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Propofol Not the only real Option for Abdominal Surgery Anesthesia in Seniors

Older patients who received anesthesia with etomidate had no higher threat of major complications after elective abdominal surgery in comparison to propofol, a randomized trial found.

Among 1,917 such patients, rates of major in-hospital morbidity were 9.3% with etomidate versus 8.7% with propofol within an intention-to-treat analysis. The chance difference of 0.6% (95% CI -1.6% to 2.7%) easily met the prespecified margin of non-inferiority of 3%, in accordance with Lize Xiong, MD, PhD, of the Shanghai Fourth People’s Hospital in China, and colleagues.

However, etomidate did result in transient adrenal suppression, as evidenced by lower mean cortisol levels by the end of surgery (4.8 vs 6.1 g/dL, P<0.001), the investigators wrote in JAMA Surgery.

Additionally, the etomidate group had lower aldosterone levels in accordance with propofol:

  • By the end of surgery: 0.13 vs 0.15 ng/dL
  • Post-operative day one: 0.14 vs 0.16 ng/dL

Etomidate might be a better option for anesthesia induction the type of at risky for perioperative morbidity and mortality because of hemodynamic stability, but there were concerns surrounding its effect on relative adrenal insufficiency, Xiong’s group noted. This is actually the first study to judge the impact of etomidate on adrenal suppression and complications among older patients after surgery.

“Propofol may be the most typical IV [intravenous] anesthesia medication useful for general anesthesia in conjunction with analgesia and neuromuscular blockade,” Jason Johanning, MD, MS, of the University of Nebraska INFIRMARY in Omaha, stated within an accompanying editorial. “But propofol is definately not perfect having an adverse effect profile having significant influence on cardiovascular parameters, including reduced blood circulation pressure and elevated heartrate.”

Because of this single-blind trial, called EPIC, Xiong and colleagues enrolled patients age 65-80 scheduled for abdominal surgery with total intravenous anesthesia, randomizing 967 to get etomidate (mean age 70.3, 60% men) and 950 to propofol (mean age 70.6; 56% men). Surgeries were performed in 22 Chinese hospitals from August 2017 to November 2020.

Mean BMI among participants was 23. Nearly three-quarters had an American Society of Anesthesiologists physical status class of 2. More underwent gastrointestinal surgery (59-60%) than hepatobiliary surgery (40-41%) having an average duration of 2 hours. Average anesthesia duration was about 2.5 hours.

General anesthesia was administered with a target-controlled titrated infusion, with target plasma concentrations during surgery set at 0.5-0.8 g/mL for etomidate induction and 0.2-0.4 g/mL for maintenance. For both induction and maintenance, the prospective plasma concentration for propofol was 2-4 g/mL. Additionally, both groups also received sufentanil (Dsuvia) and cisatracurium (Nimbex). Patients may possibly also receive nicardipine or norepinephrine to regulate blood circulation pressure, if needed.

More etomidate patients developed pneumonia (2.0% vs 0.3%). Pulmonary complications were the only real significantly greater in-hospital complication on the list of etomidate group (19% vs 5%). A prior study, however, found no link between etomidate and pneumonia, leading Xiong and colleagues to create, “Collective evidence supports cautious usage of etomidate infusion in patients at an increased risk for pulmonary complications.”

Etomidate patients experienced more hypertension (3.8% vs 10.3%), but less hypotension (10.5% vs 2.4%) and consistently higher diastolic blood circulation pressure, except at 120 minutes after incision.

No factor in mortality was seen at six months (2.2% with etomidate vs 3.0% with propofol) and 12 months after surgery (3.3% vs 3.9%).

Nor have there been any significance differences in postoperative nausea/vomiting scores of 3 or more or pain around 3 days later.

“The EPIC trial offers a solid basis for etomidate as another agent to take into account for total IV anesthesia,” Johanning wrote. “The caveat may be the trial was performed in and the outcomes should be put on normal-risk patients of older age.”

Xiong’s group acknowledged limitations to the info. Findings might not be generalizable to surgeries lasting around 4 hours or even to patients beyond China. Also, frequency and duration of events linked to abnormal blood circulation pressure weren’t evaluated, the researchers stated.

  • author['full_name']

    Zaina Hamza is really a staff writer for MedPage Today, covering Gastroenterology and Infectious disease. She actually is located in Chicago.

Disclosures

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

Study authors and the editorialist declared that they had no relevant financial interests.

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