Effects of etomidate combined with dexmedetomidine on adrenocortical function in elderly patients: a double-blind randomized controlled trial

Abstract

Etomidate has been advocated to be used in anesthesia for the elderly and the critically ill patients due to its faint effect on cardiovascular system. But the dose-dependent suppression of etomidate on adrenal cortex function leads to the limitation of its clinical application. Clinical research showed that dexmedetomidine could reduce the dose requirements for intravenous or inhalation anesthetics and opioids, and the hemodynamics was more stable during the operation. The objective was to observe the effect of etomidate combined with dexmedetomidine on adrenocortical function in elderly patients. 180 elderly patients scheduled for elective ureteroscopic holmium laser lithotripsy were randomly allocated to PR group anesthetized with propofol-remifentanil, ER group anesthetized with etomidate-remifentanil, and ERD group anesthetized with dexmedetomidine combined with etomidate-remifentanil. Patients in each group whose operation time was less than or equal to 1 h were incorporated into short time surgery group (PR₁ group, ER₁ group and ERD₁ group), and whose surgical procedure time was more than 1 h were incorporated into long time surgery group (PR₂ group, ER₂ group and ERD₂ group). The primary outcome was the serum cortisol and ACTH concentration. The secondary outcomes were the values of SBP, DBP, HR and SpO₂, the time of surgical procedure, the dosage of etomidate and remifentanil administered during surgery, the time to spontaneous respiration, recovery and extubation, and the duration of stay in the PACU. The Serum cortisol concentration was higher at t_1~2 in ERD₁ group compared to ER₁ group (P < 0.05). The Serum cortisol concentration at t_1~3 was higher in ERD₂ group than in ER₂ group (P < 0.05). The Serum ACTH concentration was lower at t_1~2 in ERD₁ group compared to ER₁ group (P < 0.05). The Serum ACTH concentration at t_1~3 was lower in ERD₂ group compared to ER₂ group (P < 0.05). The SBP at T₁ and T₃ were higher in ER₂ and ERD₂ group than in PR₂ group (P < 0.05). The DBP in ER₁ and ERD₁ group were higher at T₁ compared to PR₁ group (P < 0.05). The dosage of etomidate was significantly lower in ERD₁ group and ERD₂ group than in ER₁ group and ER₂ group (P < 0.05), respectively. The administration of dexmedetomidine combined with etomidate can attenuate the inhibition of etomidate on adrenocortical function in elderly patients and maintain intraoperative hemodynamic stability.

Figure 1

One hundred aneighty patients were screened for eligibility, and subsequently allocated to three groups. No patient dropped out of the trial. A total of one hundred and eighty patients completed the study (in this figure).

Figure 2

The Serum cortisol concentration changes in the short operation time groups at different time points. The Serum cortisol concentration at different time points in short operation time groups are shown in this figure. The Serum cortisol concentration were lower at t_1~2 in ER1 group and t₁ in ERD₁ group compared to t₀ and PR₁ group (P < 0.05). The Serum cortisol concentration were higher at t_1~2 in ERD₁ group compared to ER₁ group (P < 0.05), (in this figure).

Figure 3

The Serum cortisol concentration changes in the long operation time groups at different time points. The Serum cortisol concentration at different time points in long operation time groups are shown in this figure. The Serum cortisol concentration were lower at t_1~3 in ER₂ group and t_1~2 in ERD₂ group compared to t₀ and PR₂ group (P < 0.05). The Serum cortisol concentration were higher at t_1~3 in ERD₂ group compared to ER₂ group (P < 0.05), (in this figure).

Figure 4

The Serum ACTH concentration changes in the short operation time groups at different time points. The Serum ACTH concentration at different time points in short operation time groups are shown in this figure. The Serum ACTH concentration were higher at t_1~2 in ER₁ group and t₁ in ERD₁ group compared to t₀ and PR₁ group (P < 0.05). The Serum ACTH concentration were lower at t_1~2 in ERD₁ group compared to ER₂ group (P < 0.05), (in this figure).

Figure 5

The Serum ACTH concentration changes in the long operation time groups at different time points. The Serum ACTH concentration at different time points in long operation time groups are shown in this figure. The Serum ACTH concentration were higher at t_1~3 in ER₂ group and t_1~2 in ERD₂ group compared to t₀ and PR₂ group (P < 0.05). The Serum ACTH concentration were lower at t_1~3 in ERD₂ group compared to ER₂ group (P < 0.05) (in this figure).