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Etomidate during endoscopy provides deeper sedation, less respiratory depression than propofol
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Etomidate showed better sedative efficacy and fewer respiratory depression events than propofol during upper endoscopy procedures in a double-blind randomized controlled trial.
However, myoclonus and increased blood pressure occurred more often during or after procedures with etomidate.
“Although propofol is routinely administered for GI endoscopy, it is associated with several adverse events such as hypoxia, hypotension, arrhythmia, and risk of respiratory depression including apnea,” investigators wrote. “Etomidate, a traditional anesthesia-inducing drug, is an appropriate hypnotic agent with rapid onset (5-15 seconds) and recovery (5-15 minutes). It also leads to minor adverse effects on cardiovascular and respiratory parameters, protects the brain, and does not stimulate a histamine release.”
To compare the safety and efficacy of etomidate vs. propofol during endoscopic ultrasound (EUS), investigators randomly assigned 128 EUS patients to receive either drug. Both patients and endoscopists were masked to which was administered.
Cardiopulmonary adverse events, the primary outcome, occurred in 34.38% of those who received etomidate vs. 51.56% of those who received propofol, which was not a significant difference.
However, those who received etomidate showed significantly lower rates of oxygen desaturation (6.25% vs. 31.25%; P = .001) and respiratory depression (7.81% vs. 32.81%; P = .001).
Additionally, myoclonus occurred significantly more often in those who received etomidate (34.37% vs. 12.5%; P = .012). The investigators also observed that time and sedation group significantly affected systolic blood pressure, which was greater in those who received etomidate.
The investigators also noted that the need for patient restraint was significantly higher in those who received propofol (35.94% vs. 7.81%; P < .001), “despite the frequency of severe cough interfering with endoscopic procedure not being significantly different between the groups.”
Finally, physician satisfaction was greater in the etomidate group, but there was no significant difference in patient satisfaction between groups.
Given its lower respiratory depression rate and better sedative efficacy, “etomidate may be particularly useful in endoscopy centers where an anesthesiologist is unavailable during the endoscopic procedure,” the researchers concluded.
While these data show promise for the use of etomidate in the future, propofol will remain the mainstay for sedation in GI endoscopy until further studies are performed, John J. Vargo, MD, MPH, of the department of gastroenterology and hepatology at the Cleveland Clinic, wrote in a related editorial.
He noted that the numerically lower rate of cardiopulmonary events with etomidate was “tantalizingly close to reaching statistical significance,” and speculated that its superiority may have been shown in a larger sample. Further, he noted that the study included only healthy patients, that no data on nausea and vomiting were provided, and that the fivefold higher need for patient restraint with propofol is “odd, given the fact that the level of targeted sedation was the same. The potential of undersedation and oversedation was not broached by the authors.”
Vargo concluded that it is too soon to replace propofol with etomidate until further research is performed to, for example, study its use in high risk patients, and in other advanced endoscopic procedures. – by Adam Leitenberger
Disclosures: The researchers and Vargo report no relevant financial disclosures.
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