Comparison of the hemodynamic effects of etomidate-midazolam and ketamine-midazolam combinations in anesthesia induction in coronary artery bypass surgery

Öz

Aims: We aimed to compare the effects of anesthesia induction on hemodynamic parameters of ketamine-midazolam or etomidate-midazolam combinations and coronary artery bypass grafting surgery. Material and Methods: 40 adult patients undergoing CABG were randomly allocated into two groups for this prospective randomized double-blinded study. Ketamine group (n = 20) and Etomidate group (n = 20). Intraoperative and postoperative hemodynamic variables, adrenal gland functions and intensive care period were compared after anesthesia induction with etomidate and ketamine. Results: Perioperative hemodynamic parameters were not significantly different between the groups. Despite similar baseline measurements, cortisol levels were significantly higher 5 minutes after induction, during rewarming, and after ACTH stimulation test at postoperative day 1 in group ketamine than group etmidate. The groups were not significantly different in terms of duration of postoperative mechanical ventilation, frequency of postoperative delirium, and intensive care unit and hospital lengths of stay. Conclusion: Ketamine-midazolam combination is an acceptable alternative to etomidate-midazolam combination in terms of hemodynamic stability. Compared with the ketamine-midazolam combination, the etomidate-midazolam combination significantly decreased cortisol levels during the intraoperative and early postoperative periods

Anahtar Kelimeler

• Coronary artery bypass grafting
• hemodynamic instability
• adrenal suppression
• etomidate
• ketamine

KORONER ARTER BYPASS CERRAHİSİNDE ANESTEZİ İNDÜKSİYONUNDA ETOMİDAT-MİDAZOLAM VE KETAMİN-MİDAZOLAM KOMBİNASYONLARININ HEMODİNAMİK ETKİLERİNİN KARŞILAŞTIRILMASI

Öz

Amaç: Ketamin-midazolam veya etomidat-midazolam kombinasyonları ile koroner arter baypas greftleme (KABG) cerrahisinin anestezi indüksiyonunun hemodinamik parametreler üzerindeki etkilerini karşılaştırmayı amaçladık. Gereç ve Yöntemler: KABG cerrahisi uygulanan 40 yetişkin hasta, prospektif randomize çift kör çalışma için rastgele iki gruba ayrıldı. Ketamin grubu (n = 20) ve Etomidat grubu (n = 20). Anestezi indüksiyonu sonrası her iki grupta intraoperatif ve postoperatif hemodinamik değişkenler, adrenal bez fonksiyonları ve yoğun bakım süreci karşılaştırıldı. Bulgular: Perioperatif hemodinamik parametreler gruplar arasında anlamlı farklılık göstermedi. Benzer başlangıç ölçümlerine rağmen kortizol seviyeleri, indüksiyondan 5 dakika sonra, yeniden ısınma sırasında ve postoperatif 1. gün ACTH stimülasyon testinden sonra grup ketaminde, grup etmidata göre anlamlı derecede yüksekti. Gruplar arasında postoperatif mekanik ventilasyon süresi, postoperatif deliryum sıklığı, yoğun bakım ve hastanede kalış süreleri açısından anlamlı fark yoktu. Sonuç: Hemodinamik stabilite açısından ketamin-midazolam kombinasyonu, etomidat-midazolam kombinasyonuna göre kabul edilebilir bir alternatiftir. Ketamin-midazolam kombinasyonu ile karşılaştırıldığında, etomidat-midazolam kombinasyonu, intraoperatif ve erken postoperatif dönemlerde kortizol seviyelerini önemli ölçüde azaltır.

Anahtar Kelimeler

• Koroner arter bypas greftleme,
• hemodinamik instabilite,
• adrenal süpresyon,
• etomidat,
• ketamin

Teşekkür

Çalışmada destek ve katkısı için Prof. Dr. Arash Pirat hocamıza çok teşekkür ederiz.

Kaynakça

1. 1. Baradari AG, Alipour A, Habibi MR, Rashidaei S, Emami Zeydi A: A randomized clinical trial comparing hemodynamic responses to ketamine-propofol combination (ketofol) versus etomidate during anesthesia induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery. Arch Med Sci 2017, 13(5):1102-1110.
2. 2. ÜÇKan İp, LafÇI A, GÖĞÜŞ N: Endovasküler prosedürlerde uygulanan anestezi yöntemlerinin intraoperatif ve postoperatif etkilerinin karşılaştırılması. Turkish Journal of Clinics and Laboratory 2020.
3. 3. Sharda SC, Bhatia MS: Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022, 26(1):108-113.
4. 4. Tichkule S: A COMPARATIVE STUDY ON THE HEMODYNAMIC EFFECTS OF PROPOFOL AND ETOMIDATE USED AS INDUCING AGENTS IN GENERAL ANAESTHESIA.
5. 5. Velásquez JA, Rodríguez J, Higuita-Gutiérrez L, Vergara MM: A systematic review and meta-analysis of the hemodynamic effects of etomidate versus other sedatives in patients undergoing rapid sequence intubation. Revista Española de Anestesiología y Reanimación (English Edition) 2022.
6. 6. Gregers MCT, Mikkelsen S, Lindvig KP, Brøchner AC: Ketamine as an anesthetic for patients with acute brain injury: a systematic review. Neurocritical care 2020, 33(1):273-282.
7. 7. Loomba RS, Care CI: Hemodynamic effects of ketamine in children with congenital heart disease and/or pulmonary hypertension.
8. 8. Jor O, Maca J, Koutna J, Gemrotova M, Vymazal T, Litschmannova M, et al: Hypotension after induction of general anesthesia: occurrence, risk factors, and therapy. A prospective multicentre observational study. J Anesth 2018, 32(5):673-680.

9. 9. Khan A, Fischer M, Pedoto A, Seier K, Tan K, Dalbagni G, et al: The impact of fluid optimisation before induction of anaesthesia on hypotension after induction. Anaesthesia 2020, 75(5):634-641.
10. 10. Daşkaya H, Uzman S: Comparison of the hemodynamic effects of etomidate between hypertensive and normotensive patients. Journal of Clinical and Experimental Investigations 2014, 5:164-168.
11. 11. Raffa GM, Agnello F, Occhipinti G, Miraglia R, Lo Re V, Marrone G, et al: Neurological complications after cardiac surgery: a retrospective case-control study of risk factors and outcome. J Cardiothorac Surg 2019, 14(1):23.
12. 12. Nega MH, Ahmed SA, Tawuye HY, Mustofa SY: Incidence and factors associated with post-induction hypotension among adult surgical patients: Prospective follow-up study. International Journal of Surgery Open 2022, 49:100565.
13. 13. Reich DL, Bodian CA, Krol M, Kuroda M, Osinski T, Thys DM: Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery. Anesthesia & Analgesia 1999, 89(4):814.
14. 14. Wagner RL, White PF: Etomidate inhibits adrenocortical function in surgical patients. Anesthesiology 1984, 61(6):647-651.
15. 15. Duthie D, Fraser R, Nimmo W: Effect of induction of anaesthesia with etomidate on corticosteroid synthesis in man. British Journal of Anaesthesia 1985, 57(2):156-159.
16. 16. Annane D, Bellissant E, Bollaert P-E, Briegel J, Confalonieri M, De Gaudio R, et al: Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. Jama 2009, 301(22):2362-2375.
17. 17. Sarda BG, Raipure AM, Ruparel DH: Serum cortisol levels with etomidate induction: A speculation that needs to be reviewed. Anesthesia, Essays and Researches 2021, 15(3):312.
18. 18. Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, et al: Hydrocortisone therapy for patients with septic shock. New England Journal of Medicine 2008, 358(2):111-124.
19. 19. Levett D, Grimmett C: Psychological factors, prehabilitation and surgical outcomes: evidence and future directions. Anaesthesia 2019, 74:36-42.
20. 20. Morel J, Salard M, Castelain C, Bayon M, Lambert P, Vola M, et al: Haemodynamic Consequences of Etomidate Administration in Elective Cardiac Surgery: A Randomized Double-Blinded Study. Survey of Anesthesiology 2012, 56(4):162-163.
21. 21. De Gregorio D, Aguilar-Valles A, Preller KH, Heifets BD, Hibicke M, Mitchell J, et al: Hallucinogens in mental health: preclinical and clinical studies on LSD, psilocybin, MDMA, and ketamine. Journal of Neuroscience 2021, 41(5):891-900.