The Effects of Etomidate and Propofol Induction on Hemodynamic and Endocrine Response Undergoing CABG Surgery

Abstract

Objectives: Effects of propofol and etomidate induction on hemodynamic and endocrine stress response in patients undergoing elective coronary artery bypass graft (CABG) surgery were investigated in this study. Patients and Methods: After the approval of the local ethics committee was obtained, forty, American Society of Anesthesiologists (ASA) status II-III patients undergoing scheduled coronary artery bypass surgery were enrolled in the study. Patients were allocated randomly to receive either propofol or etomidate for anesthesia induction. Anesthesia was maintained in both groups with 1% isoflurane, 50% nitrous oxide and 50% oxygen. Results: Hemodynamically, Group E was more stable than Group P following induction of anesthesia (p<0.05). There were no significant differences between the groups in terms of glucose response. There was a significant difference in Adrenocorticotropic hormone (ACTH) levels between the groups in control and t4 measurements (p<0.05). In group P, levels of blood cortisol significantly decreased after induction (p<0.05) but increased with Cardio Pulmonary By-pass (CPB). In group E, significant decrements ase in cortisol levels continued also during CPB, (p<0.05). Conclusion: Etomidate may be preferred to propofol for the induction of anesthesia in CABG because of its hemodynamic stability. Etomidate inhibited cortisol secretion temporarily and this inhibition may be useful to prevent stress response due to CABG surgery. Turkish Başlık: KABG Cerrahisinde Etomidat ve Propofol İndüksiyonunun Hemodinamik ve Endokrin Yanıt Üzerine Etkileri Anahtar Kelimeler: Anestezikler; propofol; etomidat; KABG; stres yanıt; kortizol Amaç: Bu çalışmada elektif koroner arter baypas grefti (KABG) planlanan hastalarda, propofol ve etomidatla indüksiyonun hemodinamik ve endokrin stres yanıt üzerine etkileri araştırıldı. Hastalar ve Yöntemler: Hastane etik kurul onayı alındı ktan sonra, American Society of Anesthesiologists (ASA) II-III statüsünde elektif koroner arter baypas cerrahisi yapılacak 40 hasta çalışmaya alındı. Hastalar anestezi indüksiyonunda propofol (grup P) veya etomidat (grup E) alacak şekilde rastgele iki gruba ayrıldı. Anestezi idamesi %1 izofloran, %50 azotropotoksit, %50 oksijenle yapıldı. Bulgular: Grup E anestezi indüksiyondan itibaren hemodinamik açıdan grup P'den daha stabil seyretti (p<0.05). İki grupta glukoz yanıtı açısından anlamlı bir fark yoktu. Adrenokortikotrop hormon (ACTH) seviyesinde kontrol ve t4 ölçümlerinde iki grup arasında anlamlı fark olduğu görüldü (p<0.05). Kan kortizol seviyesi grup P'de indüksiyondan sonra kontrol değerine göre anlamlı olarak azaldı (p<0.05) fakat kardiyopulmoner baypasla (KPB) yükseldi. Grup E'de KPB süresince de anlamlı olarak düşmeye devam etti (p<0.05). Sonuç: Etomidat KABG'de anestezi indüksiyonunda sağladığı hemodinamik stabilite nedeniyle propofole tercih edilebilir. Etomidat geçici bir süreyle kortizol sekresyonunda inhibisyona neden olmuştur, bu inhibisyon KABG'ye bağlı stres yanıtın önlenmesinde faydalı olabilir.

Keywords

• Anaesthetics; propofol; etomidate; CABG; stress response; cortisol

KABG Cerrahisinde Etomidat ve Propofol İndüksiyonunun Hemodinamik ve Endokrin Yanıt Üzerine Etkileri

Öz

Amaç: Bu çalışmada elektif koroner arter baypas grefti (KABG) planlanan hastalarda, propofol ve etomidatla indüksiyonun hemodinamik ve endokrin stres yanıt üzerine etkileri araştırıldı. Hastalar ve Yöntemler: Hastane etik kurul onayı alındıktan sonra, American Society of Anesthesiologists (ASA) II-III statüsünde elektif koroner arter baypas cerrahisi yapılacak 40 hasta çalışmaya alındı. Hastalar anestezi indüksiyonunda propofol (grup P) veya etomidat (grup E) alacak şekilde rastgele iki gruba ayrıldı. Anestezi idamesi %1 izofloran, %50 azotropotoksit, %50 oksijenle yapıldı. Bulgular: Grup E anestezi indüksiyondan itibaren hemodinamik açıdan grup P’den daha stabil seyretti (p < 0.05). İki grupta glukoz yanıtı açısından anlamlı bir fark yoktu. Adrenokortikotrop hormon (ACTH) seviyesinde kontrol ve t4 öl- çümlerinde iki grup arasında anlamlı fark olduğu görüldü (p < 0.05). Kan kortizol seviyesi grup P’de indüksiyondan sonra kontrol değerine göre anlamlı olarak azaldı (p < 0.05) fakat kardiyopulmoner baypasla (KPB) yükseldi. Grup E’de KPB süresince de anlamlı olarak düşmeye devam etti (p < 0.05). Sonuç: Etomidat KABG’de anestezi indüksiyonunda sağladığı hemodinamik stabilite nedeniyle propofole tercih edilebilir. Etomidat geçici bir süreyle kortizol sekresyonunda inhibisyona neden olmuştur, bu inhibisyon KABG’ye bağlı stres yanıtın önlenmesinde faydalı olabilir.

Anahtar Kelimeler

• Anestezikler, propofol, etomidat, KABG, stres yanıt, kortizol

References

1. Liem TH, Booij LH, Gielen MJ, Hasenbos MA, van Egmond J. Coronary artery bypass grafting using two different anesthetic techniques: Part 3: Adrenergic responses. J Cardiothorac Vasc Anesth 1992;6:162-7.
2. Kirno K, Friberg P, Grzegorczyk A, Milocco I, Ricksten SE, Lundin S. Thoracic epidural anesthesia during coronary artery bypass surgery: effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg 1994;79:1075-81.
3. Reves JG, Karp RB, Buttner EE, Tosone S, Smith LR, Samuelson PN, et al. Neuronal and adrenomedul- lary catecholamine release in response to cardiopul- monary bypass in man. Circulation 1982;66:49-55.
4. Liem TH, Hasenbos MA, Booij LH, Gielen MJ. Coronary artery bypass grafting using two different anesthetic techniques: Part 2: Postoperative out- come. J Cardiothorac Vasc Anesth 1992;6:156-61.
5. Mangano DT, Siliciano D, Hollenberg M, Leung JM, Browner WS, Goehner P, et al. Postoperative myocardial ischemia. Therapeutic trials using inten- sive analgesia following surgery. The Study of Perioperative Ischemia (SPI) Research Group. Anesthesiology 1992;76:342-53.
6. Anand KJ, Hickey PR. Halothane-morphine com- pared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326:1-9.
7. Kayhan Z. Klinik anestezi. İstanbul: Logos Yayıncı- lık. 1997.
8. Pagel PS, Warltier DC. Negative inotropic effects of propofol as evaluated by the regional preload recruitable stroke work relationship in chronically instrumented dogs. Anesthesiology 1993;78:100-8.

9. Wagner RL, White PF, Kan PB, Rosenthal MH, Feldman D. Inhibition of adrenal steroidogenesis by the anesthetic etomidate. N Engl J Med 1984; 310:1415-21.
10. Duthie DJ, Fraser R, Nimmo WS. Effect of induction of anaesthesia with etomidate on corticosteroid syn- thesis in man. Br J Anaesth 1985;57:156-9.
11. Hoar PF, Stone JG, Faltas AN, Bendixen HH, Head RJ, Berkowitz BA. Hemodynamic and adrenergic responses to anesthesia and operation for myocar- dial revascularization. J Thorac Cardiovasc Surg 1980;80:242-8.
12. Gerhardt MA, Booth JV, Chesnut LC, Funk BL, el- Moalem HE, Kwatra MM, et al. Acute myocardial beta-adrenergic receptor dysfunction after car- diopulmonary bypass in patients with cardiac valve disease. Duke Heart Center Perioperative Desensitization Group. Circulation 1998;98(19 Suppl):II275-81.
13. Loick HM, Schmidt C, Van Aken H, Junker R, Erren M, Berendes E, et al. High thoracic epidural anesthe- sia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coro- nary artery bypass grafting. Anesth Analg 1999; 88:701-9.
14. Williams JP, McArthur JD, Walker WE. A compari- son of the hemodynamics of diprivan (propofol), thiopental and etomidate for induction of anesthesia In patients with coronary artery disease. Semin Anesth 1988;7(suppl 11):112-5.
15. Patrick MR, Blair IJ, Feneck RO, Sebel PS. A compari- son of the haemodynamic effects of propofol (Diprivan) and thiopentone in patients with coronary artery disease. Postgrad Med J 1985;61 Suppl 3:23-7.
16. Stephan H, Sonntag H, Schenk HD, Kettler D, Khambatta HJ. Effects of propofol on cardiovascular dynamics, myocardial blood flow and myocardial metabolism in patients with coronary artery disease. Br J Anaesth 1986;58:969-75.
17. Al-Khudhairi D, Gordon G, Morgan M, Whitwam JG. Acute cardiovascular changes following diso- profol. Effects in heavily sedated patients with coro- nary artery disease. Anaesthesia 1982;37:1007-10.
18. Kling D, Laubenthal H, Borner U, Boldt J, Hempelmann G. Comparative hemodynamic study of anesthesia induction with propofol (Diprivan), thiopental, methohexital, etomidate and midazolam in patients with coronary disease. Anaesthesist 1987;36:541-7. [Abstract]
19. Wang JY, Winship SM, Thomas SD, Gin T, Russell GN. Induction of anaesthesia in patients with coro- nary artery disease: a comparison between sevoflu- rane-remifentanil and fentanyl-etomidate. Anaesth Intensive Care 1999;27:363-8.
20. Haessler R, Madler C, Klasing S, Schwender D, Peter K. Propofol/fentanyl versus etomidate/fentanyl for the induction of anesthesia in patients with aortic insufficiency and coronary artery disease. J Cardiothorac Vasc Anesth 1992;6:173-80.
21. Seitz W, Lubbe N, Schaps D, Haverich A, Kirchner E. Propofol for induction and maintenance of anesthe- sia during heart surgery. Results of pharmacological studies in man. Anaesthesist 1991;40:145-52. [Abstract]
22. Criado A, Maseda J, Navarro E, Escarpa A, Avello F. Induction of anaesthesia with etomidate: haemody- namic study of 36 patients. Br J Anaesth 1980;52:803-6.
23. Jain U, Body SC, Bellows W, Wolman R, Mangano CM, Mathew J, et al. Multicenter study of target-con- trolled infusion of propofol-sufentanil or sufentanil- midazolam for coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Anesthesiology 1996; 85:522-35.
24. Taylor KM, Wright GS, Reid JM, Bain WH, Caves PK, Walker MS, et al. Comparative studies of pul- satile and nonpulsatile flow during cardiopul- monary bypass. II. The effects on adrenal secretion of cortisol. J Thorac Cardiovasc Surg 1978;75:574-8.
25. Taylor KM, Jones JV, Walker MS, Rao S, Bain WH. The cortisol response during heart-lung bypass. Circulation 1976;54:20-5.
26. Flezzani P, Croughwell ND, McIntyre RW, Reves JG. Isoflurane decreases the cortisol response to car- diopulmonary bypass. Anesth Analg 1986;65:1117-22.
27. Lacoumenta S, Yeo TH, Paterson JL, Burrin JM, Hall GM. Hormonal and metabolic responses to cardiac surgery with sufentanil-oxygen anaesthesia. Acta Anaesthesiol Scand 1987;31:258-63.
28. Helman J, Browner W, Li J, Mangano D. Prognostic importance of preoperative hypertension. Anesthe- siology 1991;75:A110.
29. Roizen MF, Lampe GH, Benefiel DJ. Is increased operative stres associated with worse outcome? Anesthesiology 1987;67:A1.
30. Dönmez A, Kaya H, Haberal A, Kutsal A, Arslan G. The effect of etomidate induction on plasma cortisol levels in children undergoing cardiac surgery. J Cardiothorac Vasc Anesth 1998;12:182-5.
31. Crozier TA, Schlaeger M, Wuttke W, Kettler D. TIVA with etomidate-fentanyl versus midazolam-fen- tanyl. The perioperative stress of coronary surgery overcomes the inhibition of cortisol synthesis caused by etomidate-fentanyl anesthesia. Anaesthesist 1994; 43:605-13. [Abstract]
32. Fragen RJ, Weiss HW, Molteni A. The effect of propofol on adrenocortical steroidogenesis: a com- parative study with etomidate and thiopental. Anesthesiology 1987;66:839-42.
33. Reves JG, Glass SA, Lubarsky DA. Nonbarbiturate intravenous anesthetics. In: Miller RD, editor. Anest- hesia. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 228-72.
34. Kenyon CJ, McNeil LM, Fraser R. Comparison of the effects of etomidate, thiopentone and propofol on cortisol synthesis. Br J Anaesth 1985;57:509-11.
35. Lambert A, Mitchell R, Robertson WR. Effect of propofol, thiopentone and etomidate on adrenal steroidogenesis in vitro. Br J Anaesth 1985;57:505-8.
36. O’Flaherty D, Catania A, Krishnan S, Giesecke AH, Lipton JM. Total intravenous anesthesia with propo- fol profoundly inhibits cortisol response to stress. Anesth Analg 1992;74:S368:S223.
37. NG A, Tan SS, Lee HS, Chew SL. Effect of propofol infusion on the endocrine response to cardiac surgery. Anaesth Intensive Care 1995;23:543-7.
38. Myles PS, Buckland MR, Morgan DJ, Weeks AM. Serum lipid and glucose concentrations with a propofol infusion for cardiac surgery. J Cardiothorac Vasc Anesth 1995;9:373-8.
39. Schricker T, Carli F, Schreiber M, Wachter U, Geisser W, Lattermann R, et al. Propofol/sufentanil anesthe- sia suppresses the metabolic and endocrine response during, not after, lower abdominal surgery. Anesth Analg 2000;90:450-5.
40. Moore RA, Allen MC, Wood PJ, Rees LH, Sear JW. Peri-operative endocrine effects of etomidate. Anaesthesia 1985;40:124-30.