Surgical management of pituitary adenomas
Philip E. Harris, Pierre-Marc G. Bouloux in Endocrinology in Clinical Practice, 2014
Medication treatment options include cortisol synthesis inhibition in the adrenal cortex, neuromodulator agents acting on the hypothalamic-pituitary system, and glucocorticoid antagonists. Metyrapone and ketoconazole are well-established cortisol synthesis inhibitors. They inhibit 11β-hydroxylase necessary for converting 11-deoxycortisol to cortisol. Metyrapone works well to decrease cortisol levels, but it has significant androgenous side effects, including hirsutism and acne. Although efficacious in decreasing cortisol levels, ketoconazole is associated with a 5%–10% risk of reversible hepatotoxicity with occasional serious hepatic injury.40 Etomidate is a parenterally administered imidazole derivative anesthetic. Although its uses are limited, it remains an option for severe, life-threatening Cushing’s disease.41,42 Newer suppressive agents such as mifepristone and paseriotide have been used in clinical trials and now have Food and Drug Administration (FDA) approval for treatment of Cushing’s disease.
Neuropharmacology: Age-related changes
Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor in Essentials of Geriatric Neuroanesthesia, 2019
Etomidate is routinely used as an anesthetic due to its rapid onset of action, producing sedation within 1 minute. After a single bolus dose of 0.3 mg/kg, patients generally recover within 5 minutes. Etomidate uniquely inhibits 11-beta-hydroxylase, thereby reducing plasma cortisol concentrations for up to 8 hours. In contrast to younger adult patients who experience no clinically significant cardiac effects from a bolus dose of etomidate, geriatric patients may experience decreases in heart rate, cardiac index, and mean arterial pressure (MAP). Geriatric patients with hypertension at baseline are particularly affected. Since older adult brains do not have a heightened sensitivity to etomidate, these effects on hemodynamics are likely the result of higher plasma concentrations after bolus administration due to reductions in volume of distribution and albumin-binding, which together significantly increase the free concentration of etomidate in the plasma compartment. The brains of older adults have not been shown to be more sensitive to etomidate (41,43). In addition to these hemodynamic effects, CBF decreases 20%–30% with etomidate and occurs with a proportional reduction in CMRO2. ICPs are transiently reduced after etomidate induction. Use of etomidate for neuroanesthesia is primarily limited to induction doses versus continuous infusions or long-term use due to its effects on cortisol and since each milliliter of etomidate contains 35% propylene glycol v/v. Etomidate also causes pain on injection and myoclonus (44).
Traumatized Airway
Stephen M. Cohn, Matthew O. Dolich, Kenji Inaba in Acute Care Surgery and Trauma, 2016
Commonly selected induction agents for trauma patients include etomidate and ketamine for their favorable hemodynamic effects. In a randomized controlled trial by Jabre et al., there was no difference in mortality found between the use of etomidate and ketamine for intubation of acutely ill patients [21]. The main concern with the usage of etomidate is that it can produce adrenal insufficiency; however, studies have failed to conclusively prove that this increases morbidity or mortality [21,22]. Ketamine has generally been avoided in patients with suspected traumatic brain injury due to concern that it increases intracranial pressure, but that fact remains controversial, and some newer data suggest that ketamine may even be neuroprotective [23].
Review on the use of zebrafish embryos to study the effects of anesthetics during early development
Published in Critical Reviews in Toxicology, 2019
Luís Félix, Ana Maria Coimbra, Ana Maria Valentim, Luís Antunes
Etomidate is an intravenous anesthetic that potentiates the GABA neurotransmitter system by altering the transmembrane chloride conductance (Tobias 2015). This compound is an interesting alternative to the most common intravenous anesthetics because etomidate possesses some advantages that make it an attractive option to use in pediatric procedures (Mandt et al. 2012) although its neuronal and cognitive effects remain elusive particularly during early infancy (Nyman et al. 2016). In human neonates and infants clinical settings, the minimal hypnotic plasma concentration is around 1 µM (Su et al. 2015) and no teratogenic effects have been described in the literature for its administration during pregnancy in clinically effective doses. However, there is a lack of adequate and well-controlled studies during gestation and early development for etomidate (Perna et al. 2015). In this regard, a recent study reported that general anesthesia of 6 dpf larval zebrafish has been achieved at concentrations of 30 µM, causing the loss of brain functions (Du et al. 2018). Still, further studies are necessary to conclude on the teratogenic potential of this anesthetic.
Dynamic prediction of hypoxemia risk at different time points based on preoperative and intraoperative features: machine learning applications in outpatients undergoing esophagogastroduodenoscopy
Published in Annals of Medicine, 2023
Zhaojing Fang, Daizun Zou, Weigen Xiong, Hongguang Bao, Xiuxiu Zhao, Chen Chen, Yanna Si, Jianjun Zou
The Nanjing First Hospital ethics committee approved this study and waived the requirement for informed consent [grant number: KY20220509-01-KS-01]. Outpatients’ data of the derivation cohort from June to September 2021 were collected retrospectively from electronic medical records. Patients who received routine anaesthesia-assisted EGD were included according to the following criteria: ≥18 years old; American Society of Anesthesiologists (ASA) class I–III. Exclusion criteria were as follows: pregnancy, severe cardiopulmonary diseases (uncontrolled circulatory and respiratory diseases that can be life-threatening, including severe aortic stenosis, unstable angina pectoris, acute exacerbations of chronic obstructive pulmonary disease, etc.), presence of acute upper respiratory tract infection, and unavailability of complete data. Patients who were induced with etomidate were also excluded.
The effects of etomidate on expression of high mobility group box 1 via the nuclear factor kappa B pathway in rat model of sepsis
Published in Libyan Journal of Medicine, 2023
Yoo Jung Park, Kwon Hui Seo, Jin Deok Joo, Hong Soo Jung, Yong Shin Kim, Ji Yung Lee, Hunwoo Park
Etomidate, a potent imidazole hypnotic, has been frequently used as an anesthetic induction agent or sedative for old or critically ill patients owing to its fast onset of therapeutic effect, brief duration of action, and hemodynamic safety [9]. However, for critically ill patients, administration of etomidate may cause mortality and morbidity due to its suppressive effects on adrenal steroidogenesis by inhibition of the 11β-hydroxylase enzyme [10, 11]. Although single-dose etomidate use does not seem to lead to mortality of septic patients [12, 13], available evidence is limited. A few previous studies have revealed that etomidate regulates excessive immune responses by inhibiting pro-inflammatory cytokines such as interleukin (IL)-1β, IL-6, and tumor necrosis factor alpha (TNF-α) and lipopolysaccharide (LPS)-induced nuclear factor kappa B (NF-ĸB) activation in an acute lung injury model and rat macrophages [14,15]. The reciprocal relationship among acute-phase cytokines, HMGB1, and NF-ĸB activity has been determined [4], but the effects of etomidate on HMGB1 expression and release have not yet been elucidated in sepsis.
Related Knowledge Centers
- Cardioversion
- Electroconvulsive Therapy
- Rapid Sequence Induction
- Tracheal Intubation
- Traumatic Brain Injury
- General Anaesthesia
- Sedation
- British Approved Name
- Intravenous Therapy
- Procedural Sedation & Analgesia