Steroid administration after anaesthetic induction with etomidate does not reduce in-hospital mortality or cardiovascular morbidity after non-cardiac surgery

Abstract

Steroid administration after induction of anaesthesia with etomidate did not reduce mortality or cardiovascular morbidity.

Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient

“…In the study assessing etomidate/hydrocortisone (42-hr infusion of hydrocortisone 200 mg/d [350 mg total]) compared with etomidate/placebo, there was no difference in ventilator days (median: 2 d [range 1–10] vs 4 d [range 1–10]) (72), duration of norepinephrine administration (median: 2 d [range 1–3] vs 2 d [range 1–4]) (72), time-to-resolution of shock (maintenance of SBP ≥ 90 mm Hg without vasopressor support for ≥ 24 hr) (mean: 3 d [95% CI, 2.5–3.5] vs 3.8 d [95% CI, 3.1–4.4], p = 0.42) (73), or ICU length of stay (mean: 4 d [range 1–10] vs 8 d [range 4–17]), NS (72). In patients who had undergone noncardiac surgery, there was a difference in ICU length of stay after adjusting for history of cardiac disease and year of surgery (hazard ratio: 0.89; 95% CI, 0.8–0.98); however, for obvious reasons, this patient population differs from the general ICU population (76). None of the trials documented adverse events of corticosteroids (i.e., infection) and this outcome could not be evaluated.…”

“…Of the seven studies, six assessed mortality (72–77); however, the corticosteroid used, dose, frequency, and duration of administration were not consistent across studies. There were two separate RCTs (72, 73).…”

“…There was no difference in all-cause 28-day mortality, ICU mortality, or hospital mortality among the 23 patients that received etomidate with or without hydrocortisone (75). Although not conducted in patients undergoing out-of-OR RSI, a retrospective study used propensity score matching (2:1) to evaluate surgical patients who received intraoperative steroids with those who did not receive steroids (76). Among 582 patients who received etomidate/corticosteroids (hydrocortisone, dexamethasone, or methylprednisolone for a median of 6 days, IQR 3–10 d) and 1,023 patients who received etomidate and no steroids, there was no difference in in-hospital mortality (4.6% in each group, OR 1.01 [97.5% CI, 0.58–1.76], p = 0.97.…”

Early Resumption of β Blockers Is Associated with Decreased Atrial Fibrillation after Noncardiothoracic and Nonvascular Surgery

“…Matching was then implemented through a greedy algorithm (SAS macro: gmatch), restricting successful matches to those with the same type of surgery (i.e., first exact matching on type of surgery because it is so related to both exposure and outcome and thus such an important confounder) and those whose estimated propensity score logits (i.e., estimated propensity score) were within 0.2 propensity score logit standard deviations of each other. [12][13][14] for International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. We chose this fairly granular method of adjusting for type of surgery because surgical procedure has been shown to be a strong confounding variable in observational studies in perioperative medicine.…”

“…We chose this fairly granular method of adjusting for type of surgery because surgical procedure has been shown to be a strong confounding variable in observational studies in perioperative medicine. 12 Assessment of balance on the covariables used for the propensity score matching was performed using absolute standardized differences (i.e., the absolute difference in means or proportions divided by the pooled SD). Imbalance was defined as a standardized difference greater than 0.10 in Beta Blockers after Noncardiac Surgery absolute value; any such covariables were included in the models comparing early and late β-blocker patients on outcomes to reduce potential confounding.…”