Advertisement

Etomidate versus propofol sedation for complex upper endoscopic procedures: a prospective double-blinded randomized controlled trial

  • Mi Gang Kim
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
  • Se Woo Park
    Correspondence
    Reprint requests: Professor Se Woo Park, Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea.
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
  • Jae Hyun Kim
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
  • Jin Lee
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
  • Sea Hyub Kae
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
  • Hyun Joo Jang
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
  • Dong Hee Koh
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
  • Min Ho Choi
    Affiliations
    Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
    Search for articles by this author
Published:March 08, 2017DOI:https://doi.org/10.1016/j.gie.2017.02.033

      Background and Aims

      Although a growing body of evidence demonstrates that propofol-induced deep sedation can be effective and performed safely, cardiopulmonary adverse events have been observed frequently. Etomidate is a new emerging drug that provides hemodynamic and respiratory stability, even in high-risk patient groups. The objective of this study was to compare safety and efficacy profiles of etomidate and propofol for endoscopic sedation.

      Methods

      A total of 128 patients undergoing EUS were randomized to receive either etomidate or propofol blinded administered by a registered nurse. The primary outcome was the proportion of patients with any cardiopulmonary adverse events.

      Results

      Overall cardiopulmonary adverse events were identified in 22 patients (34.38%) of the etomidate group and 33 patients (51.56%) of the propofol group, without significant difference (P = .074). However, the incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%]; P =.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%]; P =.001) was significantly lower in the etomidate group than in the propofol group. The frequency of myoclonus was significantly higher in the etomidate group (22/64 [34.37%]) compared with the propofol group (8/64 [12.50%]) (P =.012). Repeated measure analysis of variance revealed significant effects of sedation group and time on systolic blood pressure (etomidate group greater than propofol group). Physician satisfaction was greater in the etomidate group than in the propofol group.

      Conclusions

      Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. (Clinical trial registration number: KCT0001701.)

      Abbreviations:

      ASA (American Society of Anesthesiologists Physical Status Classification System), MOAAS (Modified Observer's Assessment of Alertness/Sedation Scale), SpO2 (pulse oximetry)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rex D.K.
        • Khalfan H.K.
        Sedation and the technical performance of colonoscopy.
        Gastrointest Endosc Clin N Am. 2005; 15: 661-672
        • Sipe B.W.
        • Rex D.K.
        • Latinovich D.
        • et al.
        Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists.
        Gastrointest Endosc. 2002; 55: 815-825
        • Vargo J.J.
        • Zuccaro Jr., G.
        • Dumot J.A.
        • et al.
        Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial.
        Gastroenterology. 2002; 123: 8-16
        • McQuaid K.R.
        • Laine L.
        A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures.
        Gastrointest Endosc. 2008; 67: 910-923
        • Wang D.
        • Chen C.
        • Chen J.
        • et al.
        The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis.
        PloS one. 2013; 8: e53311
        • Bergen J.M.
        • Smith D.C.
        A review of etomidate for rapid sequence intubation in the emergency department.
        J Emerg Med. 1997; 15: 221-230
        • Guldner G.
        • Schultz J.
        • Sexton P.
        • et al.
        Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events.
        Acad Emerg Med. 2003; 10: 134-139
        • Zed P.J.
        • Abu-Laban R.B.
        • Harrison D.W.
        Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study.
        Acad Emerg Med. 2006; 13: 378-383
        • Oglesby A.J.
        Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department?.
        Emerg Med J. 2004; 21: 655-659
        • Eames W.O.
        • Rooke G.A.
        • Wu R.S.
        • et al.
        Comparison of the effects of etomidate, propofol, and thiopental on respiratory resistance after tracheal intubation.
        Anesthesiology. 1996; 84: 1307-1311
        • Dewitt J.
        • McGreevy K.
        • Sherman S.
        • et al.
        Nurse-administered propofol sedation compared with midazolam and meperidine for EUS: a prospective, randomized trial.
        Gastrointest Endosc. 2008; 68: 499-509
        • Samsoon G.L.
        • Young J.R.
        Difficult tracheal intubation: a retrospective study.
        Anaesthesia. 1987; 42: 487-490
        • Fellows I.W.
        • Bastow M.D.
        • Byrne A.J.
        • et al.
        Adrenocortical suppression in multiply injured patients: a complication of etomidate treatment.
        Brit Med J. 1983; 287: 1835-1837
        • Wagner R.L.
        • White P.F.
        • Kan P.B.
        • et al.
        Inhibition of adrenal steroidogenesis by the anesthetic etomidate.
        New Engl J Med. 1984; 310: 1415-1421
        • Rex D.K.
        • Overley C.A.
        • Walker J.
        Registered nurse-administered propofol sedation for upper endoscopy and colonoscopy: Why? When? How?.
        Rev Gastroenterol Disord. 2003; 3: 70-80
        • Miner J.R.
        • Danahy M.
        • Moch A.
        • et al.
        Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department.
        Ann Emerg Med. 2007; 49: 15-22
        • Kiriyama S.
        • Gotoda T.
        • Sano H.
        • et al.
        Safe and effective sedation in endoscopic submucosal dissection for early gastric cancer: a randomized comparison between propofol continuous infusion and intermittent midazolam injection.
        J Gastroenterol. 2010; 45: 831-837
        • American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists
        Practice guidelines for sedation and analgesia by non-anesthesiologists.
        Anesthesiology. 2002; 96: 1004-1017
        • Ho W.M.
        • Yen C.M.
        • Lan C.H.
        • et al.
        Comparison between the recovery time of alfentanil and fentanyl in balanced propofol sedation for gastrointestinal and colonoscopy: a prospective, randomized study.
        BMC Gastroenterology. 2012; 12: 164
        • Faught E.
        Clinical presentations and phenomenology of myoclonus.
        Epilepsia. 2003; 44: 7-12
        • Doenicke A.W.
        • Roizen M.F.
        • Kugler J.
        • et al.
        Reducing myoclonus after etomidate.
        Anesthesiology. 1999; 90: 113-119
        • Cohen L.B.
        • Hightower C.D.
        • Wood D.A.
        • et al.
        Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam.
        Gastrointest Endosc. 2004; 59: 795-803
        • Riphaus A.
        • Geist C.
        • Schrader K.
        • et al.
        Intermittent manually controlled versus continuous infusion of propofol for deep sedation during interventional endoscopy: a prospective randomized trial.
        Scand J Gastroenterol. 2012; 47: 1078-1085
        • Lee C.K.
        • Lee S.H.
        • Chung I.K.
        • et al.
        Balanced propofol sedation for therapeutic GI endoscopic procedures: a prospective, randomized study.
        Gastrointest Endosc. 2011; 73: 206-214
        • Shin S.
        • Lee S.K.
        • Min K.T.
        • et al.
        Sedation for interventional gastrointestinal endoscopic procedures: Are we overlooking the “pain”?.
        Surg Endosc. 2014; 28: 100-107
        • Park C.H.
        • Shin S.
        • Lee S.K.
        • et al.
        Assessing the stability and safety of procedure during endoscopic submucosal dissection according to sedation methods: a randomized trial.
        PloS one. 2015; 10: e0120529
        • Lee T.H.
        • Lee C.K.
        • Park S.H.
        • et al.
        Balanced propofol sedation versus propofol monosedation in therapeutic pancreaticobiliary endoscopic procedures.
        Dig Dis Sci. 2012; 57: 2113-2121
        • Donmez A.
        • Kaya H.
        • Haberal A.
        • et al.
        The effect of etomidate induction on plasma cortisol levels in children undergoing cardiac surgery.
        J Cardiothorac Vasc Anesth. 1998; 12: 182-185
        • Möller Petrun A.
        • Kamenik M.
        Bispectral index-guided induction of general anaesthesia in patients undergoing major abdominal surgery using propofol or etomidate: a double-blind, randomized, clinical trial.
        Br J Anaesth. 2013; 110: 388-396
        • Bendel S.
        • Ruokonen E.
        • Polonen P.
        • et al.
        Propofol causes more hypotension than etomidate in patients with severe aortic stenosis: a double-blind, randomized study comparing propofol and etomidate.
        Acta Anaesthesiol Scand. 2007; 51: 284-289
        • Toklu S.
        • Iyilikci L.
        • Gonen C.
        • et al.
        Comparison of etomidate-remifentanil and propofol-remifentanil sedation in patients scheduled for colonoscopy.
        Eur J Anaesthesiol. 2009; 26: 370-376
        • Falk J.
        • Zed P.J.
        Etomidate for procedural sedation in the emergency department.
        Ann Pharmacother. 2004; 38: 1272-1277
        • Huter L.
        • Schreiber T.
        • Gugel M.
        • et al.
        Low-dose intravenous midazolam reduces etomidate-induced myoclonus: a prospective, randomized study in patients undergoing elective cardioversion.
        Anesth Analg. 2007; 105: 1298-1302
        • Schwarzkopf K.R.
        • Hueter L.
        • Simon M.
        • et al.
        Midazolam pretreatment reduces etomidate-induced myoclonic movements.
        Anaesth Intensive Care. 2003; 31: 18-20
        • Hwang J.Y.
        • Kim J.H.
        • Oh A.Y.
        • et al.
        A comparison of midazolam with remifentanil for the prevention of myoclonic movements following etomidate injection.
        J Int Med Res. 2008; 36: 17-22
        • Choi J.M.
        • Choi I.C.
        • Jeong Y.B.
        • et al.
        Pretreatment of rocuronium reduces the frequency and severity of etomidate-induced myoclonus.
        J Clin Anesth. 2008; 20: 601-604
        • Song J.C.
        • Sun Y.M.
        • Zhang M.Z.
        • et al.
        The etomidate requirement is decreased in patients with obstructive jaundice.
        Anesth Analg. 2011; 113: 1028-1032
        • Modica P.A.
        • Tempelhoff R.
        Intracranial pressure during induction of anaesthesia and tracheal intubation with etomidate-induced EEG burst suppression.
        Can J Anaesth. 1992; 39: 236-241
        • Moss E.
        • Powell D.
        • Gibson R.M.
        • et al.
        Effect of etomidate on intracranial pressure and cerebral perfusion pressure.
        Brit J Anaesth. 1979; 51: 347-352
        • Kulka P.J.
        • Bremer F.
        • Schuttler J.
        Anesthesia induction using etomidate in a lipid emulsion [in German].
        Der Anaesthesist. 1993; 42: 205-209
        • Absalom A.
        • Pledger D.
        • Kong A.
        Adrenocortical function in critically ill patients 24 h after a single dose of etomidate.
        Anaesthesia. 1999; 54: 861-867
        • Fragen R.J.
        • Shanks C.A.
        • Molteni A.
        • et al.
        Effects of etomidate on hormonal responses to surgical stress.
        Anesthesiology. 1984; 61: 652-656
      1. Effect on plasma cortisol concentrations of a single induction dose of etomidate or thiopentone.
        Lancet. 1983; 2: 625-626
        • Du Y.
        • Chen Y.J.
        • He B.
        • et al.
        The effects of single-dose etomidate versus propofol on cortisol levels in pediatric patients undergoing urologic surgery: a randomized controlled trial.
        Anesth Analg. 2015; 121: 1580-1585