Basciani Reto M, Rindlisbacher Antje, Begert Esther, Brander Luc, Jakob Stephan M, Etter Reto, Carrel Thierry, Eberle Balthasar
From the Department of Anesthesiology and Pain Medicine (RMB, BE); Department of Intensive Care Medicine (AR, EB, LB, SMJ, RE); and Department of Cardiovascular Surgery, (TC) University Hospital, University of Bern, Bern, Switzerland. Current affiliation of LB: Department of Anesthesia, Cantonal Hospital, Lucerne, Switzerland.
Eur J Anaesthesiol. 2016 Jun;33(6):417-24. doi: 10.1097/EJA.0000000000000434.
Etomidate is perceived as preserving haemodynamic stability during induction of anaesthesia. It is also associated with adrenocortical dysfunction. The risk/benefit relationship is controversial.
We tested the hypotheses that single-dose etomidate increases cumulative vasopressor requirement, time to extubation and length of stay in the ICU.
Double-blind randomised controlled trial.
Bern University Hospital, Switzerland, from November 2006 to December 2009.
There were 90 patients undergoing coronary artery bypass grafts (CABG) and 40 patients undergoing mitral valve surgery (MVS). Reasons for noninclusion were known adrenocortical insufficiency, use of etomidate or propofol within 1 week preoperatively, use of glucocorticoids within 6 months preoperatively, severe renal or liver dysfunction, or carotid stenosis.
CABG patients were allocated randomly to receive either etomidate 0.15 mg kg with placebo, propofol 1.5 mg kg with placebo or etomidate 0.15 mg kg with hydrocortisone (n = 30 in each arm). Risk stratification (low vs. high) was achieved by block randomisation. MVS patients received either etomidate 0.15 mg kg or propofol 1.5 mg kg (n = 20 in each arm).
Cumulative vasopressor requirements, incidence of adrenocortical insufficiency, length of time to extubation and length of stay in ICU.
Cumulative vasopressor requirements 24 h after induction did not differ between treatments in patients who underwent CABG, whereas more noradrenaline was used in MVS patients following propofol induction (absolute mean difference 5.86 μg kg over 24 h P = 0.047). The incidence of relative adrenocortical insufficiency was higher after etomidate alone than propofol (CABG 83 vs. 37%, P < 0.001; MVS: 95 vs. 35%, P < 0.001). The time to extubation, length of stay in ICU and 30-day mortality did not differ among treatments. Within low and high-risk subgroups, no differences in vasopressor use or outcomes were found.
In elective cardiac surgery, laboratory indicators of etomidate-induced adrenal insufficiency do not translate into increased vasopressor requirement or inferior early outcomes.
ClinicalTrials.gov Identifier: NCT 00415701.
依托咪酯被认为在麻醉诱导期间能维持血流动力学稳定。它也与肾上腺皮质功能障碍有关。风险/效益关系存在争议。
我们检验了以下假设，即单剂量依托咪酯会增加血管升压药的累积需求量、拔管时间和重症监护病房（ICU）住院时间。
双盲随机对照试验。
2006年11月至2009年12月期间，瑞士伯尔尼大学医院。
90例行冠状动脉旁路移植术（CABG）的患者和40例行二尖瓣手术（MVS）的患者。不纳入的原因包括已知的肾上腺皮质功能不全、术前1周内使用过依托咪酯或丙泊酚、术前6个月内使用过糖皮质激素、严重的肾或肝功能障碍或颈动脉狭窄。
CABG患者被随机分配接受0.15mg/kg依托咪酯加安慰剂、1.5mg/kg丙泊酚加安慰剂或0.15mg/kg依托咪酯加氢皮质激素（每组n = 30）。通过区组随机化实现风险分层（低风险与高风险）。MVS患者接受要么0.15mg/kg依托咪酯要么1.5mg/kg丙泊酚（每组n = 20）。
血管升压药的累积需求量、肾上腺皮质功能不全的发生率、拔管时间和ICU住院时间。
CABG患者诱导后24小时血管升压药的累积需求量在各治疗组间无差异，而丙泊酚诱导后MVS患者使用了更多去甲肾上腺素（24小时内绝对平均差异为5.86μg/kg，P = 0.047）。单独使用依托咪酯后相对肾上腺皮质功能不全的发生率高于丙泊酚（CABG组：83%对37%，P < 0.001；MVS组：95%对35%，P < 0.001）。各治疗组间拔管时间、ICU住院时间和30天死亡率无差异。在低风险和高风险亚组中，血管升压药使用情况或结局无差异。
在择期心脏手术中，依托咪酯诱导的肾上腺功能不全的实验室指标并未转化为血管升压药需求量增加或早期结局较差。
ClinicalTrials.gov标识符：NCT 00415701。
