Comparison of clinical outcome variables in patients with and without etomidate-facilitated anesthesia induction ahead of major cardiac surgery: a retrospective analysis

Sebastian Heinrich, Joachim Schmidt, Andreas Ackermann, Andreas Moritz, Frank Harig, Ixchel Castellanos, Sebastian Heinrich, Joachim Schmidt, Andreas Ackermann, Andreas Moritz, Frank Harig, Ixchel Castellanos

Abstract

Introduction: It is well known that etomidate may cause adrenal insufficiency. However, the clinical relevance of adrenal suppression after a single dose of etomidate remains vague. The aim of this study was to investigate the association between the administration of a single dose of etomidate or an alternative induction regime ahead of major cardiac surgery and clinical outcome parameters associated with adrenal suppression and onset of sepsis.

Methods: The anesthesia and intensive care unit (ICU) records from patients undergoing cardiac surgery over five consecutive years (2008 to 2012) were retrospectively analyzed. The focus of the analysis was on clinical parameters like mortality, ventilation hours, renal failure, and sepsis-linked serum parameters. Multivariate analysis and Cox regression were applied to derive the results.

Results: In total, 3,054 patient records were analyzed. A group of 1,775 (58%) patients received a single dose of etomidate; 1,279 (42%) patients did not receive etomidate at any time. There was no difference in distribution of age, American Society of Anesthesiologists physical score, duration of surgery, and Acute Physiology and Chronic Health Evaluation II score. Postoperative data showed no significant differences between the two groups in regard to mortality (6.8% versus 6.4%), mean of mechanical ventilation hours (21.2 versus 19.7), days in the ICU (2.6 versus 2.5), hospital days (18.7 versus 17.4), sepsis-associated parameters, Sequential Organ Failure Assessment score, and incidence of renal failure. Administration of etomidate showed no significant influence (P = 0.6) on hospital mortality in the multivariate Cox analysis.

Conclusions: This study found no evidence for differences in key clinical outcome parameters based on anesthesia induction with or without administration of a single dose of etomidate. In consequence, etomidate might remain an acceptable option for single-dose anesthesia induction.

Figures

Figure 1
Figure 1
Flow chart showing the case selection and data collection of the study. ICU, intensive care unit; PDMS, patient data management system.

References

    1. Budde AO, Mets B. Pro: etomidate is the ideal induction agent for a cardiac anesthetic. J Cardiothorac Vasc Anesth. 2013;27:180–183. doi: 10.1053/j.jvca.2012.08.024.
    1. Watkins J. Potential hazards of prolonged anaesthesia with etomidate and althesin. Lancet. 1983;1:1434–1435.
    1. Miranda DR, Stoutenbeek CP. Etomidate in the intensive care unit. Lancet. 1983;2:684–685.
    1. Shehabi Y, Bellomo R, Mehta S, Riker R, Takala J. Intensive care sedation: the past, present and the future. Crit Care. 2013;17:322. doi: 10.1186/cc12679.
    1. Absalom A, Pledger D, Kong A. Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia. 1999;54:861–867. doi: 10.1046/j.1365-2044.1999.01003.x.
    1. Hildreth AN, Mejia VA, Maxwell RA, Smith PW, Dart BW, Barker DE. Adrenal suppression following a single dose of etomidate for rapid sequence induction: a prospective randomized study. J Trauma. 2008;65:573–579. doi: 10.1097/TA.0b013e31818255e8.
    1. Chan CM, Mitchell AL, Shorr AF. Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis*. Crit Care Med. 2012;40:2945–2953. doi: 10.1097/CCM.0b013e31825fec26.
    1. Cuthbertson BH, Sprung CL, Annane D, Chevret S, Garfield M, Goodman S, Laterre PF, Vincent JL, Freivogel K, Reinhart K, Singer M, Payen D, Weiss YG. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Intensive Care Med. 2009;35:1868–1876. doi: 10.1007/s00134-009-1603-4.
    1. Albert SG, Ariyan S, Rather A. The effect of etomidate on adrenal function in critical illness: a systematic review. Intensive Care Med. 2011;37:901–910. doi: 10.1007/s00134-011-2160-1.
    1. Sunshine JE, Deem S, Weiss NS, Yanez ND, Daniel S, Keech K, Brown M, Treggiari MM. Etomidate, adrenal function, and mortality in critically ill patients. Respir Care. 2013;58:639–646.
    1. Hohl CM, Kelly-Smith CH, Yeung TC, Sweet DD, Doyle-Waters MM, Schulzer M. The effect of a bolus dose of etomidate on cortisol levels, mortality, and health services utilization: a systematic review. Ann Emerg Med. 2010;56:105–113. doi: 10.1016/j.annemergmed.2010.01.030. e105.
    1. Dmello D, Taylor S, O’Brien J, Matuschak GM. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138:1327–1332. doi: 10.1378/chest.10-0790.
    1. McPhee LC, Badawi O, Fraser GL, Lerwick PA, Riker RR, Zuckerman IH, Franey C, Seder DB. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41:774–783. doi: 10.1097/CCM.0b013e318274190d.
    1. Ray DC, McKeown DW. Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock. Crit Care. 2007;11:R56. doi: 10.1186/cc5916.
    1. Riche FC, Boutron CM, Valleur P, Berton C, Laisne MJ, Launay JM, Chappuis P, Peynet J, Vicaut E, Payen D, Cholley BP. Adrenal response in patients with septic shock of abdominal origin: relationship to survival. Intensive Care Med. 2007;33:1761–1766. doi: 10.1007/s00134-007-0770-4.
    1. Tekwani KL, Watts HF, Sweis RT, Rzechula KH, Kulstad EB. A comparison of the effects of etomidate and midazolam on hospital length of stay in patients with suspected sepsis: a prospective, randomized study. Ann Emerg Med. 2010;56:481–489. doi: 10.1016/j.annemergmed.2010.05.034.
    1. Jung B, Clavieras N, Nougaret S, Molinari N, Roquilly A, Cisse M, Carr J, Chanques G, Asehnoune K, Jaber S. Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis. Crit Care. 2012;16:R224. doi: 10.1186/cc11871.
    1. Asehnoune K, Mahe PJ, Seguin P, Jaber S, Jung B, Guitton C, Chatel-Josse N, Subileau A, Tellier AC, Masson F, Renard B, Malledant Y, Lejus C, Volteau C, Sébille V, Roquilly A. Etomidate increases susceptibility to pneumonia in trauma patients. Intensive Care Med. 2012;38:1673–1682. doi: 10.1007/s00134-012-2619-8.
    1. Iribarren JL, Jimenez JJ, Hernandez D, Lorenzo L, Brouard M, Milena A, Mora ML, Martinez R. Relative adrenal insufficiency and hemodynamic status in cardiopulmonary bypass surgery patients. A prospective cohort study. J Cardiothorac Surg. 2010;5:26. doi: 10.1186/1749-8090-5-26.
    1. Morel J, Salard M, Castelain C, Bayon MC, Lambert P, Vola M, Auboyer C, Molliex S. Haemodynamic consequences of etomidate administration in elective cardiac surgery: a randomized double-blinded study. Br J Anaesth. 2011;107:503–509. doi: 10.1093/bja/aer169.
    1. Wagner CE, Bick JS, Johnson D, Ahmad R, Han X, Ehrenfeld JM, Schildcrout JS, Pretorius M. Etomidate use and postoperative outcomes among cardiac surgery patients. Anesthesiology. 2014;120:579–589. doi: 10.1097/ALN.0000000000000087.
    1. Chalk K, Meisel C, Spies C, Volk T, Thuenemann K, Linneweber J, Wernecke KD, Sander M. Dysfunction of alveolar macrophages after 3 cardiac surgery and postoperative pneumonia? - an 5 observational study. Crit Care. 2013;17:R285. doi: 10.1186/cc13148.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829. doi: 10.1097/00003246-198510000-00009.
    1. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707–710. doi: 10.1007/BF01709751.
    1. Castellanos I, Bürkle T, Prokosch H-U, Schüttler J. Concept for the hospital wiede implementation of a patient data management system at a large clinical center - an interdisciplinary challenge. Anaesth Intensivmed. 2009;50:618–629.
    1. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429–434. doi: 10.1007/BF03011357.
    1. Cormack RS. Cormack-Lehane classification revisited. Br J Anaesth. 2010;105:867–868. doi: 10.1093/bja/aeq324.
    1. Zwolinski R, Jander S, Ostrowski S, Bartczak K, Adamek Kosmider A, Banys A, Jaszewski R. Early and long term coronary artery bypass grafting outcomes in patients under 45 years of age. Kardiol Pol. 2013;71:32–39.
    1. Martin LM, Holmes SD, Henry LL, Schlauch KA, Stone LE, Roots A, Hunt SL, Ad N. Health-related quality of life after coronary artery bypass grafting surgery and the role of gender. Cardiovasc Revasc Med. 2012;13:321–327.
    1. Zed PJ, Abu-Laban RB, Harrison DW. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Acad Emerg Med. 2006;13:378–383. doi: 10.1111/j.1553-2712.2006.tb00313.x.
    1. Anand D, Das S, Ray S, Bhargava S, Srivastava LM. Interrelationship between procalcitonin and organ failure in sepsis. Indian J Clin Biochem. 2014;29:93–96. doi: 10.1007/s12291-013-0326-z.
    1. Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, Bertrand L, Beltramini A, Gamand P, Albizzati S, Perdrizet D, Lebail G, Chollet-Xemard C, Maxime V, Brun-Buisson C, Lefrant JY, Bollaert PE, Megarbane B, Ricard JD, Anguel N, Vicaut E, Adnet F. KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009;374:293–300. doi: 10.1016/S0140-6736(09)60949-1.
    1. Moreno R, Vincent JL, Matos R, Mendonca A, Cantraine F, Thijs L, Takala J, Sprung C, Antonelli M, Bruining H, Willatts S. The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Working Group on Sepsis related Problems of the ESICM. Intensive Care Med. 1999;25:686–696. doi: 10.1007/s001340050931.
    1. Guirgis FW, Khadpe JD, Kuntz GM, Wears RL, Kalynych CJ, Jones AE. Persistent organ dysfunction after severe sepsis: A systematic review. J Crit Care. 2014;29:320–326. doi: 10.1016/j.jcrc.2013.10.020.
    1. Gomez H, Ince C, De Backer D, Pickkers P, Payen D, Hotchkiss J, Kellum JA. A unified theory of sepsis-induced acute kidney injury: inflammation, microcirculatory dysfunction, bioenergetics, and the tubular cell adaptation to injury. Shock. 2014;41:3–11.
    1. Kiessling AH, Dietz J, Reyher C, Stock UA, Beiras-Fernandez A, Moritz A. Early postoperative serum cystatin C predicts severe acute kidney injury following cardiac surgery: a post-hoc analysis of a randomized controlled trial. J Cardiothorac Surg. 2014;9:10. doi: 10.1186/1749-8090-9-10.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner