Use of etomidate in patients with heart failure undergoing noncardiac surgery

Background: Patients with symptomatic and asymptomatic heart failure undergoing noncardiac surgery may benefit from the haemodynamic profile of etomidate. However, the safety of etomidate in this population is unknown. We examined anaesthesiologist variation in etomidate use and assessed its safety using an instrumental variable approach to account for differences in treatment selection. Methods: A retrospective cohort study of 19 714 patients with heart failure undergoing noncardiac surgery at two tertiary care institutions from January 2006 to December 2017 was performed. The proportion of etomidate use among 294 anaesthesiologists was examined and adjusted risk differences (aRD) for in-hospital and 30-day mortality were calculated using physician preference for etomidate as an instrumental variable. Results: Etomidate was used in 14.3% (2821/19 714) of patients. Preference for etomidate varied substantially among individual anaesthesiologists with the lowest and highest quartile users using etomidate in 0–4.7% and 20.4–66.7% of their own heart failure patients, respectively. The adjusted instrumental variable analysis showed no significant differences in the risk of in-hospital (aRD –0.2%; 95% confidence interval, –2.4%–1.9%; P=0.83) or 30 day mortality (aRD 0.2%; 95% confidence interval, –2.5%–2.9%; P=0.90). Anaesthesiologists with higher preferences for etomidate were more experienced (greater heart failure and total case volume) than anaesthesiologists with lower preferences for etomidate. Conclusions: We found substantial variability in anaesthesiologists' preference for etomidate for use in patients with heart failure undergoing noncardiac surgery. There was no association between etomidate use and in-hospital or 30-day mortality. Etomidate is not inferior to other currently used options for induction of general anaesthesia in patients with heart failure.