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Anesthetic Induction with Etomidate, Rather than Propofol, Is Associated with Increased 30-Day Mortality and Cardiovascular Morbidity After Noncardiac Surgery

Komatsu, Ryu MD*; You, Jing MS†‡; Mascha, Edward J. PhD†‡; Sessler, Daniel I. MD; Kasuya, Yusuke MD§; Turan, Alparslan MD

doi: 10.1213/ANE.0b013e318299a516
Patient Safety: Research Report

BACKGROUND: Because etomidate impairs adrenal function and blunts the cortisol release associated with surgical stimulus, we hypothesized that patients induced with etomidate suffer greater mortality and morbidity than comparable patients induced with propofol.

METHODS: We evaluated the electronic records of 31,148 ASA physical status III and IV patients who had noncardiac surgery at the Cleveland Clinic. Among these, anesthesia was induced with etomidate and maintained with volatile anesthetics in 2616 patients whereas 28,532 were given propofol for induction and maintained with volatile anesthetics. Two thousand one hundred forty-four patients given etomidate were propensity matched with 5233 patients given propofol and the groups compared on 30-day postoperative mortality, length of hospital stay, cardiovascular and infectious morbidities, vasopressor requirement, and intraoperative hemodynamics.

RESULTS: Patients given etomidate had 2.5 (98% confidence interval [CI], 1.9–3.4) times the odds of dying than those given propofol. Etomidate patients also had significantly greater odds of having cardiovascular morbidity (odds ratio [OR] [98% CI]: 1.5 [1.2–2.0]), and significantly longer hospital stay (hazard ratio [95% CI]: 0.82 [0.78–0.87]). However, infectious morbidity (OR [98% CI]: 1.0 [0.8–1.2]) and intraoperative vasopressor use (OR [95% CI] 0.92: [0.82–1.0]) did not differ between the agents.

CONCLUSION: Etomidate was associated with a substantially increased risk for 30-day mortality, cardiovascular morbidity, and prolonged hospital stay. Our conclusions, especially on 30-day mortality, are robust to a strong unmeasured binary confounding variable. Although our study showed only an association between etomidate use and worse patients’ outcomes but not causal relationship, clinicians should use etomidate judiciously, considering that improved hemodynamic stability at induction may be accompanied by substantially worse longer-term outcomes.

From the *Anesthesiology Institute, Department of Quantitative Health Sciences, and Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; and §Department of Anesthesiology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan.

Accepted for publication April 17, 2013.

Funding: This research was supported solely by internal sources.

The authors declare no conflicts of interest.

This report was previously presented, in part, at the International Anesthesia Research Society 2012 Annual Meeting on May 18 to 21, 2012, Boston, MA, the Association of University Anesthesiologists 59th Annual Meeting on May 17 to 19, Cleveland, OH, and the American Society of Anesthesiologist 2012 Annual Meeting on October 13 to 17, 2012, Washington, DC.

Reprints will not be available from the authors.

Address correspondence to Ryu Komatsu, MD, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, Ohio 44195. Address e-mail to On the world wide web,

© 2013 International Anesthesia Research Society