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Propofol is not the only option for anesthesia for abdominal surgery in older adults

A randomized trial found no higher risk of major complications after elective abdominal surgery in older patients undergoing etomidate anesthesia compared with propofol.

In an intention-to-treat analysis of 1,917 such patients, the incidence of major hospitalizations was 9.3% in the etomidate group and 8.7% in the propofol group. According to Lize Xiong, MD, of the Fourth People’s Hospital of Shanghai, China, and colleagues, a risk difference of 0.6% (95% CI -1.6% to 2.7%) easily reached the prespecified noninferiority margin of 3% .

However, etomidate did cause transient adrenal suppression, with lower mean cortisol levels at the end of surgery (4.8 vs 6.1 μg/dL, P JAMA Surgery.

In addition, the etomidate group had lower aldosterone levels relative to propofol:

  • At the end of surgery: 0.13 vs 0.15 ng/dL
  • On the first day after surgery: 0.14 vs 0.16 ng/dL

In patients with high perioperative morbidity and mortality due to hemodynamic stability, etomidate may be A better option for induction of anesthesia, but Xiong’s team noted concerns about its effect on relative adrenal insufficiency. This is the first study to evaluate the effect of etomidate on postoperative adrenal suppression and complications in elderly patients.

“Propofol is the most common intravenous [intravenous] anesthetic drug used for general anesthesia,” Jason Johanning, M.D., M.D., University of Nebraska Medical Center, Omaha, in accompanying “But propofol is far from perfect, and its adverse effect profile has significant effects on cardiovascular parameters, including lower blood pressure and elevated heart rate.” “

For this single-blind trial, called EPIC, Xiong and colleagues recruited patients aged 65-80 years with total intravenous anesthesia scheduled for abdominal surgery, and randomly assigned 967 people to receive etomidate. ester (mean age 70.3, 60% male) and 950 received propofol (mean age 70.6; 56% male). Surgery was performed in 22 Chinese hospitals from August 2017 to November 2020.

The mean BMI of the participants was 23. Nearly three-quarters of the American Society of Anesthesiologists had a physical condition class of 2. More underwent gastrointestinal surgery (59-60%) than hepatobiliary surgery ( 40-41%) The mean duration was 2 hours. The mean duration of anesthesia was approximately 2.5 hours.

General anesthesia was administered by target-controlled titration infusion, and the target plasma concentration during surgery was set at 0.5 -0.8 μg/mL for etomidate induction and 0.2 μg/mL -0.4 μg/mL for maintenance. For induction and maintenance, the target plasma concentration of propofol was 2-4 μg/mL. In addition, both groups also Sufentanil (Dsuvia) and cisatracurium (Nimbex) were received. If needed, the patient could also receive nicardipine or norepinephrine to control blood pressure.

More Pneumonitis occurred in etomidate patients (2.0% vs 0.3%). Pulmonary complications were the only significantly greater in-hospital complications in the etomidate group (19% vs 5%). However, a previous study found that The lack of a link between etomidate and pneumonia led Xiong and colleagues to write, “The collective evidence supports the cautious use of etomidate infusion in patients at risk for pulmonary complications. “

Etomidate patients had more hypertension (3.8% vs. 10.3%), but less hypotension (10.5% vs. 2.4%) and persistently elevated diastolic blood pressure after incision Except for 120 minutes.

No significant difference at 6 months postoperatively (etomidate 2.2% vs propofol 3.0%) and 1 year postoperatively (3.3% vs 3.9%) Mortality difference.

Postoperative nausea/vomiting score of 3 or higher or pain up to 3 days later.

“EPIC trial based Imidate provides a solid basis as another agent to consider for total intravenous anesthesia,” Johanning wrote. “It is important to note that the trial was conducted in a trial and the results should apply to older normal-risk patients. “

Xiong’s group acknowledges data limitations. The findings may not be generalizable to procedures lasting up to 4 hours or to patients outside of China. In addition, the researchers stated that there were no assessments with Frequency and duration of events related to abnormal blood pressure.

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      Zaina Hamza is a staff writer for Medicine Today covering gastroenterology and infectious diseases She is based in Chicago.

Disclosure

This study was supported by the National Natural Science Foundation of China.

The study authors and editors declare that they have no relevant economic benefit.

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