<p>Comparison of the efficacy and safety of remifentanil versus different pharmacological approaches on prevention of etomidate-induced myoclonus: a meta-analysis of randomized controlled trials</p>

Abstract

Objective: Myoclonus was considered as one conundrum in etomidate induction, which led to multiple risks during clinical anesthesia. The present study was conducted to compare the efficacy of pretreatment with remifentanil to different pharmacological approaches on reducing etomidate-induced myoclonus. Methods: We searched PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure from the inception to October 2018. Randomized controlled trials comparing remifentanil versus other pharmacological approaches in reducing etomidate-induced myoclonus were eligible to be analyzed. Results: Overall, 13 trials with 1,392 patients met with the inclusion criteria. 1) Pretreatment with remifentanil could reduce the incidence of etomidate-induced myoclonus compared to placebo and fentanyl; few differences were found between the use of remifentanil and the use of midazolam: (incidence of myoclonus: 5.56% with remifentanil vs 71.65% with saline, RR=0.08, with 95% CI [0.05, 0.12], P <0.0001; 3.80% with remifentanil vs 13.33% with fentanyl, RR with 95% 0.31 [0.11, 0.86], P =0.02; 46.00% with remifentanil vs 55.45% with midazolam, RR=0.82, with 95% CI [0.64, 1.06], P =0.13). 2) Compared with placebo, pretreatment with remifentanil could reduce the incidence of mild, moderate, and severe myoclonus; compared with midazolam, patients receiving remifentanil experienced lower occurrence of severe myoclonus; compared with fentanyl, pretreatment with remifentanil associated with significant low occurrence of moderate and severe myoclonus. 3) The outcomes also indicated that pretreatment with remifentanil could prevent excessive hemodynamic changes after endotracheal intubation compared to fentanyl. Conclusions: Pretreatment with remifentanil could be considered as one operative option to reduce both incidence and severity of etomidate-induced myoclonus. Compared with fentanyl, it also provides efficacy in preventing excessive hemodynamic changes after endotracheal intubation. However, the best treatment and the proper prophylactic dosage calls for more high quality evidence with large sample size.

Comparison of The Effects of Remifentanil and Fentanyl Combined with Desflurane on Intraoperative Hemodynamic Parameters and Postoperative Recovery Period in Anesthesia for Day Case Surgery

“…However, in the fentanyl group, values of systolic, diastolic and mean blood pressures were detected higher, especially during intubation, intraoperative period, pre-and post-extubation periods, compared to remifentanil. In support of our data, some authors found SBP, DBP and MAP higher values in fentanyl group during intubation, intraoperative and extubation periods (Albertin et al,2001;Twersky et al, 2001;Lang et al, 2019). In contrast, some other authors reported that they could not find any significant difference between SBP, DBP and MAP in preoperative, peroperative and postoperative periods between administration of remifentanil 0.5 mcg /kg bolus, 0.2 mcg/kg/min infusion and fentanyl 1 mcg/kg bolus and 2mcg/kg/hour infusion (Doyle et al,2001;Choi et al, 2016 ).It was thought that these results may be due to using different dosage and way of remifentanil and fentanyl.…”

A Comparative Study of Different Doses of Lignocaine on Prevention of Etomidate Induced Myoclonus during Induction of Anesthesia

“…The occurrence of myoclonus during anesthesia induction will affect the stability of hemodynamic and also increase the risk of emergence agitation and other adverse reactions. 7 Therefore, various methods to prevent etomidate induced myoclonus has been the focus of clinical research. The mechanisms of etomidate-induced myoclonus are complex and not completely clear, and currently known mechanisms are as follows: (1) neural inhibitory pathway is more easily inhibited than excitatory pathway, and etomidate inhibits brainstem reticular formation function through gamma aminobutyric acid (GABA) receptor, increases the sensitivity of neural pathway that controls skeletal muscle, and thus leads to increased neural discharge and myoclonus; (2) etomidate can be combined with dopamine receptor in brain striatum, substantia nigra and other structures, and thus inhibit the biological function of dopamine which is manifested as endogenous dopamine deficiency, that is, myoclonus.…”

Efficacy of Granisetron versus Sufentanil on Reducing Myoclonic Movements Following Etomidate

“…Inclusion criteria were patients undergoing general anesthesia with (1) American Society of Anesthesiologists Classification (ASA) I, II, (2) and age between 15-60 years. Exclusion criteria included (1) adrenal dysfunction, (2) history of allergy to opioid analgesics and hypnotics drugs, (3) mental disorders, (4) neuromuscular diseases, (5) seizure, (6) electrolyte imbalanced, (7) history of addiction, (8) long QT syndrome, as well as severe cardiovascular diseases, (9) high Intracranial pressure (ICP) and Intraocular pressure(IOP), and (10) increased intra-abdominal pressure. Written consent was obtained from all subjects, and they were assured that all their information would remain confidential.…”

“…Since the majority of myoclonic jerks are believed to be caused by hyperexcitability of a group of neurons in certain cerebral structures, the relationship of myoclonic jerks with EEG activity is of primary importance in the study of myoclonus. 7,8 Different drugs (fentanyl, 9 remifentanil, 10 midazolam, 11 etc.) have been used as pretreatment for myoclonus caused by etomidate, each with exclusive side effects, while the best option for clinical treatment of etomidate-induced myoclonus has not yet been determined.…”