI: 10.1177/0885066620957596] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Etomidate causes adrenal insufficiency. Yet in critically ill patients, it is controversial whether it increases mortality rates above that of comparator anesthetic induction agents. We postulated that etomidate would increase relative mortality rates correspondingly to the severity of illness as defined by SAPS or APACHE scores. MATERIALS AND METHODS A literature search was performed on Pub Med, SCOPUS, and Cochrane Reviews for human studies, regardless of language, between 1983 and February 2020. The search strategy used keywords, "etomidate," "adrenal insufficiency," "glucocorticoid," and "intensive care." Both authors reviewed electronic data search titles, abstracts and extracted data, which were checked by the other reviewer. Primary outcome was 28-day survival. Secondary outcome was adrenal insufficiency. RESULTS There were 29 trials of etomidate versus comparators in 8584 patients. Etomidate was associated with adrenal insufficiency (risk ratio (rr) = 1·54, 95% CI; 1·42, 1·67, p < 0.001) and increased overall relative mortality rates (rr = 1.09, CI;1.04,1.16, p = 0.001). Meta-regression showed that with etomidate there was a continuous progressive relative risk of mortality associated with increasing severity of illness (predefined in each article by standard critical illness scores). In those patients who had a predicted mortality rate > the median for this analysis (predicted mortality 44%) the relative mortality rate (rr) = 1.20, Ci;1.12,1.29, p < 0.001, the absolute risk difference (rd) = 0.08, CI;0.05,0.11, p < 0.0001 and the number needed to harm (1/rd) was 12.5. In those with a calculated predicted mortality <44% there was no increase in relative mortality rate. CONCLUSIONS Whereas etomidate causes adrenal insufficiency, it was not shown to increase mortality in many analyzed here in ICU settings. However, etomidate associated relative mortality rates increased progressively and correlated with the severity of critical illness scores. Intensivists should anticipate the need for glucocorticoid supplementation after etomidate in those with severe critical illness and in those with acute deterioration of vital signs.
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Affiliation(s)
- Stewart G Albert
- Division of Endocrinology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Sujata Sitaula
- Division of Endocrinology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO, USA
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12
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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Etomidate Is NOT a First-Line Induction Agent in Critically Ill Patients: Primum Non Nocere-Above All, Do No Harm. Crit Care Med 2019; 46:1495-1496. [PMID: 29923932 DOI: 10.1097/ccm.0000000000003291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Neuroendocrine Derangements in Early Septic Shock: Pharmacotherapy for Relative Adrenal and Vasopressin Insufficiency. Shock 2018; 48:284-293. [PMID: 28296657 DOI: 10.1097/shk.0000000000000864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Septic shock is a leading cause of mortality in intensive care units throughout the world. While this disease state represents a highly complex pathophysiology involving numerous organ systems, the early approach to care includes adequate hemodynamic support traditionally achieved via infusions of vasoactive medications after adequate fluid resuscitation. Relative adrenal and vasopressin deficiencies are a common feature of septic shock that contribute to impaired hemodynamics. Hydrocortisone and vasopressin are endocrine system hormone analogues that target the acute neuroendocrine imbalance associated with septic shock. This clinically focused annotated review describes the pathophysiological mechanisms behind their use and explores the potential clinical roles of early administration and synergy when combined.
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Anaesthetic induction with etomidate in cardiac surgery: A randomised controlled trial. Eur J Anaesthesiol 2018; 33:417-24. [PMID: 26914224 DOI: 10.1097/eja.0000000000000434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Etomidate is perceived as preserving haemodynamic stability during induction of anaesthesia. It is also associated with adrenocortical dysfunction. The risk/benefit relationship is controversial. OBJECTIVES We tested the hypotheses that single-dose etomidate increases cumulative vasopressor requirement, time to extubation and length of stay in the ICU. DESIGN Double-blind randomised controlled trial. SETTING Bern University Hospital, Switzerland, from November 2006 to December 2009. PATIENTS There were 90 patients undergoing coronary artery bypass grafts (CABG) and 40 patients undergoing mitral valve surgery (MVS). Reasons for noninclusion were known adrenocortical insufficiency, use of etomidate or propofol within 1 week preoperatively, use of glucocorticoids within 6 months preoperatively, severe renal or liver dysfunction, or carotid stenosis. INTERVENTIONS CABG patients were allocated randomly to receive either etomidate 0.15 mg kg with placebo, propofol 1.5 mg kg with placebo or etomidate 0.15 mg kg with hydrocortisone (n = 30 in each arm). Risk stratification (low vs. high) was achieved by block randomisation. MVS patients received either etomidate 0.15 mg kg or propofol 1.5 mg kg (n = 20 in each arm). MAIN OUTCOME MEASURES Cumulative vasopressor requirements, incidence of adrenocortical insufficiency, length of time to extubation and length of stay in ICU. RESULTS Cumulative vasopressor requirements 24 h after induction did not differ between treatments in patients who underwent CABG, whereas more noradrenaline was used in MVS patients following propofol induction (absolute mean difference 5.86 μg kg over 24 h P = 0.047). The incidence of relative adrenocortical insufficiency was higher after etomidate alone than propofol (CABG 83 vs. 37%, P < 0.001; MVS: 95 vs. 35%, P < 0.001). The time to extubation, length of stay in ICU and 30-day mortality did not differ among treatments. Within low and high-risk subgroups, no differences in vasopressor use or outcomes were found. CONCLUSION In elective cardiac surgery, laboratory indicators of etomidate-induced adrenal insufficiency do not translate into increased vasopressor requirement or inferior early outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT 00415701.
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Komatsu R, You J, Rajan S, Kasuya Y, Sessler DI, Turan A. Steroid administration after anaesthetic induction with etomidate does not reduce in-hospital mortality or cardiovascular morbidity after non-cardiac surgery. Br J Anaesth 2017; 120:501-508. [PMID: 29452806 DOI: 10.1016/j.bja.2017.11.079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 09/06/2017] [Accepted: 09/11/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND We tested the primary hypothesis that corticosteroid administration after etomidate exposure reduces a composite of in-hospital mortality and cardiovascular morbidity after non-cardiac surgery. METHODS We evaluated ASA physical status III and IV patients who had non-cardiac surgery with general anaesthesia at the Cleveland Clinic. Amongst 4275 patients in whom anaesthesia was induced with etomidate, 804 were also given steroid intraoperatively, mostly dexamethasone at a median dose of 6 mg. We successfully matched 582 steroid patients with 1023 non-steroid patients. The matched groups were compared on composite of in-hospital mortality and cardiovascular morbidity using a generalized-estimating-equation model. Secondly, the matched groups were compared on length of hospital stay using a Cox proportional hazard model, and were descriptively compared on intraoperative blood pressures using a standardized difference. RESULTS There was no significant association between intraoperative steroid administration after anaesthetic induction with etomidate and the composite of in-hospital mortality or cardiovascular morbidity; the estimated common odds ratio across the two components of the composite was 0.86 [95% confidence interval (CI): 0.64, 1.16] for steroid vs non-steroid, P=0.33. The duration of postoperative hospitalisation was significantly shorter amongst steroid patients [median (Q1, Q3): 6 (3, 10) days] than non-steroid patients [7 (4, 11) days], with an estimated hazard ratio of 0.89 (0.80, 0.98) for steroid vs non-steroid, P=0.01. Intraoperative blood pressures were similar in steroid and non-steroid patients. CONCLUSIONS Steroid administration after induction of anaesthesia with etomidate did not reduce mortality or cardiovascular morbidity.
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Affiliation(s)
- R Komatsu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305695, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - J You
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH 44195, USA
| | - S Rajan
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Y Kasuya
- Department of Anesthesiology, Tokyo Women's Medical University, Shinjuku, Tokyo 162-8666, Japan
| | - D I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - A Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Rello J, Valenzuela-Sánchez F, Ruiz-Rodriguez M, Moyano S. Sepsis: A Review of Advances in Management. Adv Ther 2017; 34:2393-2411. [PMID: 29022217 PMCID: PMC5702377 DOI: 10.1007/s12325-017-0622-8] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Indexed: 12/28/2022]
Abstract
Infections represent a common health problem in people of all ages. Usually, the response given to them is appropriate and so little treatment is needed. Sometimes, however, the response to the infection is inadequate and may lead to organ dysfunction; this is the condition known as sepsis. Sepsis can be caused by bacteria, fungi or viruses and at present there is no specific treatment; its management basically focuses on containing the infection through source control and antibiotics plus organ function support. This article reviews key elements of sepsis management, focusing on diagnosis, biomarkers and therapy. The main recent advance in therapy is the strategy of personalized medicine, based on a precise approach using biomarkers to identify specific individuals who are likely to benefit from more personalized attention.
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Affiliation(s)
- Jordi Rello
- CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain.
| | | | | | - Silvia Moyano
- CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain
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Besnier E, Clavier T, Compere V. The Hypothalamic–Pituitary–Adrenal Axis and Anesthetics. Anesth Analg 2017; 124:1181-1189. [DOI: 10.1213/ane.0000000000001580] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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20
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Zakaria S, Kwong HJ, Sevransky JE, Williams MS, Chandra-Strobos N. Editor's Choice-The cardiovascular implications of sedatives in the cardiac intensive care unit. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:671-683. [PMID: 29064259 DOI: 10.1177/2048872617695231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients admitted to the cardiac intensive care unit frequently develop multi-organ system dysfunction associated with their cardiac disease. In many cases, invasive mechanical ventilation is required, which often necessitates sedation for patient-ventilator synchrony, reduction of work of breathing, and patient comfort. In this paper, we describe the use of common sedatives available in the endotracheally intubated critically ill patient and emphasize the clinical and cardiovascular effects. We review γ-aminobutyric acid agonists such as etomidate, benzodiazepines, and propofol, the centrally acting α2-agonist dexmedetomidine, and the N-methyl-D-aspartate receptor antagonist ketamine. Additionally, we outline the use of opioids and their role in potentiating other sedatives. We note that some sedatives are associated with increased delirium rates, and emphasize that judicious strategies minimizing sedative use are associated with decreases in morbidity and mortality. We also discuss standardized sedation assessment scales and highlight the importance of sedation weaning. Finally, we offer recommendations for sedation use during therapeutic hypothermia, and discuss the use of adjuvant neuromuscular blocking agents.
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Affiliation(s)
- Sammy Zakaria
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Helaine J Kwong
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
| | | | - Marlene S Williams
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
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Hammond DA, Vines CE, McPhee AL, Bhandari NR, Jones KM, Meena N, Painter JT. Effect of Etomidate on Pneumonia Development in Critically Ill, Nontrauma Patients. J Intensive Care Med 2016; 34:34-39. [PMID: 28027685 DOI: 10.1177/0885066616686052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE: To determine whether etomidate use before intubation increased development of hospital-acquired pneumonia (HAP) in critically ill, nontrauma patients. MATERIALS AND METHODS: A single-center, retrospective, cohort study of critically ill, nontrauma patients admitted to the medical intensive care unit (ICU) from 2012 to 2015 and intubated with or without etomidate was conducted. Demographics, comorbidities, primary diagnosis, critical illness scores, concomitant medications, and outcomes were obtained from medical records. Student t, chi-square, and Fisher exact tests were performed as appropriate. Relevant characteristics were modeled using logistic regression techniques to determine whether any predicted HAP independently. RESULTS: Of the 174 patients, 94 (54%) received etomidate and 80 (46%) did not. There was no difference in HAP between etomidate and no etomidate groups (13.8% vs 23.7%, P = .092). Duration of mechanical ventilation (4.4 vs 4.6 days, P = .845), ICU length of stay (7.4 vs 6.9 days, P = .547), ICU mortality (14.9% vs 12.5%, P = .648), and hospital mortality (17% vs 16.2%, P = .892) were similar between the groups. For each 1-day increase in mechanical ventilation duration, the likelihood of HAP development increased by 21%. Patients who received etomidate but no neuromuscular-blocking drug were 80% less likely to develop HAP than those who did not receive etomidate or a neuromuscular-blocking drug (odds ratio: 0.202, 95% confidence interval: 0.045-0.908). CONCLUSION: Etomidate use was not associated with a difference in HAP development in critically ill, nontrauma patients.
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Affiliation(s)
- Drayton A Hammond
- 1 Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Claire E Vines
- 2 Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ashley L McPhee
- 1 Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Naleen Raj Bhandari
- 1 Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Kendrea M Jones
- 1 Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Nikhil Meena
- 3 Department of Internal Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, USA
| | - Jacob T Painter
- 1 Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
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Zhang Y, Li RM, Wang C, Liu N, Lv S, Xiong JY. Etomidate inhibits nuclear factor-κB through decreased expression of glucocorticoid receptor in septic rats. Mol Med Rep 2016; 14:5760-5766. [DOI: 10.3892/mmr.2016.5947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 10/18/2016] [Indexed: 12/29/2022] Open
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Allen C, Washington S. The role of etomidate as an anaesthetic induction agent for critically ill patients. Br J Hosp Med (Lond) 2016; 77:282-6. [PMID: 27166106 DOI: 10.12968/hmed.2016.77.5.282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Etomidate is an anaesthetic induction agent which may be favoured in critically ill patients because of its cardiovascular stability. However, etomidate causes adrenocortical suppression which may be particularly harmful in these patients. This article reviews current evidence and debates the use of etomidate in critical illness.
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Affiliation(s)
- Claire Allen
- ST6 in Anaesthesia in the Department of Anaesthesia, University Hospital of South Manchester NHS Foundation Trust, Manchester M23 9LT
| | - Stephen Washington
- Consultant Anaesthetist in the Department of Anaesthesia, University Hospital of South Manchester NHS Foundation Trust, Manchester
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Short TG, Hannam JA, Laurent S, Campbell D, Misur M, Merry AF, Tam YH. Refining Target-Controlled Infusion: An Assessment of Pharmacodynamic Target-Controlled Infusion of Propofol and Remifentanil Using a Response Surface Model of Their Combined Effects on Bispectral Index. Anesth Analg 2016; 122:90-7. [PMID: 26683103 DOI: 10.1213/ane.0000000000000386] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Propofol and remifentanil are commonly combined for total IV anesthesia. The pharmacokinetics (PK), pharmacodynamics (PD), and drug interactions of the combination are well understood, but the use of a combined PK and PD model to control target-controlled infusion pumps has not been investigated. In this study, we prospectively tested the accuracy of a PD target-controlled infusion algorithm for propofol and remifentanil using a response surface model of their combined effects on Bispectral Index (BIS). METHODS Effect-site, target-controlled infusions of propofol and remifentanil were given using an algorithm based on standard PK models linked to a PD response surface model of their combined effects on BIS. The combination of a targeted BIS value and adjustable ratio of propofol to remifentanil was used to adjust infusion rates. The standard model performance measures of median performance error (bias) and median absolute performance error (inaccuracy), expressed as percentages, were used to assess accuracy of the infusions in a convenience sample of 50 adult patients undergoing surgery with general anesthesia. The influence of age and weight on the performance of the model was also assessed. RESULTS Patients had a mean (range) age of 48 (19-73) years, weight of 80 (45-169) kg, and body mass index of 28 (19-45) kg/m. The overall model had a bias of 8% (SD 24%) and inaccuracy of 25% (SD 13%). Performance was least accurate during the early induction phase of anesthesia. There was no significant bias in BIS predictions with increasing age (P = 0.44) or weight (P = 0.56). CONCLUSIONS The algorithm performed adequately in a clinical setting. The algorithm could be further refined, and assessment of its accuracy and utility in comparison to current clinical practice for giving IV anesthesia is warranted.
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Affiliation(s)
- Timothy G Short
- From the *Department of Anaesthesiology, University of Auckland, Auckland, New Zealand; †Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand; and ‡Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Archambault P, Dionne CE, Lortie G, LeBlanc F, Rioux A, Larouche G. Adrenal inhibition following a single dose of etomidate in intubated traumatic brain injury victims. CAN J EMERG MED 2015; 14:270-82. [DOI: 10.2310/8000.2012.110560] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTBackground:Etomidate is frequently used to intubate traumatic brain injury (TBI) victims, even though it has been linked to adrenal insufficiency (AI) in some populations. Few studies have explored the risk of prolonged etomidateinduced AI among TBI victims.Objective:To determine the risk and the length of AI induced by etomidate in patients intubated for moderate and severe TBI.Methods:Participants in this observational study were moderate to severe intubated TBI victims aged ≥ 16 years. The anesthetic used (etomidate versus others) was determined solely by the treating emergency physician. Adrenocorticotropic hormone (ACTH) stimulation tests (250 µg) were performed 24, 48, and 168 hours after intubation. AI was defined as an increase in serumcortisol 1 hour post–ACTH test (delta cortisol) of less than 248.4 nmol/L.Results:Forty subjects (participation 42.6%) underwent ACTH testing. Fifteen received etomidate, and 25 received another anesthetic. There were no statistically significant differences between groups as to the cumulative incidence of AI at any measurement time. However, at 24 hours, exploratory post hoc analyses showed a significant decrease in delta cortisol (adjusted means: etomidate group: 305.1 nmol/L, 95% CI 214.7–384.8 versus other anesthetics: 500.5 nmol/L, 95% CI 441.8–565.7). This decrease was not present at 48 and 168 hours.Conclusion:In TBI victims, although a single dose of etomidate does not increase the cumulative incidence of AI as defined, it seems to decrease the adrenal response to an ACTH test for 24 hours. The clinical impacts of this finding remain to be determined.
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Gu WJ, Wang F, Tang L, Liu JC. Single-dose etomidate does not increase mortality in patients with sepsis: a systematic review and meta-analysis of randomized controlled trials and observational studies. Chest 2015; 147:335-346. [PMID: 25255427 DOI: 10.1378/chest.14-1012] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The effect of single-dose etomidate on mortality in patients with sepsis remains controversial. We systematically reviewed the literature to investigate whether a single dose of etomidate for rapid sequence intubation increased mortality in patients with sepsis. METHODS PubMed, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched for randomized controlled trials (RCTs) and observational studies regarding the effect of single-dose etomidate on mortality in adults with sepsis. The primary outcome was all-cause mortality. The Mantel-Haenszel method with random-effects modeling was used to calculate pooled relative risks (RRs) and 95% CIs. RESULTS Eighteen studies (two RCTs and 16 observational studies) in 5,552 patients were included. Pooled analysis suggested that single-dose etomidate was not associated with increased mortality in patients with sepsis in both the RCTs (RR, 1.20; 95% CI, 0.84-1.72; P = .31; I(2) = 0%) and the observational studies (RR, 1.05; 95% CI, 0.97-1.13; P = .23; I(2) = 25%). When only adjusted RRs were pooled in five observational studies, RR for mortality was 1.05 (95% CI, 0.79-1.39; P = .748; I(2) = 71.3%). These findings also were consistent across all subgroup analyses for observational studies. Single-dose etomidate increased the risk of adrenal insufficiency in patients with sepsis (eight studies; RR, 1.42; 95% CI, 1.22-1.64; P < .00001). CONCLUSIONS Current evidence indicates that single-dose etomidate does not increase mortality in patients with sepsis. However, this finding largely relies on data from observational studies and is potentially subject to selection bias; hence, high-quality and adequately powered RCTs are warranted.
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Affiliation(s)
- Wan-Jie Gu
- Department of Anaesthesiology, First Affiliated Hospital of Guangxi Medical University, Nanning
| | - Fei Wang
- Department of Anaesthesiology, General Hospital of Jinan Military Command, Jinan, China
| | - Lu Tang
- Department of Anaesthesiology, General Hospital of Jinan Military Command, Jinan, China
| | - Jing-Chen Liu
- Department of Anaesthesiology, General Hospital of Jinan Military Command, Jinan, China.
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Adrenal Insufficiency. EVIDENCE-BASED CRITICAL CARE 2015. [PMCID: PMC7123184 DOI: 10.1007/978-3-319-11020-2_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Etomidate increases mortality in septic rats through inhibition of nuclear factor kappa-B rather than by causing adrenal insufficiency. J Surg Res 2015; 193:399-406. [DOI: 10.1016/j.jss.2014.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/08/2014] [Accepted: 07/01/2014] [Indexed: 01/10/2023]
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Trentzsch H, Münzberg M, Luxen J, Urban B, Prückner S. Etomidat zur „rapid sequence induction“ bei schwerem Trauma. Notf Rett Med 2014. [DOI: 10.1007/s10049-014-1899-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Alday NJ, Jones GM, Kimmons LA, Phillips GS, McCallister JW, Doepker BA. Effects of etomidate on vasopressor use in patients with sepsis or severe sepsis: A propensity-matched analysis. J Crit Care 2014; 29:517-22. [DOI: 10.1016/j.jcrc.2014.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/29/2014] [Accepted: 02/02/2014] [Indexed: 11/28/2022]
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Blackwood B, Clarke M, McAuley DF, McGuigan PJ, Marshall JC, Rose L. How outcomes are defined in clinical trials of mechanically ventilated adults and children. Am J Respir Crit Care Med 2014; 189:886-93. [PMID: 24512505 DOI: 10.1164/rccm.201309-1645pp] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Systematic reviews have considerable potential to provide evidence-based data to aid clinical decision-making. However, there is growing recognition that trials involving mechanical ventilation lack consistency in the definition and measurement of ventilation outcomes, creating difficulties in combining data for meta-analyses. To address the inconsistency in outcome definitions, international standards for trial registration and clinical trial protocols published recommendations, effectively setting the "gold standard" for reporting trial outcomes. In this Critical Care Perspective, we review the problems resulting from inconsistent outcome definitions and inconsistent reporting of outcomes (outcome sets). We present data highlighting the variability of the most commonly reported ventilation outcome definitions. Ventilation outcomes reported in trials over the last 6 years typically fall into four domains: measures of ventilator dependence; adverse outcomes; mortality; and resource use. We highlight the need, first, for agreement on outcome definitions and, second, for a minimum core outcome set for trials involving mechanical ventilation. A minimum core outcome set would not restrict trialists from measuring additional outcomes, but would overcome problems of variability in outcome selection, measurement, and reporting, thereby enhancing comparisons across trials.
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Abstract
PURPOSE OF REVIEW To evaluate the most recent publications in the long-lived debate over the use of etomidate in critically ill septic and trauma patients. RECENT FINDINGS Virtually without controversy is the hemodynamic stability after its use for induction of anesthesia on the one hand, and its negative effect on steroid synthesis on the other. The rating of the relative importance of both phenomena for the outcome of patients is however a highly controversial issue. We will discuss the most recent publications for two patient groups: trauma and critically ill septic patients. New meta-analyses and smaller studies have been published and might help us to weigh pros and cons in our patients. Sufficiently powered randomized controlled trials remain absent. The question whether supplemented corticosteroids after etomidate improve outcome is answered negatively by two recent studies. SUMMARY A single dose of etomidate supplies good intubation conditions with hemodynamic stability, but increases the risk for adrenal insufficiency. The relative importance of these characteristics for the patients' outcome remains controversial, as there is a lack of direct evidence. According to the principle 'nihil nocere', reasoning argues against its use, especially in septic patients or in those at major risk to develop septic complications (e.g. trauma patients).
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ERDOES G, BASCIANI RM, EBERLE B. Etomidate--a review of robust evidence for its use in various clinical scenarios. Acta Anaesthesiol Scand 2014; 58:380-9. [PMID: 24588359 DOI: 10.1111/aas.12289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 02/02/2023]
Abstract
Etomidate is an intravenous hypnotic with a favourable clinical profile in haemodynamic high-risk scenarios. Currently, there is an active debate about the clinical significance of the drug's side effects and its overall risk-benefit ratio. Etomidate-induced transient adrenocortical suppression is well documented and has been associated with increased mortality in sepsis. In surgical patients at risk of hypotensive complications, however, a review of current literature provides no robust evidence to contraindicate a single-bolus etomidate induction. Large randomised controlled trials as well as additional observational data are required to compare safety of etomidate and its alternatives.
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Affiliation(s)
- G. ERDOES
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
| | - R. M. BASCIANI
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
| | - B. EBERLE
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
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Besnier E, Clavier T, Castel H, Gandolfo P, Morin F, Tonon MC, Marguerite C, Veber B, Dureuil B, Compère V. [Interaction between hypnotic agents and the hypothalamic-pituitary-adrenocorticotropic axis during surgery]. ACTA ACUST UNITED AC 2014; 33:256-65. [PMID: 24631003 DOI: 10.1016/j.annfar.2014.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/27/2014] [Indexed: 01/07/2023]
Abstract
During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adrenal axis (HPA), which via the synthesis of glucocorticoids will modulate the intensity of the inflammatory response. Anaesthetic agents could be interacting with the HPA axis during surgery. Although etomidate currently remains in the center of the discussions, it seems, at least experimentally, that most hypnotics have the capacity to modulate the synthesis of adrenal steroids. Nevertheless, with the large literature on this subject, etomidate seems to be the most deleterious hypnotic agent on the HPA axis function. Its use should be limited when HPA axis is already altered.
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Affiliation(s)
- E Besnier
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - T Clavier
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - H Castel
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - P Gandolfo
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - F Morin
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - M-C Tonon
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - C Marguerite
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - B Veber
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - B Dureuil
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - V Compère
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France.
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Affiliation(s)
- Matthieu Legrand
- *Paris-Diderot University, Assistance Publique-Hôpitaux de Paris, Department of Anesthesiology and Critical Care and Burn Unit, Groupe Hospitalier Saint-Louis-Lariboisière; †Institut National de la Santé et de la Recherche Médicale (INSERM), Hôpital Lariboisière; and ‡Paris-Diderot University, Assistance Publique-Hôpitaux de Paris, Department of Anesthesiology and Critical Care, Groupe Hospitalier Saint-Louis-Lariboisière, Paris, France
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Abstract
PURPOSE OF REVIEW Corticosteroids have been widely administered in critically ill patients for various indications. Their clinical benefit is broadly investigated but remains controversial. The purpose of this review is to explore the use of corticosteroids in intensive care, their impact on patient outcome and to provide practical guidance for the use of corticosteroids in the ICU. RECENT FINDINGS Critical illness is the result of significant tissue damage, due to cellular ischemia, trauma or infection, inducing a systemic inflammatory syndrome. Recent advances in the understanding of the immunologic and molecular mechanisms of inflammation support, in part, the conceptual use of corticosteroids as an adjunct immunomodulatory therapy. But use of corticosteroids carries the risk of severe adverse effects, partly because of their anti-infammatory effects. Recently, clinical research has focused on critical illness-related corticosteroid insufficiency and several trials investigated the role of corticosteroids therapy in septic and critically ill patients with severe systemic inflammation such as acute respiratory distress syndrome, severe community-acquired pneumonia and meningitis. Improved morbidity has been demonstrated in some studies but a clear benefit in term of mortality was not observed. SUMMARY Critical illnesses stem from a group of heterogeneous medical conditions. Failure to target subgroups more likely to benefit from the use of corticosteroids may be one explanation for the largely disappointing results in clinical trials, thus, far.
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Reply to: Anaesthesia for renal transplant surgery. Eur J Anaesthesiol 2013; 30:716-7. [PMID: 23867779 DOI: 10.1097/eja.0b013e328363f789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Single-Dose Etomidate Is Not Associated With Increased Mortality in ICU Patients With Sepsis. Crit Care Med 2013; 41:774-83. [DOI: 10.1097/ccm.0b013e318274190d] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jung B, Clavieras N, Nougaret S, Molinari N, Roquilly A, Cisse M, Carr J, Chanques G, Asehnoune K, Jaber S. Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R224. [PMID: 23171852 PMCID: PMC3672604 DOI: 10.1186/cc11871] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 11/12/2012] [Indexed: 12/19/2022]
Abstract
Introduction Endotracheal intubation in the ICU is associated with a high incidence of complications. Etomidate use is debated in septic shock because it increases the risk of critical illness-related corticosteroid insufficiency, which may impact outcome. We hypothesized that hydrocortisone, administered in all septic shock cases in our ICU, may counteract some negative effects of etomidate. The aim of our study was to compare septic shock patients who received etomidate versus another induction drug both for short-term safety and for long-term outcomes. Methods A single-center observational study was carried out in septic shock patients, treated with hydrocortisone and intubated within the first 48 hours of septic shock. Co-primary end points were life-threatening complications incidence occurring within the first hour after intubation and mortality during the ICU stay. Statistical analyses included unmatched and matched cohorts using a propensity score analysis. P < 0.05 was considered significant. Results Sixty patients in the etomidate cohort and 42 patients in the non-etomidate cohort were included. Critical illness-related corticosteroid insufficiency was 79% in the etomidate cohort and 52% in the non-etomidate cohort (P = 0.01). After intubation, life-threatening complications occurred in 36% of the patients whatever the cohort. After adjustment with propensity score analysis, etomidate was a protective factor for death in the ICU both in unmatched (hazard ratio, 0.33 (0.15 to 0.75); P < 0.01)) and matched cohorts (hazard ratio, 0.33 (0.112 to 0.988); P = 0.04). Conclusion In septic shock patients treated with hydrocortisone, etomidate did not decrease life-threatening complications following intubation, but when associated with hydrocortisone it also did not impair outcome.
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Malhotra AK. Con: etomidate--the ideal induction agent for a cardiac anesthetic? J Cardiothorac Vasc Anesth 2012; 27:178-9. [PMID: 23127693 DOI: 10.1053/j.jvca.2012.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Anita K Malhotra
- Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
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Flynn G, Shehabi Y. Pro/con debate: Is etomidate safe in hemodynamically unstable critically ill patients? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:227. [PMID: 22809235 PMCID: PMC3580672 DOI: 10.1186/cc11242] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Etomidate is an induction agent known for its smooth intubating conditions and cardiovascular stability. Studies, however, have shown that a single dose of etomidate can result in a prolonged adrenal insufficiency. The impact of this in patients with sepsis has been a matter for debate. This review presents a pro/con case for using etomidate in hemodynamically unstable critically ill patients and provides guidance for alternative induction techniques and when the use of etomidate might be justified despite these concerns.
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Supplemental corticosteroids after intubation using etomidate in severe sepsis and septic shock. Crit Care Med 2012; 40:2003-4; author reply 2004. [PMID: 22610230 DOI: 10.1097/ccm.0b013e31824e1d0a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Asehnoune K, Mahe PJ, Seguin P, Jaber S, Jung B, Guitton C, Chatel-Josse N, Subileau A, Tellier AC, Masson F, Renard B, Malledant Y, Lejus C, Volteau C, Sébille V, Roquilly A. Etomidate increases susceptibility to pneumonia in trauma patients. Intensive Care Med 2012; 38:1673-82. [PMID: 22777514 DOI: 10.1007/s00134-012-2619-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 05/30/2012] [Indexed: 12/20/2022]
Abstract
PURPOSE To investigate the impact of etomidate on the rate of hospital-acquired pneumonia (HAP) in trauma patients and the effects of hydrocortisone in etomidate-treated patients. METHODS This was a sub-study of the HYPOLYTE multi-centre, randomized, double-blind, placebo-controlled trial of hydrocortisone in trauma patients (NCT00563303). Inclusion criterion was trauma patient with mechanical ventilation (MV) of ≥48 h. The use of etomidate was prospectively collected. Endpoints were the results of the cosyntropin test and rate of HAP on day 28 of follow-up. RESULTS Of the 149 patients enrolled in the study, 95 (64 %) received etomidate within 36 h prior to inclusion. 79 (83 %) of 95 patients receiving etomidate and 34 of the 54 (63 %) not receiving etomidate had corticosteroid insufficiency (p = 0.006). The administration of etomidate did not alter basal cortisolemia (p = 0.73), but it did decrease the delta of cortisolemia at 60 min (p = 0.007). There was a correlation between time from etomidate injection to inclusion in the study and sensitivity to corticotropin (R (2) = 0.19; p = 0.001). Forty-nine (51.6 %) patients with etomidate and 16 (29.6 %) patients without etomidate developed HAP by day 28 (p = 0.009). Etomidate was associated with HAP on day 28 in the multivariate analysis (hazard ratio 2.48; 95 % confidence interval 1.19-5.18; p = 0.016). Duration of MV with or without etomidate was not significantly different (p = 0.278). Among etomidate-exposed patients, 18 (40 %) treated with hydrocortisone developed HAP compared with 31 (62 %) treated with placebo (p = 0.032). Etomidate-exposed patients treated with hydrocortisone had fewer ventilator days (p < 0.001). CONCLUSIONS Among the patients enrolled in the study, etomidate did not alter basal cortisolemia, but it did decrease reactivity to corticotropin. We suggest that in trauma patients, etomidate is an independent risk factor for HAP and that the administration of hydrocortisone should be considered after etomidate use.
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Affiliation(s)
- Karim Asehnoune
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu-HME, University Hospital of Nantes, Nantes, France.
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Tobin JM, Varon AJ. Review article: update in trauma anesthesiology: perioperative resuscitation management. Anesth Analg 2012; 115:1326-33. [PMID: 22763906 DOI: 10.1213/ane.0b013e3182639f20] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of trauma patients has matured significantly since a systematic approach to trauma care was introduced nearly a half century ago. The resuscitation continuum emphasizes the effect that initial therapy has on the outcome of the trauma patient. The initiation of this continuum begins with prompt field medical care and efficient transportation to designated trauma centers, where lifesaving procedures are immediately undertaken. Resuscitation with packed red blood cells and plasma, in parallel with surgical or interventional radiologic source control of bleeding, are the cornerstones of trauma management. Adjunctive pharmacologic therapy can assist with resuscitation. Tranexamic acid is used in Europe with good results, but the drug is slowly being added to the pharmacy formulary of trauma centers in United States. Recombinant factor VIIa can correct abnormal coagulation values, but its outcome benefit is less clear. Vasopressin shows promise in animal studies and case reports, but has not been subjected to a large clinical trial. The concept of "early goal-directed therapy" used in sepsis may be applicable in trauma as well. An early, appropriately aggressive resuscitation with blood products, as well as adjunctive pharmacologic therapy, may attenuate the systemic inflammatory response of trauma. Future investigations will need to determine whether this approach offers a similar survival benefit.
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Affiliation(s)
- Joshua M Tobin
- Department of Anesthesiology, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St., T1R77, Baltimore, MD 21201, USA.
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