Etomidate for Induction in the Hemodynamically Unstable Patient: Con

Educational Objectives

The goal of this program is to improve patient outcomes by presenting data on the effects of etomidate, and through the appropriate clinical use of mobile computing devices. After hearing and assimilating this program, the clinician will be better able to:

1. Cite potential complications of administration of etomidate.

Summary

Studies comparing etomidate to other agents: all studies showing no difference in clinical outcomes underpowered (eg, N = 50-100); most studies cited compared etomidate to ketamine (drug not often used for induction of anesthesia); no studies available comparing etomidate to propofol, except in patients undergoing cardiac surgery (whose outcomes depend on factors other than induction agents)

Complications associated with etomidate: thrombophlebitis — incidence 7% to 80% (≈7% when etomidate injected into antecubital vein, ≈80% when injected into small vein in hand); during period of propofol shortage (2010-2011), incidence of thrombophlebitis with administration of etomidate 24% to 30%; nausea and vomiting — incidence 30% to 40% (which explains limited use in cases for which timely discharge desired)

Harmful effects of etomidate: Ledingham et al reported 70% to 100% mortality associated with use of etomidate for sedation in critically ill trauma patients (attributed to adrenal suppression); inhibits almost all products of cortisol synthesis and results in only 3 products, pregnenolone, progesterone, and deoxycortisone; meta-analysis (Chan et al) — all studies demonstrated harm associated with etomidate; combined data show increased risk for mortality with etomidate; concluded that use as single-dose agent for induction in septic patients produced measurable deflection in 28-day mortality

Effects of etomidate vs those of other factors: triple low — defined as low bispectral index score, minimum alveolar concentration, and mean arterial blood pressure; increases 30-day mortality; occurs in only 6% of patients; quadruples 30-day mortality (from 0.8% to 3.2%); etomidate — Komatsu and colleagues demonstrated that use of etomidate for induction associated with 4% absolute increase in death, compared with propofol and other agents, despite its apparent beneficial effects on hemodynamics and weaker hypotensive effect; speaker concludes that avoidance of etomidate would have far greater influence on outcomes than addressing triple low; cyclooxygenase (COX)-2 inhibitors — increase risk for myocardial event or death from 100/1000 patient-yr to 160/1000 patient-yr, which translates to ≈0.3% increase in risk for death (ie, much smaller than 4% increase cited above with etomidate)

Conclusions: data suggest that etomidate should probably not be used as induction agent for patients with ASA classification 3 or 4 (exactly those patients believed by anesthesiologists to most benefit from its use); no randomized prospective trial demonstrates any benefit of etomidate, and several databases demonstrate association with excess mortality

Readings

Suggested Reading

Alcock R et al: Peri-operative myocardial necrosis in higher-risk cardiovascular patients undergoing elective non-cardiac surgery. Heart 2012 98:792-798; Chan CM et al: Etomidate is associated with adrenal insufficiency in sepsis: a meta-analysis. Crit Care Med 2012;40:2945-2953; Cuthertson BH et al: The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Int Care Med 2009 Nov;35(11):1868-76; Epstein RH et al: Communication latencies of wireless devices suitable for time-critical messaging to anesthesia providers. Anesth Analg 2013 Apr;116(4):911-8; Hohl CM et al: The effect of a bolus dose of etomidate on cortisol levels, mortality, and health services utilization: a systematic review. Ann Emerg Med 2010 Aug;56(2):105-13; Komatsu R et al: Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day morality and cardiovascular morbidity after noncardiac surgery. Anesth Analg 2013 Dec;117(6):1329-37; Langley A et al: Comparison of the glidescope®, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study. BMC Anesthesiol 2014 Feb;145:10; Ledingham IM, Watt I: Influence of sedation on mortality in critically ill multiple trauma patients. Lancet 1983 Jun;1(8336):1270; Miyashita T et al: FaceTime(®) for teaching ultrasound-guided anesthetic procedures in remote place. J Clin Monit Comput 2014 Apr;28(2):211-5; Monk TG et al: Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005 Jan;100(1):4-10; Patanwala AE et al: Retrospective analysis of etomidate versus ketamine for first-pass intubation success in an academic emergency department. Acad Emerg Med 2014 Jan;21(1):87-91; Regenbogen SE et al: Does the surgical Apgar score measure intraoperative performance? Ann Surg 2008 Aug;248(2):320-328; Tan TW et al: The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality. J Vasc Surg 2014 Jan;59(1):16-24; van den Heuvel I, Wurmb TE et al: Pros and cons of etomidate — more discussion than evidence? Curr Opin Anaesthesiol 2013;26(4):404-8; Vinclair M et al: Duration of adrenal inhibition following a single dose of etomidate in critically ill patients. Int Care Med 2008:34(4):714-9; Wagner CE et al: Etomidate use and postoperative outcomes among cardiac surgery patients. Anesthesiology 2014 Mar;120(3):579-89; Walsh M et al: Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology 2013 Sep;119(3):507-15.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing relevant to disclose. In his lecture, Dr. O’Connor presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. O’Connor spoke at the 68th Annual Postgraduate Assembly in Anesthesiology, held December 12-16, 2014, in New York, NY, and presented by the New York State Society of Anesthesiologists. For information on upcoming CME offerings from the New York State Society of Anesthesiologists, please visit nyssa-pga.org, or visit our website, Audio-Digest.org, and click on “Upcoming Meetings.” The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AN571302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.