Anesthetic Induction with Etomidate, Rather than Propofol, Is Associated with Increased 30-Day Mortality and Cardiovascular Morbidity After Noncardiac Surgery
Anesthetic Induction with Etomidate, Rather than Propofol, Is Associated with Increased 30-Day Mortality and Cardiovascular Morbidity After Noncardiac Surgery
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DOI：
10.1213/ane.0b013e318299a516
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发表时间：
2013-12-01
影响因子：
5.7
通讯作者：
Turan, Alparslan
中科院分区：
文献类型：
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作者：
Komatsu, Ryu;You, Jing;Turan, Alparslan
背景技术背景：由于依托咪酯损害肾上腺功能，并钝化与手术刺激相关的皮质醇释放，我们假设，依托咪酯诱导的患者遭受更大的死亡率和发病率比可比患者诱导propofol.METHODS：我们评估了31，148阿萨身体状态III和IV的患者在克利夫兰诊所非心脏手术的电子记录。其中，2616例患者使用依托咪酯诱导麻醉并使用挥发性麻醉药维持，而28，532例患者使用丙泊酚诱导并使用挥发性麻醉药维持。2144例给予依托咪酯的患者与5233例给予丙泊酚的患者进行了倾向匹配，并在术后30天死亡率、住院时间、心血管和感染发病率、血管加压药需求和术中血流动力学方面进行了比较。依托咪酯组患者的死亡率是丙泊酚组的2.5倍（98%可信区间[CI]，1.9-3.4）。依托咪酯组的心血管发病率也显著更高（比值比[OR] [98% CI]：1.5 [1.2-2.0]），住院时间显著更长（风险比[95% CI]：0.82 [0.78-0.87]）。然而，感染发病率（OR [98%CI]：1.0 [0.8-1.2]）和术中血管加压药的使用（OR [95%CI] 0.92：[0.82-1.0]）之间没有差异agents.CONCLUSION：依托咪酯与30天死亡率，心血管疾病发病率和住院时间延长的风险大幅增加。我们的结论，特别是30天死亡率，是强大的不可测量的二元混杂变量。尽管我们的研究仅显示依托咪酯的使用与患者预后恶化之间存在关联，但没有因果关系，考虑到诱导时血流动力学稳定性的改善可能伴随着长期预后的显著恶化，临床医生应谨慎使用依托咪酯。
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.