Single-dose etomidate does not increase mortality in patients with sepsis: a systematic review and meta-analysis of randomized controlled trials and observational studies

Meta-analysis of structural and functional abnormalities in behavioral addictions

BACKGROUND

The incidence of behavioral addictions (BAs) associated with scientific and technological advances has been increasing steadily. Unfortunately, a large number of studies on the structural and functional abnormalities have shown poor reproducibility, and it remains unclear whether different addictive behaviors share common underlying abnormalities. Therefore, our objective was to conduct a quantitative meta-analysis of different behavioral addictions to provide evidence-based evidence of common structural and functional changes.

METHODS

We conducted systematic searches in PubMed, Web of Science and Scopus from January 2010 to December 2023, supplementing reference lists of high-quality relevant meta-analyses and reviews, to identify eligible voxel-based morphometry (VBM) and functional magnetic resonance imaging (fMRI) studies. Using anisotropic seed-based D-Mapping (AES-SDM) meta-analysis methods, we compared brain abnormalities between BAs and healthy controls (HCs).

RESULTS

There were 11 GMV studies (287 BAs and 292 HCs) and 26 fMRI studies (577 BAs and 545 HCs) that met inclusion criteria. Compared with HCs, BAs demonstrated significant reductions in gray matter volume (GMV) in (1) right anterior cingulate gyri extending into the adjacent superior frontal gyrus, as well as in the left inferior frontal gyrus and right striatum. (2) the bilateral precuneus, right supramarginal gyrus, and right fusiform gyrus were hyperfunction; (3) the left medial cingulate gyrus extended to the superior frontal gyrus, the left inferior frontal gyrus, and right middle temporal gyrus had hypofunction.

CONCLUSIONS

Our study identified structural and functional impairments in brain regions involved in executive control, cognitive function, visual memory, and reward-driven behavior in BAs. Notably, fronto-cingulate regions may serve as common biomarkers of BAs.

Parental Inflammatory Bowel Disease with Child Autism: A Comprehensive Review and Meta-Analysis

Inflammatory bowel disease (IBD) has been shown to be connected to a greater possibility of neurologically developed problems, such as autism spectrum disorders (ASDs). However, the proof linking parental IBD with ASD in offspring is inconclusive. Thus, we carried out a meta-analysis and comprehensive review to elucidate such linking. Prior research was identified through reviewing multiple internet-based sources, including Cochrane, Web of Knowledge, Embase, CINAHL, PubMed, and PsycINFO, from 1960 to December 2022. Pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs) were determined employing random-effects models, in spite of the I2 statistic measurement of heterogeneity. Prediction intervals (PIs) have been presented to allow for more useful inferences and to indicate the range of genuine effects that might be predicted in future scenarios. Six studies (two case-control studies and four cohort studies) involving 3,200,199 participants were incorporated into the meta-analysis. The pooled RRs of ASDs among offspring of IBD parents were 1.15 (95% CI, 0.92 to 1.45, P = 0.226; I2 = 81.4%, P = 0.003; PI, 0.53-2.62), indicating no significant connection between parental IBD and the likelihood of ASDs in children. Type of IBD, and sex both also yielded no statistically significant results according to subgroup analysis. Our meta-analysis does not provide evidence that parental IBD is connected with the elevated likelihood of ASDs in their children. To confirm these results and understand their underlying mechanisms, additional research with larger sample sizes and improved study designs is required.

Risk Factors for Incontinence-Associated Dermatitis in Critically Ill Patients with Incontinence: A Systematic Review and Meta-analysis

PURPOSE

This systematic review analyzed evidence related to risk factors for Incontinence Associated Dermatitis (IAD) in critically ill incontinent patients.

METHOD

Systematic review and meta-analysis.

SEARCH STRATEGY

Eight databases, including PubMed, Embase, CINAHL, Cochrane Library, and Web of Science, were searched for studies published in the English language. The China National Knowledge Infrastructure, WanFang Data, and Chinese Scientific Journal Database were also searched for studies evaluating risk of IAD in critically ill incontinent patients published in the Chinese language.

FINDINGS

Twenty-four studies with moderate-to-high methodological quality were included. Significant risk factors for developing IAD were being older [odds ratio (OR) = 1.06, 95% confidence interval (CI): 1.02-1.10, P = .007], fever (OR = 2.57, 95% CI: 1.87-3.57, P < .00001), diagnosed with consciousness disorder (OR = 5.70, 95% CI: 2.28-14.22, P = .0002), having higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR = 1.71, 95% CI: 1.25-2.35, P = .0009), lower Braden score (OR = 0.73, 95% CI: 0.56-0.96, P = .02), lower oxygen saturation (OR = 2.76, 95% CI: 1.52-5.00, P = .0008), double incontinence (OR = 4.10, 95% CI: 2.34-7.17, P < .00001), liquid stool (OR = 6.55, 95% CI: 4.12-10.41, P < .00001), frequent incontinence (OR = 1.21, 95% CI: 1.03-1.43, P = .02), and higher perineal assessment tool (PAT) score (OR = 3.18, 95% CI: 1.76-5.76, P = .0001).

IMPLICATIONS

Findings of this systematic review and meta-analysis suggest that healthcare providers should consider risk factors such as older age, fever, consciousness disorder, higher APACHE II score, lower Braden score and double incontinence matter when developing strategies for the prevention and management of IAD in critically ill incontinent patients.

Extra-cardiac management of cardiogenic shock in the intensive care unit

Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.

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.

The effects of etomidate on expression of high mobility group box 1 via the nuclear factor kappa B pathway in rat model of sepsis

Etomidate is an anesthetic agent used in hemodynamically unstable patients, but its use has been controversial in septic patients. The response of high-mobility group box 1 (HMGB1), a late-phase lethal cytokine in sepsis, to etomidate has not been reported. This study investigated the effects of etomidate on the expression and release of HMGB1 and the underlying mechanism using a cecal ligation and puncture (CLP) model. Thirty-six male Sprague-Dawley rats were divided into sham, CLP, and Etomi groups. Sepsis was induced in the CLP and Etomi groups, and intravenous etomidate (4 mg/kg) was infused for 40 min immediately after operation in the Etomi group. Serum creatinine, alanine aminotransferase (ALT), tumor necrosis factor (TNF)-α, interleukin (IL)-6, and HMGB1 levels were measured 6 and 24 hours after surgery. Activation of nuclear factor (NF)-ĸB and HMGB1 mRNA expression in the liver, lung, kidney, and ileum tissues were measured, and immunohistochemical staining of HMGB1 was implemented. Increases of the TNF-α level 6 h after CLP and ALT and IL-6 levels 24 h after CLP were significantly inhibited by etomidate treatment. Etomidate treatment also significantly attenuated the increase in serum HMGB1 level at 6 and 24 h after CLP and suppressed the NF-ĸB and HMGB1 mRNA in multiple organs 24 h after CLP. Immunohistochemical staining also revealed that etomidate treatment inhibited HMGB1 expression. Etomidate inhibited the systemic release of HMGB1 and its expression in various organs. The mechanism may be associated with the inhibitory effects of etomidate on pro-inflammatory cytokine release and NF-ĸB activity.

Factors Associated with Postintubation Hypotension Among Patients with Suspected Sepsis in Emergency Department

Purpose

Postintubation hypotension (PIH) is a recognized complication that increases both in-hospital mortality and hospital length of stay. Sepsis is reportedly a factor associated with PIH. However, no study to date has examined which factors, including the intubation method, may be clinical predictors of PIH in patients with sepsis. This study aims to investigate factors associated with the occurrence of PIH in patients with suspected sepsis in emergency department.

Patients and Methods

This retrospective cross-sectional study was performed over a 5-year period (January 2013-December 2017) and involved patients with suspected sepsis who underwent endotracheal intubation in the emergency department of Ramathibodi Hospital. The patients were divided into those with and without PIH, and factors associated with the occurrence of PIH were analyzed. PIH was defined as any recorded systolic blood pressure of <90 mmHg within 60 minutes of intubation.

Results

In total, 394 patients with suspected sepsis were included. PIH occurred in 106 patients (26.9%) and was associated with increased in-hospital mortality (43.00% in the PIH group vs 31.25% in the non-PIH group, P = 0.034). Multivariable logistic regression showed that the factors associated with PIH were an age of ≥61 years (adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 1.14-4.43; P = 0.019) and initial serum lactate concentration of >4.4 mmol/L (aOR 2.00; 95% CI 1.16-3.46; P = 0.013). Rapid sequence intubation and difference types of induction agents was unrelated to PIH.

Conclusion

Monitoring the development of PIH in patients with sepsis is essential because of its correlation with higher in-hospital mortality. This is particularly critical for older individuals and those with severe infections and high initial lactate concentrations.

A Nomogram Model for Post-Intubation Hypotension in Patients with Severe Pneumonia in the Emergency Department

Background

Post-intubation hypotension (PIH) frequently occurs in the management of critically ill patients and is associated with prognosis. The study aimed to construct a prediction model for PIH events by analyzing risk factors in patients with severe pneumonia in the emergency department.

Methods

We retrospectively enrolled 572 patients with severe pneumonia diagnosed in the emergency department of West China Hospital of Sichuan University. Five hundred patients with severe pneumonia who underwent endotracheal intubation were included in the study. All patients were randomized according to 7:3 and divided into a training cohort (n=351) and a validation cohort (n=149). Risk factors for PIH were analyzed using Least Absolute Shrinkage and Selection Operator (LASSO) and multivariable logistic regression. Calibration curves, receiver operating characteristic (ROC) curve, and decision curve analysis were applied to assess the predictive model's fitness, discrimination, and clinical utility.

Results

A total of 500 patients with severe pneumonia who underwent endotracheal intubation were enrolled in this study, and PIH occurred in 234 (46.8%) of these patients. Age, heart rate, systolic blood pressure, chronic obstructive pulmonary disease, acute physiology and chronic health evaluation II score, and induction agent use were identified as significant risk factors for the occurrence of PIH. Additionally, the body mass index was the opposite of the above. The area under the ROC curve (AUC) for the model was 0.856 (95% CI, 0.818-0.894) in the training cohort and 0.849 (95% CI, 0.788-0.910) in the validation cohort. The nomogram model was validated and demonstrated good calibration and high net clinical benefit. Finally, to facilitate application by clinicians, an online server has been set up which can be accessed free of charge via the website https://chinahospitals.shinyapps.io/DynNomapp/.

Conclusion

The nomogram is used for individualized prediction of patients with severe pneumonia prior to intubation and is simple to perform with high clinical value.

The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial

BACKGROUND

The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine.

OBJECTIVE

This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension.

METHODS

This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization.

RESULTS

A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different.

CONCLUSIONS

There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.

Pharmacotherapy optimization for rapid sequence intubation in the emergency department

PURPOSE

Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods.

SUMMARY

There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use.

AREAS FOR FUTURE RESEARCH

The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Clinical outcomes after a single induction dose of etomidate versus ketamine for emergency department sepsis intubation: a randomized controlled trial

Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard practice, but the best choice of induction agent in sepsis remains controversial. We conducted a randomized, controlled, single-blind trial in the ED. We included septic patients who were aged at least 18 years and required sedation for emergency intubation. Patients were randomly assigned by a blocked randomization to receive 0.2-0.3 mg/kg of etomidate or 1-2 mg/kg of ketamine for intubation. The objectives were to compare the survival outcomes and adverse events after intubation between etomidate and ketamine. Two hundred and sixty septic patients were enrolled; 130 patients/drug arm whose baseline characteristics were well balanced at baseline. In the etomidate group, 105 patients (80.8%) were alive at 28 days, compared with 95 patients (73.1%) in the ketamine group (risk difference [RD], 7.7%; 95% confidence interval [CI], - 2.5 to 17.9%; P = 0.092). There was no significant difference in the proportion of patients who survived at 24 h (91.5% vs. 96.2%; P = 0.097) and survived at 7 days (87.7% vs. 87.7%; P = 0.574). A significantly higher proportion of the etomidate group needed a vasopressor within 24 h after intubation: 43.9% vs. 17.7%, RD, 26.2% (95% CI, 15.4 to 36.9%; P < 0.001). In conclusion, there were no differences in early and late survival rates between etomidate and ketamine. However, etomidate was associated with higher risks of early vasopressor use after intubation. Trial registration: The trial protocol was registered in the Thai Clinical Trials Registry (identification number: TCTR20210213001). Registered 13 February 2021-Retrospectively registered, https://www.thaiclinicaltrials.org/export/pdf/TCTR20210213001 .

Anesthetic management of the traumatic brain injury patients undergoing non-neurosurgery

This article describes the anesthetic management of patients with traumatic brain injury (TBI) undergoing non-neurosurgery, primarily targeting intraoperative management for multiple-trauma surgery. The aim of this review is to promote the best clinical practice for patients with TBI in order to prevent secondary brain injury. Based on the current clinical guidelines and evidence, anesthetic selection and administration; maintenance of optimal cerebral perfusion pressure, oxygenation and ventilation; coagulation monitoring; glucose control; and temperature management are addressed. Neurological recovery, which is critical for improving the patient's quality of life, is most important; therefore, future research needs to be focused on this aspect.

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.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation

INTRODUCTION

Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate.

METHODS

A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension.

RESULTS

A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension.

CONCLUSION

In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.

Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update

PURPOSE

The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP).

SUMMARY

RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care.

CONCLUSION

While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.

Effect of Etomidate vs Propofol for Total Intravenous Anesthesia on Major Postoperative Complications in Older Patients: A Randomized Clinical Trial

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

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

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.

Meta-Analysis of Structural and Functional Brain Abnormalities in Cocaine Addiction

BACKGROUND

Previous voxel-based morphometric (VBM) and functional magnetic resonance imaging (fMRI) studies have shown changes in brain structure and function in cocaine addiction (CD) patients compared to healthy controls (HC). However, the results of these studies are poorly reproducible, and it is unclear whether there are common and specific neuroimaging changes. This meta-analysis study aimed to identify structural, functional, and multimodal abnormalities in CD patients.

METHODS

The PubMed database was searched for VBM and task-state fMRI studies performed in CD patients between January 1, 2010, and December 31, 2021, using the SEED-BASE d MAP software package to perform two independent meta-groups of functional neural activation and gray matter volume, respectively. Analysis, followed by multimodal analysis to uncover structural, functional, and multimodal abnormalities between CD and HC.

RESULTS

The meta-analysis included 14 CD fMRI studies (400 CD patients and 387 HCs) and 11 CD VBM studies (368 CD patients and 387 controls). Structurally, VBM analysis revealed significantly lower gray matter volumes in the right superior temporal gyrus, right insula, and right retrocentral gyrus than in the HC. On the other hand, the right inferior parietal gyrus increased in gray matter (GM) volume in CD patients. Functionally, fMRI analysis revealed activation in the right temporal pole, right insula, and right parahippocampal gyrus. In the right inferior parietal gyrus, the left inferior parietal gyrus, the left middle occipital gyrus, and the right middle frontal gyrus, the degree of activation was lower.

CONCLUSION

This meta-analysis showed that CD patients had significant brain GM and neural changes compared with normal controls. Furthermore, multi-domain assessments capture different aspects of neuronal alterations in CD, which may help develop effective interventions for specific functions.

Effects of standard treatments on depressive/anxiety symptoms in patients with inflammatory bowel disease: A systematic review and meta-analysis

OBJECTIVE

A combination of inflammatory bowel disease (IBD) and psychological comorbidities can influence the natural course of IBD. A systematic review and meta-analysis was performed to examine whether a standard IBD medical therapy without any antipsychotic intervention has beneficial effects on depression/anxiety in IBD patients.

METHODS

PubMed and Web of Science databases were systematically searched for related literature from their inception to March 2020. The random-effects model was used to calculate the standardized mean difference (SMD). A total of 16 eligible studies were included in the present meta-analysis.

RESULTS

Compared with baseline assessments, IBD patients with standard IBD medication had significantly reduced depression assessment scores (pooled SMD = 0.500; 95% confidence interval: 0.207, 0.793; P = 0.001). These results were obtained without any psychological interventions. Additionally, no significant differences in anxiety-related scores were detected between the baseline assessments and the end of therapy assessments (pooled SMD = 0.083; 95% confidence interval: -0.120, 0.285; P = 0.425). The meta-regression and subgroup analyses revealed that differences in assessment tools and medications might be the main source of heterogeneity.

CONCLUSION

Standard IBD treatments can significantly alleviate the depressive symptoms in IBD patients. However, more studies are needed to analyze this association.

Effect of anti-reflux therapy on pulmonary function in idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Background

Current guideline conditionally recommends regular use of anti-reflux medication in idiopathic pulmonary fibrosis (IPF). However, the effect of anti-reflux therapy in this group remains controversial. We systematically reviewed literatures to evaluate whether anti-reflux therapy could ameliorate pulmonary function in IPF.

Methods

We performed electronic search in PubMed, Embase and CENTRAL (Cochrane Central Register of Controlled Trials) to identify original articles published in English language. We included randomized controlled trials (RCTs) and observational studies regarding anti-reflux therapy on pulmonary function in IPF. Qualitative and quantitative analyses were conducted. In quantitative analysis, the inverse-variance method with fixed-effect model was used to analyze pooled data.

Results

Fifteen studies (2 RCTs and 13 observational studies) including 3,891 patients with IPF were included. Pooled analysis suggested that anti-reflux therapy did not improve forced vital capacity (FVC)% predicted [mean difference (MD) =0.88, 95% confidence interval (CI): −0.22 to 1.98, P=0.12, I² =0%, 8 studies, n=3,076], diffusing capacity of the lung for carbon monoxide (DLCO) % predicted (MD =0.75, 95% CI: −0.13 to 1.62, P=0.10, I² =0%, 8 studies, n=3,073), and FVC decline (MD =0.02, 95% CI: −0.01 to 0.04, P=0.29, I² =17%, 5 studies, n=1,586) in IPF.

Discussion

Anti-reflux therapy may not ameliorate pulmonary function in IPF. However, adequately powered studies are warranted to validate the present findings.

Comparison of therapeutic efficacy and toxicity of docetaxel, cisplatin, and fluorouracil (TPF)-based induction chemotherapy plus concurrent chemoradiotherapy and chemoradiotherapy alone in locally advanced nasopharyngeal carcinoma

PURPOSE

In recent years, docetaxel, cisplatin, and fluorouracil (TPF)-based induction chemotherapy plus concurrent chemoradiotherapy (CCRT) has been commonly applied for locally advanced nasopharyngeal carcinoma (LA-NPC). However, whether TPF+CCRT regimen is the best choice for LA-NPC remains unclear. This meta-analysis aims to elucidate and compare the efficacy and toxicity of TPF+CCRT versus CCRT alone for LA-NPC.

METHODS

Two investigators independently and systematically searched relevant studies available on PubMed, Embase, Cochrane Library, and Web of Science published before January 7, 2021. Data were extracted from eligible studies for assessing their qualities, and calculating pooled hazard ratios (HR), odds ratio (OR) and 95% confidence intervals (CI) using Review Manager software 5.3 (RevMan 5.3).

RESULTS

Five studies involving 759 LA-NPC patients were analyzed in the meta-analysis. Compared to CCRT alone, TPF-based IC plus CCRT significantly improved overall survival (OS) (HR = 0.53, 95% CI: 0.35-0.81, P = .003), progression-free survival (PFS) (HR = 0.63, 95% CI: 0.46-0.86, P = .004), distant metastasis-free survival (DMFS) (HR = 0.58, 95% CI: 0.39-0.86, P = .008), and locoregional failure-free survival (LRFFS) (HR 0.62, 95% CI: 0.43-0.90, P = .01). In addition, TPF-based IC plus CCRT mainly increased risks of grade 3/4 acute hematological toxicity and non-hematological toxicities like leukopenia (OR = 1.84, 95% CI: 0.42-8.03, P = .42), neutropenia (OR = 1.78, 95% CI: 0.23-13.82, P = .58), thrombocytopenia (OR = 1.76, 95% CI: 0.53-5.81, P = .35), febrile neutropenia (OR = 2.76, 95% CI: 0.07-101.89, P = .58), vomiting (OR = 18.94, 95% CI: 0.99-362.02, P = .05) and dry mouth (OR = 2.23, 95% CI: 0.22-22.57, P = .50), which were uncomplicated and manageable.

CONCLUSIONS

TPF + CCRT is superb than CCRT alone for the management of LA-NPC. However, TPF+CCRT increases the incidences of grade 3/4 acute hematological toxicity and some non-hematological toxicities.

Application of BRAFO-tiered approach for health benefit-risk assessment of dark tea consumption in China

Dark tea, a unique tea fermented primarily in China, has numerous potential beneficial effects. However, harmful substances present in dark tea have provoked significant concern. To conduct a quantitative benefit-risk assessment of dark tea for Chinese residents and provide guidance on rational consumption, a framework of Benefit-Risk Analysis for Foods (BRAFO) and meta-analysis was applied to construct a disability-adjusted life year (DALY). Based on the BRAFO-tiered approach, a reference scenario (no intake) and an alternative scenario (intake of 3 cups/day) were determined. The overall health impacts of dark tea were simulated by comparing the risks of fluoride and AF with benefits of reduced-risk to coronary heart disease (CHD) and diabetes in different scenarios. Three cups of fermented tea consumed per day decreased risks of CHD and diabetes by 8.16% and 12.77% respectively. After quantitative integration of information, the ultimate net health effect was found to be -1958.827 illustrating that the benefits of drinking three cups of dark tea per day outweigh the risks. However, considering the uncertainties in the process, decision-makers should proceed with caution, consulting additional well-conducted studies and further managing harmful substances in dark tea.

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies

Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

Statin use for the prevention of seizure and epilepsy in the patients at risk: A systematic review and meta-analysis of cohort studies

OBJECTIVE

Statin use for the prevention of seizure and epilepsy had been suggested but remained controversial. We sought to search existing literature to determine whether prophylactic use of statin reduced the incidence of seizure and epilepsy in the patients at risk.

METHODS

Three electronic databases were thoroughly searched to identify clinical studies investigating the effects of statin use on patients at the risk of seizure or epilepsy. Regardless of heterogeneity quantified, a random effects meta-analyses were used to synthesize the evidence, to pool odds ratios (ORs) and corresponding 95 % confidence intervals (CIs).

RESULTS

Seven cohort studies involving 26,042 patients with newly-onset epileptogenic brain insults and no history of seizure and epilepsy before were included. Compared with patients didn't receive statin treatment after epileptogenic brain insults, those treated with statin had a lower risk of epilepsy (5 studies; 22,849 patients; pooled OR, 0.48; 95 % CI, 0.31 to 0.73; p =  0.001) and seizure (4 studies; 6076 subjects; pooled OR, 0.35; 95 % CI, 0.25 to 0.48; p =  0.001).

CONCLUSIONS

Evidence from this meta-analysis suggested that the use of statin should as primary prevention for patients with risk of seizures and epilepsy. Considering the limited number and quality of available studies, future randomized controlled trials are required to further demonstrate the association between statin use and incident of seizure and epilepsy.

Anesthesia Considerations in Neurological Emergencies

Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.

A systematic review and meta-analysis of perforator flaps in plantar defects: Risk analysis of complications

The purpose of this study was to identify the risk factors for complications of perforator flaps in plantar reconstruction. A systematic review was performed by searching the PubMed, Cochrane Library, MEDLINE, and EMBASE databases from their inception date up to October 2020. Only studies on reconstructing plantar defects with perforator flaps were included, and specific data were required for each patient in the included studies. A total of 14 studies involving 111 flaps were identified and included in the meta‐analysis. Our meta‐analysis identified two risk factors for postoperative complications: flap size over 50 cm² (risk ratio [RR] = 3.12; P = .02), diabetes mellitus foot (RR = 3.26; P = .03). No significant differences were found regarding heel defects (P = .34), single perforator (P = .57), age older than 60 years (P = .19), chronic aetiology (P = .13), trauma (P = .33), tumour resection (P = .60), ulcer (P = .84), and burn (P = .76). Although more high‐quality studies with adequate sample sizes are needed, this meta‐analysis indicated that flap size over 50 cm² and diabetes mellitus foot were significant risk factors for postoperative complications of perforator flaps in plantar reconstruction.

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

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

Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management

Multiple international airway societies have created guidelines for the management of the difficult airway. In critically ill patients, there are physiologic derangements beyond inadequate airway protection or hypoxemia. These risk factors contribute to the "physiologically difficult airway" and are associated with complications including cardiac arrest and death. Importantly, they are largely absent from international guidelines. Thus, we created management recommendations for the physiologically difficult airway to provide practical guidance for intubation in the critically ill. Through multiple rounds of in-person and telephone conferences, a multidisciplinary working group of 12 airway specialists (Society for Airway Management's Special Projects Committee) over a time period of 3 years (2016-2019) reviewed airway physiology topics in a modified Delphi fashion. Consensus agreement with the following recommendations among working group members was generally high with 80% of statements showing agreement within a 10% range on a sliding scale from 0% to 100%. We limited the scope of this analysis to reflect the resources and systems of care available to out-of-operating room adult airway providers. These recommendations reflect the practical application of physiologic principles to airway management available during the analysis time period.

A Critical Appraisal of the Effects of Anesthetics on Immune-system Modulation in Critically Ill Patients With COVID-19

Purpose

The aim of the present article was to briefly summarize current knowledge about the immunomodulatory effects of general anesthetics and the possible clinical effects of this immunomodulation in patients with COVID-19.

Methods

The PubMed, Scopus, and Google Scholar databases were comprehensively searched for relevant studies.

Findings

The novel coronavirus causes a wide spectrum of clinical manifestations, with a large absolute number of patients experiencing severe pneumonia and rapid progression to acute respiratory distress syndrome and multiple organ failure. In these patients, the equilibrium of the inflammatory response is a major determinant of survival. The impact of anesthetics on immune-system modulation may vary and includes both pro-inflammatory and anti-inflammatory effects.

Implications

Inhibition of the development of severe inflammation and/or the enhancement of inflammation resolution by anesthetics may limit organ damage and improve outcomes in patients with COVID-19.

Anesthetic Induction With Etomidate in Cardiac Surgical Patients: A PRISMA-Compliant Systematic Review and Meta-Analysis

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.

Sepsis in the critically ill patient: current and emerging management strategies

Introduction: Sepsis, a dysregulated host response to infection, is a major cause of morbidity and mortality worldwide. Early identification and evidence-based treatment of sepsis are associated with improved outcomes.Areas covered: This narrative review was undertaken following a PubMed search for English language reports published before July 2020 using the terms 'sepsis,' 'septic shock,' 'fluids,' 'fluid therapy,' 'albumin,' 'corticosteroids,' 'vasopressor.' Emerging management strategies were identified following a search of the ClinicalTrails.gov database using the term 'sepsis.' Additional reports were identified by examining the reference lists of selected articles and based on personnel knowledge of the field of sepsis.Expert opinion: The core treatment of sepsis relies on source control, early antibiotics, and organ support. The main emerging strategies focus on immunomodulation, artificial intelligence, and on multi-omics approaches for a personalized therapy.

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

OBJECTIVE

The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis.

METHODS

This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine.

RESULTS

A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed.

CONCLUSIONS

Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis.

Adjuvant β-Lactam Therapy Combined with Vancomycin or Daptomycin for Methicillin-Resistant Staphylococcus aureus Bacteremia: a Systematic Review and Meta-analysis

Infections due to methicillin-resistant Staphylococcus aureus bacteremia (MRSAB) seriously threaten public health due to poor outcomes and high mortality. The objective of this study is to perform a systematic review and meta-analysis of the current evidence on adjuvant β-lactam (BL) therapy combined with vancomycin (VAN) or daptomycin (DAP) for MRSAB. PubMed, Embase, and Cochrane Library were systematically searched for publications reporting clinical outcomes of BLs+VAN or BLs+DAP for adult patients with MRSAB through 5 April 2020. Meta-analysis techniques were applied using random effects modeling. Three randomized controlled trials and 12 retrospective cohort studies were identified, totaling 2,594 patients. Combination treatment significantly reduced the risk of clinical failure (risk ratio [RR] = 0.80; 95% confidence interval [CI], 0.66 to 0.96; P = 0.02; I² = 39%), bacteremia recurrence (RR = 0.66; 95% CI, 0.50 to 0.86; P = 0.002; I² = 0%), and persistent bacteremia (RR = 0.65; 95% CI, 0.55 to 0.76; P < 0.00001; I² = 0%) and shortened the duration of bacteremia (standardized mean difference [SMD] = -0.37; 95% CI, -0.48 to -0.25; P < 0.00001; I² = 0%). There was no significant difference in the risk of crude mortality, nephrotoxicity, or thrombocytopenia between groups. Notably, combination treatment might nonsignificantly increase the risk of Clostridium difficile infection (CDI) (RR = 2.13; 95% CI, 0.98 to 4.63; P = 0.06; I² = 0%). Subgroup analysis suggested that DAP+BLs could reduce crude mortality (RR = 0.53; 95% CI, 0.28 to 0.98; P = 0.04; I² = 0%). The meta-analysis suggested that although combination therapy with BLs could improve some microbial outcomes, it could not reduce crude mortality but might increase the risk of CDI and should be applied very cautiously. Regarding mortality reduction, the combination of DAP+cephalosporins appears more promising.

Etomidate, Adrenal Insufficiency and Mortality Associated With Severity of Illness: A Meta-Analysis

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.

Use of etomidate in patients with heart failure undergoing noncardiac surgery

BACKGROUND

Patients with symptomatic and asymptomatic heart failure undergoing noncardiac surgery may benefit from the haemodynamic profile of etomidate. However, the safety of etomidate in this population is unknown. We examined anaesthesiologist variation in etomidate use and assessed its safety using an instrumental variable approach to account for differences in treatment selection.

METHODS

A retrospective cohort study of 19 714 patients with heart failure undergoing noncardiac surgery at two tertiary care institutions from January 2006 to December 2017 was performed. The proportion of etomidate use among 294 anaesthesiologists was examined and adjusted risk differences (aRD) for in-hospital and 30-day mortality were calculated using physician preference for etomidate as an instrumental variable.

RESULTS

Etomidate was used in 14.3% (2821/19 714) of patients. Preference for etomidate varied substantially among individual anaesthesiologists with the lowest and highest quartile users using etomidate in 0-4.7% and 20.4-66.7% of their own heart failure patients, respectively. The adjusted instrumental variable analysis showed no significant differences in the risk of in-hospital (aRD -0.2%; 95% confidence interval, -2.4%-1.9%; P=0.83) or 30 day mortality (aRD 0.2%; 95% confidence interval, -2.5%-2.9%; P=0.90). Anaesthesiologists with higher preferences for etomidate were more experienced (greater heart failure and total case volume) than anaesthesiologists with lower preferences for etomidate.

CONCLUSIONS

We found substantial variability in anaesthesiologists' preference for etomidate for use in patients with heart failure undergoing noncardiac surgery. There was no association between etomidate use and in-hospital or 30-day mortality. Etomidate is not inferior to other currently used options for induction of general anaesthesia in patients with heart failure.

Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations

Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao₂ <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao₂ <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.

Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium

Practice guidelines provide clear evidence-based recommendations for the use of drug therapy to manage pain, agitation, and delirium associated with critical illness. Dosing recommendations however are often based on strategies used in patients with normal body habitus. Recommendations specific to critically ill patients with extreme obesity are lacking. Nonetheless, clinicians must craft dosing regimens for this population. This paper is intended to help clinicians design initial dosing regimens for medications commonly used in the management of pain, agitation, and delirium in critically ill patients with extreme obesity. A detailed literature search was conducted with an emphasis on obesity, pharmacokinetics, and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided.

Relationship of chronic kidney disease with major air pollutants - A systematic review and meta-analysis of observational studies

BACKGROUND

Articles concerning the correlation of the risk of chronic kidney disease (CKD) with air contaminant exposure present inconsistent findings and the magnitude of the link is still unclear. Therefore, we planned to systematically and quantitatively investigate the overall strength of proofs in this field.

METHODS

Relevant articles on Cochrane, EMBASE, Medline, Web of Science, and CINHAL were searched as per relevant strategies. Only observational studies that disclosed the link of CKD risk with major air pollutants were enrolled, including PM10 and PM2.5, which were particulate matter less than 10 um and less than 2.5 um in erodynamic diameter respectively. Pooled relative risk (RR) and 95 % confidence interval (CI) were determined using random--effects models, regardless of the heterogeneity quantified by I² statistic.

RESULTS

Finally, 7 studies involving 5,812,381 participants were included. The incidence of CKD was increased by long-term exposure to PM10 (including solely estimated exposure to PM10 from studies using PM2.5) (RR 1.08, 95 %CI 1.04-1.11) with considerable heterogeneity (I² = 79 %), and the risk of CKD was raised by 8% when the long-time exposure to PM10 increased by 10 ug/m³. The pooled RR (95 %CI) with a 10 μg/m³ increase in PM2.5 for risk of CKD was 1.09 (1.03-1.17). Stratified analysis also verified the general negative effects.

CONCLUSIONS

Chronic subjection to major air contaminants (PM10 and PM2.5) is more likely to cause CKD. Thus, developing global approaches of air pollution elimination to prevent CKD is urgent.

Statin use and risk of tuberculosis: a systemic review of observational studies

OBJECTIVES

Statin intake may be linked with a lower risk of several infectious diseases, including tuberculosis, which is an important cause of mortality worldwide. The aim of this study was to investigate the definite impacts of statins on the risk of tuberculosis (TB) in diabetic patients and in the general population.

METHODS

Four databases were thoroughly searched from inception up to July 2019. Articles in any language were included if they assessed and clarified statin intake, presented the risk of TB in diabetes mellitus (DM) patients or the general population, and reported odds ratios (ORs), relative risks (RRs), or hazard ratios (HRs) or contained data for relevant calculation. RRs with 95% confidence intervals (CIs) were pooled using random-effects models regardless of heterogeneity quantified by Cochran's Q and I² statistics.

RESULTS

Six articles reporting observational studies involving 2 073 968 patients were included. Four reported cohort studies, one a nested case-control study, and one was an abstract. Statin use significantly reduced the risk of TB in DM patients by 22% (pooled RR 0.78, 95% CI 0.63-0.95), with severe heterogeneity (I² = 76.1%). Statin intake also significantly decreased the risk of TB in the general population by 40% (pooled RR 0.60, 95% CI 0.50-0.71), with severe heterogeneity (I² = 57.7%).

CONCLUSIONS

Statin use is related to a considerably lower risk of TB in both DM patients and the general population. However, these conclusions should be interpreted with caution given the possible remaining confounding, and call for large-size and multicenter randomized controlled studies in the future.

A pre-formulation strategy for the liposome encapsulation of new thioctic acid conjugates for enhanced chemical stability and use as an efficient drug carrier for MPO-mediated atherosclerotic CVD treatment

Lipoyl-apocynin and lipoyl-sesamol are bio-active conjugates of thioctic acid, synthesized using a benign chemical approachviathe combination of thioctic acid and the powerful bio-phytonutrients, apocynin and sesamol, respectively.

The effect of midazolam or lidocaine administration prior to etomidate induction of anesthesia on heart rate, arterial pressure, intraocular pressure and serum cortisol concentration in healthy dogs

OBJECTIVE

To evaluate selected effects of midazolam or lidocaine administered prior to etomidate for co-induction of anesthesia in healthy dogs.

STUDY DESIGN

Prospective crossover experimental study.

ANIMALS

A group of 12 healthy adult female Beagle dogs.

METHODS

Dogs were premedicated with intravenous (IV) butorphanol (0.3 mg kg^-1), and anesthesia was induced with etomidate following midazolam (0.3 mg kg^-1), lidocaine (2 mg kg^-1) or physiologic saline (1 mL) IV. Heart rate (HR), arterial blood pressure, respiratory rate (f_R) and intraocular pressure (IOP) were recorded following butorphanol, after co-induction administration, after etomidate administration and immediately following intubation. Baseline IOP values were also obtained prior to sedation. Etomidate dose requirements and the presence of myoclonus, as well as coughing or gagging during intubation were recorded. Serum cortisol concentrations were measured prior to premedication and 6 hours following etomidate administration.

RESULTS

Blood pressure, f_R and IOP were similar among treatments. Blood pressure decreased in all treatments following etomidate administration and generally returned to sedated values following intubation. HR increased following intubation with midazolam and lidocaine but remained stable in the saline treatment. The dose of etomidate (median, interquartile range, range) required for intubation was lower following midazolam (2.2, 2.1-2.6, 1.7-4.1 mg kg^-1) compared with lidocaine (2.7, 2.4-3.6, 2.2-5.1 mg kg^-1, p = 0.012) or saline (3.0, 2.8-3.8, 1.9-5.1 mg kg^-1, p = 0.015). Coughing or gagging was less frequent with midazolam compared with saline. Myoclonus was not observed. Changes in serum cortisol concentrations were not different among treatments.

CONCLUSIONS AND CLINICAL RELEVANCE

Midazolam administration reduced etomidate dose requirements and improved intubation conditions compared with lidocaine or saline treatments. Neither co-induction agent caused clinically relevant differences in measured cardiopulmonary function, IOP or cortisol concentrations compared with saline in healthy dogs. Apnea was noted in all treatments following the induction of anesthesia and preoxygenation is recommended.

Association of CAV1 polymorphisms with the risks of breast cancer: A systematic review and meta-analysis

BACKGROUND

Caveolin-1 (CAV1) polymorphisms have been shown to correlated with breast cancer risk in previous studies. However, the role of CAV1 polymorphisms still remained indecisive, and dual functions of CAV1 was demonstrated in breast cancer development. Consequently, a meta-analysis to evaluate and summarize the association of the CAV1 polymorphisms with breast cancer susceptibility.

MATERIAL AND METHODS

Extensive search was performed in PubMed, Web of Science, Google scholar, EMBASE.com, CNKI and Wanfang searching platform up to March 2019. The Newcastle-Ottawa Scale (NOS) were used to evaluate the quality of each study. The Odds ratios (ORs) and the 95% confidence intervals (CIs) were analyzed to evaluate the strength of the associations in five genetic models. Inter-study heterogeneity was quantified using the I-squared (I²) test. In addition, the Egger's test and Begg's test were applied to evaluate the publication bias.

RESULTS

4 case-control studies with 2115 cases and 2138 controls were enrolled into this analysis. There was a significant association between rs3807987 polymorphism of CAV1 and breast cancer in allele comparison (A vs. G: OR = 1.288, 95％CI = 1.162-1.428, P < 0.001), heterozygote comparison (AG vs. GG: OR= 1.422, 95％CI=1.233-1.639, P < 0.001), and dominant comparison (AA+AG vs. GG: OR=1.395, 95％CI=1.228-1.586, P < 0.001). A significant association of rs3807987 polymorphism in allele comparison (A vs. G: OR=1.238, 95％CI=1.109-1.383, P < 0.001), heterozygote comparison (AG VS. GG: OR=1.466, 95％CI=1.267-1.697, P < 0.05), and dominant comparison (AA+AG vs. GG: OR=1.384, 95％CI=1.209-1.585, P < 0.001) was also founded amongst Chinese population. A significant association between rs7804372 polymorphism and breast cancer amongst Chinese population in recessive comparison (AA vs. AT + TT: OR = 0.730, 95％CI = 0.567-0.940, P = 0.015) was identified. No significant association between breast cancer risk and rs1997623 was found.

CONCLUSION

CAV1 rs3807987 and rs7804372 polymorphisms are associated with the change of breast cancer risk. More well-designed and large studies in various populations are needed to further elaborate these associations.