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Which anesthetic do some doctors say is more risky?

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A new large study reports an increased risk of death in patients receiving etomidate for anesthesia. Patients receiving the widely used anesthesia drug etomidate for surgery may be at increased risk for mortality and cardiovascular events, according to an editorial published in the December 2013 issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS). The editorial is about the new study, says a December 13, 2013 news release, "New concerns over safety of common anesthetic."

The study adds to safety concerns over etomidate's use as an anesthetic and sedative drug. "There is accumulating evidence for an association between mortality and etomidate use, both in critically ill patients and now in [non-critically ill] patients undergoing noncardiac surgery," according to an editorial by Drs Matthieu Legrand and Benoît Plaud of Paris-Diderot University. The editorial is, "Etomidate and General Anesthesia: The Butterfly Effect?" published in the journal Anesthesia & Analgesia, December 2013 - Volume 117 - Issue 6 - p 1267–1269.

In Ill Surgical Patients, Increased Risks with Etomidate

The editorial comments have been published about the new study which was done by Dr Ryu Komatsu of the Cleveland Clinic and colleagues, who assessed the risk of adverse outcomes in patients receiving etomidate for induction of anesthesia. Rates of death and cardiovascular events in about 2,100 patients receiving etomidate were compared to those in a matched group of 5,200 patients receiving induction with a different intravenous anesthetic, propofol. All patients had severe but non-critical medical conditions— ASA physical status III or IV—and were undergoing noncardiac surgery, the news release explains.

The results showed significantly higher risks in patients receiving etomidate. The etomidate group had a 250 percent increase in the risk of death within 30 days. (Absolute risk of death was 6.5 percent with etomidate versus 2.5 percent with propofol.) Patients receiving etomidate also had a 50 percent increase in the risk of major cardiovascular events.

Results showed significantly higher risks in patients receiving etomidate

The results are "striking and troubling," says the news release. But the study is not the first to raise safety concerns over etomidate, as Drs. Legrand and Plaud write. Previous reports have suggested an increased risk of death in patients receiving etomidate in emergency situations or during critical illness, particularly sepsis.

Large-scale studies will be needed to definitively establish the safety of etomidate. A study in critically ill patients is already underway. Pending those results, the editorial authors conclude, "Since safe and efficient alternatives exist, a wise choice might certainly be the use of other anesthetic agents for induction of anesthesia."

Subsequent randomized trials did not show an increased risk of death in critically ill patients receiving etomidate

It's unclear how etomidate—a drug with only short-lasting effects—can affect patient outcomes several weeks later. Borrowing a metaphor from physics, Drs Legrand and Plaud suggest that it may represent a so-called butterfly effect, with "very small differences in the initial state of a physical system [making] a significant difference to the state at some later time."

While noting that the new study has some important limitations, Drs Legrand and Plaud write, according to the news release, "These findings are of major importance in light of the high number of patients who potentially receive etomidate each year worldwide." Read the article in Anesthesia & Analgesia. The journal is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health.

About Anesthesia & Analgesia

Anesthesia & Analgesia was founded in 1922 and was issued bi-monthly until 1980, when it became a monthly publication. A&A is the leading journal for anesthesia clinicians and researchers and includes more than 500 articles annually in all areas related to anesthesia and analgesia, such as cardiovascular anesthesiology, patient safety, anesthetic pharmacology, and pain management. The journal is published on behalf of the IARS by Lippincott Williams & Wilkins (LWW), a division of Wolters Kluwer Health.

About the IARS

The International Anesthesia Research Society is a nonpolitical, not-for-profit medical society founded in 1922 to advance and support scientific research and education related to anesthesia, and to improve patient care through basic research. The IARS contributes nearly $1 million annually to fund anesthesia research; provides a forum for anesthesiology leaders to share information and ideas; maintains a worldwide membership of more than 15,000 physicians, physician residents, and others with doctoral degrees, as well as health professionals in anesthesia related practice; sponsors the SmartTots initiative in partnership with the FDA; and publishes the monthly journal Anesthesia & Analgesia in print and online.

About Wolters Kluwer Health

Wolters Kluwer Health is a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Serving more than 150 countries and territories worldwide, Wolters Kluwer Health's customers include professionals, institutions and students in medicine, nursing, allied health and pharmacy. Major brands include Health Language®, Lexicomp®, Lippincott Williams & Wilkins, Medicom®, Medknow, Pharmacy OneSource®, ProVation® Medical and UpToDate®. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company.

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