Propofol decreases etomidate-related myoclonus in gastroscopy

The need to monitor emerging issues in etomidate usage: the misuse or abuse potential

Since 2011, the misuse or abuse of etomidate has gradually increased when propofol was designated a controlled drug under the Narcotics Control Act in Korea. Accordingly, the Ministry of Food and Drug Safety announced that etomidate would be under the 'Regulation on the designation of drugs that may cause concerns of misuse or abuse' rule in June 2020, which is less stringent than the Narcotics Control Act. Therefore, this review investigates potential misuse or abuse cases of etomidate to consider strengthening its management. A literature search was conducted to compare etomidate with other sedatives in their efficacy and side effects, as well as identify the adverse health outcomes, abuse cases, and analytical methods of etomidate. Etomidate has an equal or higher sedative efficacy and lower risk of adverse cardiopulmonary events than propofol. However, major adverse effects of etomidate include adrenocortical suppression and unproven associated deaths, as well as myoclonus requiring pre-treatment. Although the issue of abuse and misuse of etomidate is emerging in recent years, there are few academic reports on these issues and analytical methods in the forensic field. In order to effectively manage the misuse or abuse of etomidate, it is necessary to continuously monitor related cases with great interest and to be more intensively studied on its abuse potential.

Remimazolam vs Etomidate: Haemodynamic Effects in Hypertensive Elderly Patients Undergoing Non-Cardiac Surgery

Background

Remimazolam tosilate (RT) is a novel ultrashort-acting γ-aminobutyric acid subtype A (GABAA) agonist, with several advantages including rapid induction and recovery, stable haemodynamics, and mild respiratory inhibition. However, studies have not been conducted to explore the haemodynamic effects of RT in elderly hypertensive subjects undergoing non-cardiac surgery. Therefore, we sought to compare the effects of anaesthesia induction using different doses of RT and etomidate on the haemodynamics of this group of patients.

Methods

Patients were recruited into this single-center, prospective, randomized, double-blind trial from October 2022 to June 2023. A total of 150 hypertensive elderly undergoing non-cardiac surgery were randomly assigned into 0.2 mg/kg RT group (Group RL), 0.3 mg/kg RT group (Group RH) and 0.3 mg/kg etomidate group (Group E). The primary outcome of the study was haemodynamic changes (mean arterial pressure fluctuation value -∆MAP and heart rate fluctuation value -∆HR) observed during anaesthesia induction. Secondary outcomes included incidence of adverse cardiovascular events and adverse drug reactions (injection pain and myoclonus), cumulative doses of vasoactive drugs and vital signs at different time points.

Results

Patients in Group E and Group RL had significantly lower haemodynamic fluctuations (∆MAP), lower incidence of hypotension and cumulative dose of ephedrine than subjects in Group RH. Patients in groups RL and RH had significantly lower incidence of injection pain and myoclonus compared with patients in group E. The results showed no statistically significant differences in ∆HR, hypertension, bradycardia, tachycardia, and time to loss of eye-opening reflex and start of intubation, and vital signs at different time points among the three groups.

Conclusion

Use of low-dose RT (0.2 mg/kg) for induction of non-cardiac surgical anaesthesia in elderly hypertensive patients is more effective in maintaining haemodynamic stability and has fewer adverse effects compared with etomidate.

Effects of propofol combined with sufentanil on painless gastroscopy and hemodynamics in children under general anesthesia

OBJECTIVE

To determine the effects of propofol combined with sufentanil on painless gastroscopy and hemodynamics in children under general anesthesia.

METHODS

The data of 98 children who received painless gastroscopy in the Children's Hospital of Nanjing Medical University from May 2022 and November 2022 were analyzed retrospectively. Patients anesthetized with propofol (1.5-2 mg/kg) combined with sufentanil (0.03-0.05 μg/kg) were assigned to a study group (n=52), and patients anesthetized with propofol (1.5-2 mg/kg) combined with fentanyl (0.3-0.5 µg/kg) were included in a control group (n=46). The changes in hemodynamic levels (mean arterial pressure (MAP), heart rate (HR) and pulse oxygen saturation (SpO2) at T0 (before anesthesia), T1 (1 min after anesthesia induction), T2 (start of examination), T3 (2 min after the start of examination), and T4 (end of examination) in the two groups were analyzed and compared. The Ramsay sedation score was adopted to evaluate the sedation of the two groups at the anesthesia recovery and at 1 h and 2 h after the anesthesia recovery. The anesthetic effects (time to loss of consciousness, eye opening, and recovery of orientations) of the two groups were analyzed and compared. The excellent and good anesthesia outcomes, hospitalization time and dosage of propofol were compared between the two groups, and the adverse reactions in the two groups during and after the examination were analyzed.

RESULTS

At T0, the two groups were not significantly different in the levels of MAP, HR and SpO2 (P>0.05), but at T1, T2, T3, and T4, the study group showed a significantly higher MAP level than the control group (P<0.05). At T1 and T3, the study group exhibited a significantly higher HR level than the control group (P<0.05), and at T2 and T4, the HR level of the two groups was not greatly different (P>0.05). The SpO2 levels at T0, T1, T2, T3, and T4 were not greatly different between the two groups (P>0.05). There was no significant difference in Ramsay score between the two groups at anesthesia recovery and at 1 h and 2 h after the anesthesia recovery (P>0.05). Additionally, the study group experienced significantly earlier time to loss of consciousness, eye opening, and recovery of orientations than the control group (P<0.05). The number of patients with excellent anesthetic outcome in the study group was notably higher than that in the control group (P<0.05). Compared with the control group, the study group consumed less propofol, experienced shorter hospitalization time, and showed a notably lower incidence of adverse reactions (P<0.05).

CONCLUSION

For children undergoing painless gastroscopy under general anesthesia, sufentanil combined with propofol can deliver better anesthetic effect than propofol combined with fentanyl, with less effect on hemodynamics and fewer gastroscopy-related adverse reactions.

Etomidate versus propofol for sedation in gastrointestinal endoscopy: A systematic review and meta-analysis of outcomes

BACKGROUND

Propofol is increasingly being used for sedation in gastrointestinal endoscopy; however, owing to its side effects, an alternative drug is needed. We aimed to compare the safety, satisfaction, and efficacy outcomes of etomidate versus propofol in patients undergoing gastrointestinal endoscopy, including advanced endoscopic procedures.

METHODS

We systematically searched Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL (via EBSCO), China National Knowledge Infrastructure, and Web of Science (1946-April 2020) databases for randomized controlled trials of gastrointestinal endoscopy (upper gastrointestinal endoscopy, colonoscopy, and advanced endoscopy) using etomidate or propofol as sedatives. We pooled odds ratios (ORs) for the safety profile and patient and anesthesiologist satisfaction using mixed-effects conditional logistic models and standardized mean differences for efficiency outcomes using random-effects models.

RESULTS

Twenty-four studies involving 3875 patients were included. Compared with propofol, etomidate resulted in significantly reduced apnea (OR: 0.22; 95% confidence interval [CI]: 0.13-0.37; P < .001), hypoxemia (OR: 0.43; 95% CI: 0.35-0.54; P < .001), hypotension (OR: 0.20; 95% CI: 0.11-0.36; P < .001), and bradycardia (OR: 0.52; 95% CI: 0.30-0.91; P = .02) but led to increased myoclonus (OR: 8.54; 95% CI: 5.20-14.01; P < .001) and lowered anesthesiologist satisfaction (OR: 0.60; 95% CI: 0.39-0.91; P = .02).

CONCLUSION

Etomidate may be a good alternative to propofol for gastrointestinal endoscopy, especially advanced endoscopy. Etomidate appears to be safe as an inducer for hemodynamically unstable patients or older adult patients undergoing gastrointestinal endoscopy.

Comparison of Remimazolam Tosilate and Etomidate on Hemodynamics in Cardiac Surgery: A Randomised Controlled Trial

Background

Remimazolam tosilate (RT) is a new ultrashort-acting γ-aminobutyric acid subtype A (GABA_A) agonist, with the characteristics of rapid onset and offset, minimal cardiorespiratory depression. Currently, few studies have compared the effect of RT and etomidate on hemodynamics during anesthesia induction. Here, we aimed to compare the hemodynamic effects of different doses of RT and etomidate for anesthesia induction in patients undergoing cardiac surgeries.

Methods

Patients were recruited from January to September 2022 in this single-center, prospective, randomized, double-blind trial. A total of 117 patients undergoing selective valve replacement surgery were randomly divided into low-dose RT (0.2 mg/kg) group (group LR), high-dose RT (0.3 mg/kg) group (group HR), or etomidate (1.5 mg/kg) group (group E), respectively. The primary outcome was hemodynamic fluctuations (mean arterial pressure fluctuation value [∆MAP]; heart rate fluctuation value [∆HR]) during anesthesia induction. Secondary outcomes included the incidence of adverse drug reactions (injection pain and myoclonus) and adverse cardiovascular events, vital signs at different time points and the cumulative doses of vasoactive drugs.

Results

The hemodynamic fluctuations (∆MAP) in group LR and group E were significantly lower than that in group HR. In addition, the incidence of hypotension and the cumulative norepinephrine doses in group E and group LR were also significantly lower than that in group HR. Furthermore, the incidence of injection pain and myoclonus in group LR and group HR were less frequently recorded compared with group E. There were no significant differences in terms of ∆HR, tachycardia, hypertension, severe bradycardia, vital signs at different time points, lactic acid and blood glucose between both groups.

Conclusion

Compared with etomidate, low-dose RT (0.2mg/kg) can not only provide stable hemodynamic parameters but also cause fewer adverse reactions when used for anesthesia induction in patients with cardiac disease.

Median Effective Dose of an Etomidate-Propofol Mixture with Dezocine in Inhibiting the Response to Gastroscope Insertion: Gender Differences in a Randomized Controlled Study Using Dixon’s Up-and-Down Method

What Is Known and Objective. Appropriate doses of sedatives are crucial for a successful, painless upper gastrointestinal endoscopy. Hence, we conducted a randomized controlled study to explore the effects of dezocine on the median effective dose (ED50) of the etomidate-propofol (E-P) mixture in prohibiting response to gastroscope insertion in patients of different genders. Methods. Patients aged 18–65 years enrolled in the study of the American Society of Anesthesiologists (ASA) with physical status I or II undergoing elective gastroscopy were included. Patients were randomly assigned to the male normal saline group (MS group), male dezocine group (MD group), female normal saline group (FS group), and female dezocine group (FD group). All patients were anesthetized with an E-P mixture of 1 : 1. The FD and MD groups were intravenously injected (i.v.) 50 µg/kg dezocine 5 min before anesthesia, while the FS and MS groups were injected with an equal volume of normal saline 5 min before anesthesia. According to the preexperiment, the initial dose of the E-P mixture for the FD and MD groups was 0.4 and 0.3 mL/kg for the FS and MS groups. The variation proportion was set as 0.9 between dosages. Dixon’s up-and-down method was adopted to confirm the dose of the E-P mixture for the next patient, which was reduced if the insertion was performed successfully; otherwise, the dose was increased. Centered isotonic regression was employed to determine the ED50 and 90% confidence interval (CI) values of the E-P mixture in the four groups. The total amount of E-P mixture consumed was recorded as well as the adverse events of patients. Results. The ED50 and 90% CI of the MS, MD, FS, and FD groups were 0.315 (0.285–0.349), 0.206 (0.175–0.237), 0.329 (0.305–0.355), and 0.207 (0.188–0.227) mL/kg, respectively. The MD group was <MS group ( $P\le 0.001$ ), and the FD group was <FS group ( $P\le 0.001$ ); no statistical difference was observed between the MS and FS groups and MD and FD groups. Dezocine reduced the total amount of E-P mixture consumed and the overall incidence of adverse events. What Is New and Conclusion. Dezocine significantly decreased the ED50 of the E-P mixture in inhibiting the response of patients to gastroscope insertion and the occurrence rate of adverse events. Further, gender had no impact on the ED50 of the E-P mixture.

Comparison of the influence of low dose etomidate and propofol as priming dose on the incidence of etomidate induced myoclonus: a randomised, double-blind clinical trial

BACKGROUND

Though hemodynamically stable, etomidate is known for its myoclonus side effect following induction. The main aim of this study is an effective attempt to decrease the incidence of myoclonus with a priming agent.

METHODS

A prospective, double-blind study was carried out on 50 adults posted for elective surgery. After premedication, priming was done with etomidate 0.03 mg.kg-1 (Group E) and propofol 0.2 mg.kg-1 (Group P), i.e., 1/10th of induction dose. After 60 seconds of priming, patients were induced with etomidate by titrating dose over 60 seconds until loss of verbal command and eyelash reflex. The grading of myoclonus, induction dosage, and hemodynamics for 10 minutes post induction were recorded.

RESULTS

In the study, only 4 cases had myoclonus. Grade 1 myoclonus was encountered in three cases of etomidate group, while only one case in the propofol group had grade 2 myoclonus which was not statistically significant (p-value: 0.12). There was a significant reduction in the etomidate induction dosage in both groups.

CONCLUSION

Priming with etomidate and propofol is equally effective in reducing myoclonus with the added benefit of hemodynamic stability and reduction of an induction dose of etomidate (> 50%).

Comparison of the innovative endoscopic oropharyngeal airway and the conventional mouthpiece in elderly outpatients undergoing esophagogastroduodenoscopy under sedation: a prospective and randomized study

Background

Undesirable outcomes may appear for elderly patients undergoing esophagogastroduodenoscopy (EGD) under sedation, such as hypoxia and hypotension. The aim of our study was to investigate the ability of the innovative endoscopic oropharyngeal airway to reduce the frequency of hypoxia during EGD under sedation in elderly patients.

Methods

In this trial, aged patients undergoing EGD were randomized into airway group and mouthpiece group. The primary outcome was the incidence of the minimum pulse oxygen saturation < 90% and minimum pulse oxygen saturation. In addition, sedation dose, recovery time, emergency management and adverse reactions were recorded.

Results

360 patients completed the study (180 in each groups). The minimum pulse oxygen saturation during EGD was significantly higher in airway group (97.66 ± 2.96%) than in mouthpiece group (95.52 ± 3.84%, P < 0.001). The incidence of pulse oxygen saturation of 85–89% of airway group (5.0%, 9/180) was lower than mouthpiece group (10.6%, 19/180, P = 0.049). The endoscopy entry time in airway group was 3 (2, 4) seconds and in mouthpiece group was 5 (4, 6) (P < 0.001). Propofol total dose and awakening time were significantly lower in the airway group than in the mouthpiece group (P = 0.020 and P = 0.012, respectively). Furthermore, the incidence rate of hypotension was significantly higher in mouthpiece group (12.2%) than in airway group (5.0%) (P = 0.015). By comparison with the mouthpiece group, the satisfaction of endoscopists was higher in airway group (P = 0.012).

Conclusion

Elderly patients undergoing EGD, Endoscopy Protector was associated with a significantly lower incidence of hypoxia, shortened endoscopy entry time and more stable hemodynamics.

Trial registration: ChiCTR, ChiCTR2000031998, 17/04/2020. http://www.chictr.org.cn/index.aspx

Physical and Chemical Compatibility of Etomidate and Propofol Injectable Emulsions

INTRODUCTION

The mixture of etomidate and propofol is widely used in clinical practice to improve efficacy of general anesthesia and to minimize side effects. As a thermodynamically unstable system, emulsion is prone to destabilization through mechanisms including coalescence, flocculation, and creaming. Such unwanted phenomenon can induce fat embolism after intravenous administration. This study was aimed to investigate the physical and chemical stability of the mixture of etomidate and propofol in the dosage form of emulsion.

METHODS

This compatibility study focused on the critical quality attributes (CQAs) of drug-containing emulsions, such as appearance, pH, particle size and distribution, zeta potential, the observation under centrifugation, and drug content and impurity.

RESULTS

As the results, there were no significant changes in the CQAs of the mixed emulsions up to 24 h after mixing at refrigeration temperature (4°C), room temperature (25°C), and body temperature (37°C).

CONCLUSIONS

These results demonstrate that etomidate emulsion is physically and chemically compatible with propofol emulsions up to 24 h at 4°C, 25°C, and 37°C, suggesting that etomidate and propofol can be administrated in mixture without adversely affecting product characteristics, at least in vitro.

A Comparative Study of Valsalva Maneuver, Lidocaine, and Valsalva Maneuvers with Administration of Lidocaine to Reduce the Pain Associated with Administration of Etomidate During General Anesthesia

Objectives

The purpose of this study is a comparison of Valsalva, lidocaine, and Valsalva with administration of lidocaine to reduce the pain associated with administration of etomidate.

Methods

The present study is a clinical trial study. The number of samples in each group was 30 and a total of 90 people were selected. This study was a clinical trial and the subjects were randomly divided into three groups: Group 1: Valsalva, 2: Lidocaine, 3: Valsalva and Lidocaine. Pain due to etomidate was rated on a VAS from 1 (painless) to 3 (worst imaginable pain) and their information was recorded. The collected information was entered into SPSS 22 and analyzed with appropriate statistical tests.

Results

A total of 90 subjects participated in the present study and were divided into 3 groups: Valsalva, lidocaine, and Valsalva with lidocaine. No significant difference was observed between demographic variables in the study groups. There was a significant relationship between severity of pain in the three groups. According to the results, the highest pain intensity was in the Valsalva group and the lowest pain intensity was in the Valsalva with lidocaine group.

Conclusions

Valsalva with lidocaine reduces the severity of pain caused by etomidate to a greater extent than other groups.

Progress in research of postoperative nausea and vomiting after painless gastrointestinal endoscopy

Postoperative nausea and vomiting (PONV) refers to nausea and vomiting occurring within 24 h after surgery. PONV seriously affects the quality of postoperative recovery after painless gastrointestinal endoscopy. In this paper, we review the progress in the research of PONV after painless gastrointestinal endoscopy to provide clinical guidance for improving the medical safety and service quality of painless and comfortable anesthesia. PONV after painless gastrointestinal endoscopy has unique factors and characteristics. On the basis of comprehensive evaluation and according to the patient's specific situation, the doctors should identify the risk factors, optimize the anesthesia scheme, choose anesthetics and analgesics rationally, and take comprehensive diagnostic and therapeutic measures.

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

OBJECTIVE

This study is aims to compare the anesthetic safety of propofol combined with etomidate for painless gastroscopy.

METHODS

Three hundred patients undergoing painless gastroscopy were randomly assigned to P, PE1, and PE2 groups. Patients were anesthetized with propofol (P group) or propofol combined with etomidate (volume ratio 1: 1, PE1 group; volume ratio 2: 1, PE2 group). The hemodynamics and adverse reactions were observed. The sleep quality satisfaction and nature of dreams were recorded.

RESULTS

Compared with pre-anesthesia, the mean arterial pressure and heart rate of the 3 groups were significantly slower during the examination and at the end of the examination. PE1 group had a higher incidence of muscle spasm, body moving, choking, and deglutition. The incidence of hypoxemia and injection pain was higher in P group. P and PE2 group had higher sleep quality satisfaction and dream incidence after awaking. However, there was no difference in the nature of dreams among 3 groups.

CONCLUSION

Our data indicate that the combination of 10 ml 1.0% propofol and 5 ml 0.2% etomidate for painless gastroscopy reduces adverse reactions while not affecting the patients respiratory function. Moreover, it is safe and effective, which is worthy of clinical application and promotion.

Using Etomidate and Midazolam for Screening Colonoscopies Results in More Stable Hemodynamic Responses in Patients of All Ages

Background/Aims

Recent studies have demonstrated that etomidate is a safe sedative drug with noninferior sedative effects. In our recent study, we revealed that etomidate/midazolam was more hemodynamically stable than propofol/midazolam in elderly patients undergoing colonoscopies. We aimed to investigate whether compared with propofol/midazolam, etomidate/midazolam causes fewer cardiopulmonary adverse events with noninferior efficacy for screening colonoscopies in patients of all ages.

Methods

In this single-center, randomized, double-blind study, we prospectively enrolled 200 patients. The patients were divided into etomidate and propofol groups. The primary outcome was the occurrence of cardiopulmonary adverse events. The secondary outcomes were the proportion of patients with fluctuations in vital signs (oxygen desaturation and transient hypotension), adverse events interrupting the procedure, and sedation-related outcomes.

Results

Adverse cardiopulmonary events were more common in the propofol group than the etomidate group (65.0% vs 51.0%, respectively; p=0.045). Forty-six patients (46.0%) in the propofol group and 29 (29.0%) in the etomidate group experienced fluctuations in their vital signs (p=0.013). The proportions of patients experiencing adverse events that interrupted the procedure, including myoclonus, were not significantly different between the two groups (etomidate: 20.0% vs propofol: 11.0%; p=0.079). Both groups had similar sedation-related outcomes. Multivariate analysis revealed that compared with the propofol groups, the etomidate group had a significantly lower risk of fluctuations in vital signs (odds ratio, 0.427; 95% confidence interval, 0.230 to 0.792; p=0.007).

Conclusions

Compared with using propofol/midazolam, using etomidate/midazolam for screening colonoscopies results in more stable hemodynamic responses in patients of all ages; therefore, we recommend using etomidate/midazolam for colonoscopies in patients with cardiovascular risk factors.

Safety and efficacy of combined use of propofol and etomidate for sedation during gastroscopy: Systematic review and meta-analysis

BACKGROUND

Sedation with etomidate or propofol alone during gastroscopy has many side effects. A systematic review and meta-analysis were conducted to evaluate the safety and efficacy of the combined use of propofol and etomidate for sedation during gastroscopy.

METHODS

PubMed, Embase, Medline (via Ovid SP), Cochrane library databases, CINAHL (via EBSCO), China Biology Medicine disc (CBMdisc), Wanfang, VIP, and China National Knowledge Infrastructure (CNKI) databases were systematically searched. We included randomized controlled trials (RCTs) comparing the combined use of propofol and etomidate vs etomidate or propofol alone for sedation during gastroscopy. Data were pooled using the random-effects models or fixed-effect model based on heterogeneity.

RESULTS

Fifteen studies with 2973 participants were included in the analysis. Compared to propofol alone, the combined use of propofol and etomidate possibly increased recovery time (SMD = 0.14, 95% CI = 0.04-0.24; P = .005), and the risk for myoclonus (OR = 3.07, 95% CI = 1.73-5.44; P < .001), injection pain, and nausea and vomiting. Furthermore, compared to propofol alone, the combination of propofol and etomidate produced an apparent beneficial effect for mean arterial pressure (MAP) after anesthesia (SMD = 1.32, 95% CI = 0.38-2.26; P = .006), SPO2 after anesthesia (SMD = 0.99, 95% CI = 0.43-1.55; P < .001), apnea or hypoxemia (OR = 0.16, 95% CI = 0.08-0.33; P < .001), injection pain, and body movement. Further, compared to etomidate alone, the combination of propofol and etomidate reduced the risk for myoclonus (OR = 0.15, 95% CI = 0.11-0.22; P < .001), body movement, and nausea and vomiting.

CONCLUSION

The combination of propofol and etomidate might increase recovery time vs that associated with propofol, but it had fewer side effects on circulation and respiration in patients undergoing gastroscopy. The combined use of propofol and etomidate can improve and produce an apparent beneficial effect on the adverse effects of propofol or etomidate alone, and it was safer and more effective than propofol or etomidate alone.

Etomidate Sedation for Advanced Endoscopic Procedures

BACKGROUND AND STUDY AIM

Although propofol is widely used for sedation for endoscopic procedures, concerns remain regarding cardiopulmonary adverse events. Etomidate has little effect on the cardiovascular and respiratory systems, but patient satisfaction analysis is lacking. We compared the efficacy and safety of balanced propofol and etomidate sedation during advanced endoscopic procedures.

METHODS

As a randomized noninferiority trial, balanced endoscopic sedation was achieved using midazolam and fentanyl, and patients were randomly assigned to receive propofol (BPS) or etomidate (BES) as add-on drug. The main outcomes were sedation efficacy measured on a 10-point visual analog scale (VAS) and safety.

RESULTS

In total, 186 patients (94 in the BPS group and 92 in the BES group) were evaluated. BES did not show noninferiority in terms of overall patient satisfaction, with a difference in VAS score of -0.35 (97.5 % confidence interval -1.03 to ∞, p = 0.03). Among endoscopists and nurses, BES showed noninferiority to BPS, with differences in VAS scores of 0.06 and 0.08, respectively. Incidence of cardiopulmonary adverse events was lower in the BES group (27.7 versus 14.1 %, p = 0.023). Hypoxia occurred in 5.3 and 1.1 % of patients in the BPS and BES group (p = 0.211). Myoclonus occurred in 12.1 % (11/92) in the BES group. BES had lower risk of overall cardiopulmonary adverse events (odds ratio 0.401, p = 0.018).

CONCLUSIONS

BES was not noninferior to BPS in terms of patient satisfaction. However, BES showed better safety outcomes in terms of cardiopulmonary adverse events.

Effect of Fentanyl and Nalbuphine for Prevention of Etomidate-Induced Myoclonus

BACKGROUND

Etomidate is a potent intravenous inducing agent with known undesirable side effects such as myoclonus and pain on injection in nonpremedicated patients.

AIMS

The aim of this study is to compare the effect of fentanyl and nalbuphine in the prevention of etomidate-induced myoclonus.

SETTINGS AND DESIGN

Randomized double-blind, placebo-controlled, and prospective comparative study.

MATERIALS AND METHODS

A total of 120 patients were randomly allocated to one of the three groups containing 40 patients each for intravenous administration of fentanyl 2 μg/kg diluted in 10 mL normal saline (NS) (Group 1), nalbuphine 0.3 mg/kg diluted in 10 mL NS (Group 2), and only 10 mL NS (Group 3) over 10 min. All groups subsequently received 0.3 mg/kg etomidate by intravenous bolus injection over 15-20 s and were assessed for the severity of pain using Grade IV pain scale and observed for myoclonus for 2 min and graded according to clinical severity. Serum creatinine phosphokinase (CPK) levels were obtained prior and postetomidate injection.

STATISTICAL ANALYSIS

Statistical analysis was performed by the SPSS program version 17.0 for Windows. Tests used are Shaipro-Wilk test, ANOVA, Tukey's multiple comparison test, Tamhane's T2, and the Chi-square test. For all statistical tests, P < 0.05 was considered statistically significant with 5% level of significance (α).

RESULTS

The incidence of myoclonus in Group 1 and 2 was 52.5% and 17.5%, respectively, whereas it was 92.45% in Group 3. There was no pain observed in 70%, 92.5%, and 50% of patients in Group 1, 2, and 3, respectively. There was a statistically significant difference in mean CPK level after induction among three groups (P < 0.001).

CONCLUSION

Nalbuphine is more effective than fentanyl in the prevention of etomidate-induced myoclonus and pain with the minimum rise in CPK levels.

Efficacy and safety of etomidate-midazolam for screening colonoscopy in the elderly: A prospective double-blinded randomized controlled study

BACKGROUND AND AIMS

Recent studies have shown that etomidate is associated with fewer serious adverse events than propofol and has a noninferior sedative effect. We investigated whether etomidate-midazolam is associated with fewer cardiopulmonary adverse events and has noninferior efficacy compared to propofol-midazolam for screening colonoscopy in the elderly.

METHODS

A prospective, single-center, double-blinded, randomized controlled trial was performed. Patients aged over 65 years who were scheduled to undergo screening colonoscopy were randomized to receive either etomidate or propofol based on midazolam. The primary outcome was all cardiopulmonary adverse events. The secondary outcomes were vital sign fluctuation (VSF), adverse events disturbing the procedure, and sedation-related outcomes.

RESULTS

The incidence of cardiopulmonary adverse events was higher in the propofol group (72.6%) than in the etomidate group (54.8%) (P = .040). VSF was detected in 17 (27.4%) and 31 (50.0%) patients in the etomidate and propofol groups, respectively (P = .010). The incidence rate of adverse events disturbing the procedure was significantly higher in the etomidate group (25.8%) than in the propofol group (8.1%) (P = .008). Moreover, the incidence rate of myoclonus was significantly higher in the etomidate group (16.1%) than in the propofol group (1.6%) (P = .004). There was no statistical significance between the 2 groups with respect to sedation times and sedation-related outcomes including patients' and endoscopist's satisfaction. In the multivariate analysis, the etomidate group had significantly low odds ratio (OR) associated with VSF (OR: 0.407, confidence interval: 0.179-0.926, P = .032).

CONCLUSIONS

We recommend using etomidate-midazolam in patients with high ASA score or vulnerable to risk factors; propofol-midazolam may be used as a guideline in patients with low ASA score.