ABSTRACT Objective: To compare the effect of a single induction dose of etomidate or ketamine on plasma cortisol levels in children with Tetralogy of Fallot (TOF) undergoing intra-cardiac repair on cardiopulmonary bypass (CPB). Design: A prospective randomized trial. Setting: Cardiac center of a tertiary care hospital. Participants: Thirty children with TOF undergoing intra-cardiac repair on CPB. Interventions: After random allocation of the children into two groups, the children either received etomidate 0.2 mg/kg or ketamine 2 mg/kg intravenously for anesthetic induction along with fentanyl 2 mcg/kg and midazolam 100 mcg/kg. Endotracheal intubation was accomplished with rocuronium bromide in the dose of 1 mg/kg. Anesthesia was maintained with sevoflurane in air-oxygen, titrated to response and supplemental vecuronium bromide for muscle relaxation, fentanyl chloride for pain relief. Serum cortisol was measured on three occasions, at preinduction, at the end of surgery and at 24 hours postoperatively. Measurements and Main Results: Baseline plasma cortisol (Normal 5 - 25 mcg/dl) in the etomidate group (19.91 ± 3.51 mcg/dl) decreased significantly at the end of surgery (5.78 ± 2.0 mcg/dl) and rose to significantly higher than baseline values at 24 hours (27.31 ± 8.30 mcg/dl). The baseline cortisol levels in the ketamine group (20.91 ± 3.19 mcg/dl) increased significantly at the end of surgery (44.02 ± 5.49 mcg/dl) and remained significantly higher than baseline at 24hours (45.93 ± 3.05 mcg/dl). Plasma cortisol levels in the etomidate group at end of surgery, and at 24 hours post-operatively, were significantly lower than the ketamine group. Conclusions: This study shows that etomidate is a suitable and safe agent for suppression of the increase in serum cortisol associated with the use of CPB in children with TOF undergoing intra-cardiac repair.
Cite this paper
A. Pandey, S. Chauhan, N. Makhija, U. Kiran, S. Vasdev, S. Talwar and R. Lakshmy, "The Variation in Plasma Cortisol Levels in Response to Anesthetic Induction with Etomidate or Ketamine in Children Undergoing Intracardiac Repair of Tetralogy of Fallot on Cardiopulmonary Bypass," World Journal of Cardiovascular Surgery, Vol. 2 No. 2, 2012, pp. 17-20. doi: 10.4236/wjcs.2012.22006.
 B. J. Hindman, S. L. Lillehaug and J. H. Tinker, “Cardiopulmonary Bypass and the Anesthesiologist,” In: J. A. Kaplan, Ed., Cardiac Anesthesia, Saunders, Phildelphia, 1993, pp. 919-950.
 K. J. S. Anand, D. Phil, D. D. Hansen, et al., “Hormonal-Metabolic Stress Responses in Neonates Undergoing Cardiac Surgery,” Anesthesiology, Vol. 73, No. 4, 1990, pp. 661-670. doi:10.1097/00000542-199010000-00012
 J. Helman, W. Browner, J. Li, et al., “Prognostic Importance of Preoperative Hypertension,” Anesthesiology, Vol. 75, No. 3, 1991, p. 110A.
 R. L. Wagner, P. F. White, P. B. Kan, et al., “Inhibition of Adrenal Steroidogenesis by the Anesthetic Etomidate,” The New England Journal of Medicine, Vol. 310, No. 22, 1984, pp. 1415-1421.
 M. P. Mehta, J. B. Dillman, B. M. Sherman, et al., “Etomidate Anesthesia Inhibits the Cortisol Response to Surgical Stress,” Acta Anaesthesiologica Scandinavica, Vol. 29, No. 5, 1985, pp. 486-489.
 D. J. R. Duthie, R. Fraser and W. S. Nimmo, “Effect of Induction of Anaesthesia with Etomidate on Corticosteroid Synthesis in Man,” British Journal of Anaesthesia, Vol. 57, No. 2, 1985, pp. 156-159.
 M. F. Roizen, G. H. Lampe, D. J. Beuefiel, et al., “Is Increased Operative Stress Associated with Worse Outcome?” Anesthesiology, Vol. 67, No. 3, 1987, p. A1.
 J. G. Reves and D. E. Berkowitz, “Pharmacology of Intravenous Anesthetic Drugs,” In: J. A. Kaplan, Ed., Cardiac Anesthesia, Saunders, Philadephia, 1993, pp. 512534.
 B. Kay, “A Clinical Assessment of the Use of Etomidate in Children,” British Journal of Anaesthesia, Vol. 48, No. 3, 1976, pp. 207-210. doi:10.1093/bja/48.3.207
 R. A. Moore, M. C. Allen, P. J. Wood, et al., “Perioperative Endocrine Effects of Etomidate,” Anaesthesia, Vol. 40, No. 2, 1985, pp. 124-130.
 J. W. Sear, M. C. Allen, M. Gales, et al., “Suppression by Etomidate of Normal Cortisol Response to Anaesthesia and Surgery,” Lancet, Vol. 322, No. 8357, 1983, p. 1028.
 C. J. Kenyon, J. Young, C. E. Gray, et al., “Inhibition by Etomidate of Steroidogenesis in Isolated Bovine Adrenal Cells,” The Journal of Clinical Endocrinology & Metabolism, Vol. 58, No. 5, 1984, pp. 947-949.
 P. S. Sebel, C. Verghese, H. L. J. Makin, R. J. Fragen, C. A. Shanks and A. Molteni, “Effect on Plasma Cortisol Concentrations of a Single Induction Dose of Etomidate or Thiopentone,” Lancet, Vol. 322, No. 8350, 1983, pp. 625626. doi:10.1016/S0140-6736(83)90709-2
 T. A. Crozier, C. Flamm, C. P. Speer, et al., “Effects of Etomidate on the Adrenocortical and Metabolic Adaptation of the Neonate,” British Journal of Anaesthesia, Vol. 70, No. 1, 1993, pp. 47-53. doi:10.1093/bja/70.1.47
 J. Morel, M. Salard, C. Castelain, et al., “Haemodynamic Consequences of Etomidate Administration in Elective Cardiac Surgery: A Randomized Double-Blinded Study,” British Journal of Anaesthesia, Vol. 107, No. 4, 2011, pp. 503-509. doi:10.1093/bja/aer169
 M. Malik, V. Malik, S. Chauhan, et al., “Ketamine-Etomidate for Children Undergoing Cardiac Catheterization,” Asian Cardiovascular & Thoracic Annals, Vol. 19 No. 2, 2011, pp. 143-148.