Etomidate anesthesia was noninferior to propofol for major in-hospital postoperative complications in older patients undergoing abdominal surgery (9.3% vs 8.7%; RD 0.6%; 95% CI -1.6% to 2.7%).
RCT (n=1,944)
Double-blind
1:1
Yes
Does etomidate compared to propofol for general anesthesia prevent major in-hospital postoperative complications in older patients undergoing elective abdominal surgery?
Etomidate is noninferior to propofol for major in-hospital postoperative complications in older patients undergoing abdominal surgery, though it is associated with transient adrenocortical suppression and increased pneumonia risk.
Effect estimate: RD 0.6% (95% CI -1.6 to 2.7)
Absolute Event Rate: 9.3% vs 8.7%
p-value: p=.66
Importance: Older patients may benefit from the hemodynamic stability of etomidate for general anesthesia. However, it remains uncertain whether the potential for adrenocortical suppression with etomidate may increase morbidity. Objective: To test the primary hypothesis that etomidate vs propofol for anesthesia does not increase in-hospital morbidity after abdominal surgery in older patients. Design, Setting, and Participants: This multicenter, parallel-group, noninferiority randomized clinical trial (Etomidate vs Propofol for In-hospital Complications EPIC) was conducted between August 15, 2017, and November 20, 2020, at 22 tertiary hospitals in China. Participants were aged 65 to 80 years and were scheduled for elective abdominal surgery. Patients and outcome assessors were blinded to group allocation. Data analysis followed a modified intention-to-treat principle. Interventions: Patients were randomized 1:1 to receive either etomidate or propofol for general anesthesia by target-controlled infusion. Main Outcomes and Measures: Primary outcome was a composite of major in-hospital postoperative complications (with a noninferiority margin of 3%). Secondary outcomes included intraoperative hemodynamic measurements; postoperative adrenocortical hormone levels; self-reported postoperative pain, nausea, and vomiting; and mortality at postoperative months 6 and 12. Results: A total of 1944 participants were randomized, of whom 1917 (98.6%) completed the trial. Patients were randomized to the etomidate group (n = 967; mean SD age, 70.3 4.0 years; 578 men 59.8%) or propofol group (n = 950; mean SD age, 70.6 4.2 years; 533 men 56.1%). The primary end point occurred in 90 of 967 patients (9.3%) in the etomidate group and 83 of 950 patients (8.7%) in the propofol group, which met the noninferiority criterion (risk difference RD, 0.6%; 95% CI, -1.6% to 2.7%; P = .66). In the etomidate group, mean (SD) cortisol levels were lower at the end of surgery (4.8 2.7 μg/dL vs 6.1 3.4 μg/dL; P < .001), and mean (SD) aldosterone levels were lower at the end of surgery (0.13 0.05 ng/dL vs 0.15 0.07 ng/dL; P = .02) and on postoperative day 1 (0.14 0.04 ng/dL vs 0.16 0.06 ng/dL; P = .001) compared with the propofol group. No difference in mortality was observed between the etomidate and propofol groups at postoperative month 6 (2.2% vs 3.0%; RD, -0.8%; 95% CI, -2.2% to 0.7%) and 12 (3.3% vs 3.9%; RD, -0.6%; 95% CI, -2.3% to 1.0%). More patients had pneumonia in the etomidate group than in the propofol group (2.0% vs 0.3%; RD, 1.7%; 95% CI, 0.7% to 2.8%; P = .001). Results were consistent in the per-protocol population. Conclusions and Relevance: Results of this trial showed that, compared with propofol, etomidate anesthesia did not increase overall major in-hospital morbidity after abdominal surgery in older patients, although it induced transient adrenocortical suppression. Trial Registration: ClinicalTrials.gov Identifier: NCT02910206.
Lu et al. (Wed,) conducted a rct in elective abdominal surgery (n=1,944). Etomidate vs. Propofol was evaluated on composite of major in-hospital postoperative complications (RD 0.6%, 95% CI -1.6 to 2.7, p=.66). Etomidate anesthesia was noninferior to propofol for major in-hospital postoperative complications in older patients undergoing abdominal surgery (9.3% vs 8.7%; RD 0.6%; 95% CI -1.6% to 2.7%).