Comparison of the Effectiveness of Various Drug Interventions to Prevent Etomidate-Induced Myoclonus: A Bayesian Network Meta-Analysis

Abstract

BackgroundMyoclonic movement is a very common but undesirable phenomenon during the induction of general anesthesia using etomidate. Such movement may cause unnecessary problems. Currently, there is an increasing number of drugs for preventing etomidate-induced myoclonus (EM). However, direct comparisons of various drugs are lacking, and this interferes with clinical decision-making. Our network meta-analysis (NMA) aimed to compare the efficacy of different drugs for the prevention of moderate-to-severe general myoclonus.MethodsUsing several biomedical databases, randomized controlled trials (RCTs) published in English from inception to August 22, 2021 were searched. Among the various interventions, we selected nine types of intervention drugs (dexmedetomidine, etomidate, lidocaine, NMDA receptor antagonist, κ opioid receptor agonist, μ opioid receptor agonist, muscle relaxant, gabapentin, and midazolam) for comparison, according to the number of studies. Bayesian NMA was performed using STATA16 and R softwares. The relative risk of EM was assessed using risk ratios (RRs) and the corresponding 95% confidence intervals (CI).ResultsA total of 31 RCTs (3209 patients) were included. NMA results showed that, compared with a placebo, etomidate (RR 4.0, 95%CI 2.1–7.8), κ opioid receptor agonist (RR 2.9, 95%CI 1.9–4.6), μ opioid receptor agonist (RR 3.1, 95%CI 2.3–4.3), NMDA receptor antagonist (RR 1.7, 95%CI 1.0–2.8), dexmedetomidine (RR 2.4, 95%CI 1.5–3.9), lidocaine (RR 2.1, 95%CI 1.2–3.9), and midazolam (RR 2.2, 95%CI 1.5–3.2) can significantly reduce the risk of EM. In contrast, the effects of muscle relaxants (RR 2.1, 95%CI 0.81–5.3) and gabapentin (RR 2.8, 95%CI 0.92–9.3) were inconclusive. Further subgroup analyses showed that preoperative low-dose etomidate, μ-opioid receptor agonist, and κ-opioid receptor agonist were significantly better than other interventions in the prevention of moderate to severe EM.ConclusionPreoperative use of small doses of etomidate or opioids may be the most effective way to avoid EM, especially moderate and severe EM, which makes anesthesia induction safer, more stable, and aligns better with the requirements of comfortable medicine.Systematic Review Registration[https://www.crd.york.ac.uk/prospero/], [CRD4202127706].

Effect of Pretreatment of Lignocaine Versus Midazolam in the Prevention of Etomidate Induced Myoclonus

“…According to them, both were safe and effective for making induction of anesthesia safer by preventing the myoclonus associated with etomidate. 16 Similarly, Hüter et al 17 found the same results using low dose midazolam (0.015mg/kg) 3 minutes before etomidate induction in elective cardioversion patients. Forty patients were included in their study, and all belonged to ASA-III & IV.…”

Comparative assessment of dexmedetomidine and butorphanol for attenuation of etomidate-induced myoclonus: A double-blind, randomised controlled study

“…The various agents that have been employed to suppress this effect include midazolam,[ 6 7 ] fentanyl,[ 13 ] remifentanil,[ 14 ] magnesium sulphate,[ 10 15 ] lignocaine,[ 16 ] butorphanol,[ 3 9 17 18 ] dexmedetomidine,[ 1 2 8 19 20 21 22 ] thiopental[ 21 ] and sub-hypnotic doses of etomidate. [ 23 ] Dexmedetomidine has the edge over the other agents, given its diverse actions, including conscious sedation, analgesia and preventing haemodynamic response to laryngoscopy and intubation.…”

Around anesthesia: anesthetic aspects of electroconvulsive treatment in the light of the latest reports – review article

“…[52] zwracają jednak uwagę na konieczność zachowania znacznej ostrożności w rutynowym dołączaniu remifentanylu do znieczulenia barbituranowego, gdyż nie wpływa to na długoterminowe odsetki remisji i nawrotów, a wiąże się z częstszym ryzykiem działań niepożądanych, takich jak nudności, zawroty czy bóle głowy. Według najnowszej metaanalizy sieciowej zastosowanie remifentanylu wydaje się natomiast najlepszą opcją w zapobieganiu miokloniom indukowanym przez etomidat, co może mieć szczególne znaczenie u chorych z wysokim wyjściowym stężeniem potasu przy jednoczesnym zastosowaniu sukcynylocholiny, jako że zarówno mioklonie, jak i sukcynylocholina powodują silne przesunięcie jonów potasu na zewnątrz komórki mięśniowej [53].…”