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Anaesthetic induction with etomidate in cardiac surgery: A randomised controlled trial

Basciani, Reto M.; Rindlisbacher, Antje; Begert, Esther; Brander, Luc; Jakob, Stephan M.; Etter, Reto; Carrel, Thierry; Eberle, Balthasar

European Journal of Anaesthesiology (EJA): June 2016 - Volume 33 - Issue 6 - p 417–424
doi: 10.1097/EJA.0000000000000434
Cardiac anaesthesia

BACKGROUND Etomidate is perceived as preserving haemodynamic stability during induction of anaesthesia. It is also associated with adrenocortical dysfunction. The risk/benefit relationship is controversial.

OBJECTIVES We tested the hypotheses that single-dose etomidate increases cumulative vasopressor requirement, time to extubation and length of stay in the ICU.

DESIGN Double-blind randomised controlled trial.

SETTING Bern University Hospital, Switzerland, from November 2006 to December 2009.

PATIENTS There were 90 patients undergoing coronary artery bypass grafts (CABG) and 40 patients undergoing mitral valve surgery (MVS). Reasons for noninclusion were known adrenocortical insufficiency, use of etomidate or propofol within 1 week preoperatively, use of glucocorticoids within 6 months preoperatively, severe renal or liver dysfunction, or carotid stenosis.

INTERVENTIONS CABG patients were allocated randomly to receive either etomidate 0.15 mg kg−1 with placebo, propofol 1.5 mg kg−1 with placebo or etomidate 0.15 mg kg−1 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−1 or propofol 1.5 mg kg−1 (n = 20 in each arm).

MAIN OUTCOME MEASURES Cumulative vasopressor requirements, incidence of adrenocortical insufficiency, length of time to extubation and length of stay in ICU.

RESULTS Cumulative vasopressor requirements 24 h after induction did not differ between treatments in patients who underwent CABG, whereas more noradrenaline was used in MVS patients following propofol induction (absolute mean difference 5.86 μg kg−1 over 24 h P = 0.047). The incidence of relative adrenocortical insufficiency was higher after etomidate alone than propofol (CABG 83 vs. 37%, P < 0.001; MVS: 95 vs. 35%, P < 0.001). The time to extubation, length of stay in ICU and 30-day mortality did not differ among treatments. Within low and high-risk subgroups, no differences in vasopressor use or outcomes were found.

CONCLUSION In elective cardiac surgery, laboratory indicators of etomidate-induced adrenal insufficiency do not translate into increased vasopressor requirement or inferior early outcomes.

TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT 00415701.

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.

Correspondence to Stephan M. Jakob, Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Inselspital, Freiburgstrasse, CH-3010 Bern, Switzerland Tel: +41 316321176; e-mail: stephan.jakob@insel.ch

Published online 24 February 2016

© 2016 European Society of Anaesthesiology