Efficacy and Safety of Midazolam in the Prevention of Etomidate-induced Myoclonus: A Meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

 QIUPeng , QIUShuang ,  DONGYou-jing

Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang 110022, China;

Corresponding?author：

DONGYou-jing, Email: dongyj@sj-hospital.org

Keywords：

Midazolam; Etomidate; Myoclonus; Systematic review; Meta-analysis; Randomized controlled trials

DOI：

10.7507/1672-2531.20150230

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Objective To evaluate the efficacy and safety of midazolam in the prevention of etomidate-induced myoclonus. Methods Databases including PubMed, EMbase, The Cochrane Library (Issue 8, 2015), CBM, WanFang Data, VIP, and CNKI were electronically searched to collect randomized controlled trials (RCTs) about midazolam in the prevention of etomidate-induced myoclonus from inception to August, 2015. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed by RevMan 5.2 and Stata 12.0 softwares. Results A total of 14 RCTs involving 1 274 patients were included. The results of metaanalysis showed that, compared with placebo, pretreatment with midazolam injection could reduce the incidence of myoclonus (RR=0.28, 95%CI 0.19 to 0.42, P<0.000 01). The sub-group analysis based on different doses of midazolam showed that all three different doses of midazolam (0.015 mg/kg, 0.03 mg/kg and 0.05-0.1 mg/kg) could reduce the incidence of myoclonus effectively (all P values <0.05). Conclusion Pretreatment with midazolam injection can reduce the incidence of etomidate-induced myoclonus without increasing the risk of recovery latency and over sedation. Due to the limited quality of included studies, the above conclusion needs to be further verified by more high quality studies.

Citation： QIUPeng, QIUShuang, DONGYou-jing. Efficacy and Safety of Midazolam in the Prevention of Etomidate-induced Myoclonus: A Meta-analysis. Chinese Journal of Evidence-Based Medicine, 2015, 15(12): 1407-1412. doi: 10.7507/1672-2531.20150230 Copy

1.	Doenicke A, Roizen MF, Nebauer AE, et al. A comparison of two formulations for etomidate, 2-hydroxypropyl-beta-cyclodextrin (HPCD) and propylene glycol. Anesth Analg, 1994, 79(5):933-939.
2.	Doenicke AW, Roizen MF, Kugler J, et al. Reducing myoclonus after etomidate. Anesthesiology, 1999, 90(1):113-119.
3.	Hüter L, Schwarzkopf K, Simon M, et al. Pretreatment with sufentanil reduces myoclonus after etomidate. Acta Anaesthesiol Scand, 2003, 47(4):482-484.
4.	Berry JM, Merin RG. Etomidate myoclonus and the open globe. Anesth Analg, 1989, 69(2):256-259.
5.	Shulman MS, Edelmann R. Use of etomidate for elective cardioversion. Anesthesiology, 1988, 68(4):656.
6.	Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med, 2003, 21(7):556-558.
7.	Ebrahim ZY, DeBoer GE, Luders H, et al. Effect of etomidate on the electroencephalogram of patients with epilepsy. Anesth Analg, 1986, 65(10):1004-1006.
8.	Gancher S, Laxer KD, Krieger W. Activation of epileptogenic activity by etomidate. Anesthesiology, 1984, 61(5):616-618.
9.	Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0[updated March 2011]. The Cochrane Collaboration, 2011. Available at:www.cochrane-handbook.org.
10.	Isitemiz I, Uzman S, Topta? M, et al. Prevention of etomidateinduced myoclonus:Which is superior:Fentanyl, midazolam, or a combination? A retrospective comparative study. Med Sci Monit, 2014, 20(1):262-267.
11.	Hwang JY, Kim JH, Oh AY, et al. A comparison of midazolam with remifentanil for the prevention of myoclonic movements following etomidate injection. J Int Med Res, 2008, 36(1):17-22.
12.	Schwarzkopf KR, Hueter L, Simon M, et al. Midazolam pretreatment reduces etomidate-induced myoclonic movement. Anaesth Intensive Care, 2003, 31(1):18-20.
13.	Hüter L, Schreiber T, Gugel M, et al. Low-dose intravenous midazolam reduces etomidate-induced myoclonus:A prospective, randomized study in patients undergoing elective cardioversion. Anesth Analg, 2007, 105(5):1298-1302.
14.	Gunes Y, Aktolga S, Gündüz M, et al. A comparison of midazolam or dexmedetomidine for the prevention of myoclonic movements and injection pain following etomidate injection. J Anaesthesiol Clin Pharmacol, 2010:162-166.
15.	盧吉燦, 劉超, 賈燕. 咪達唑侖預處理減少依托咪酯所致的肌陣攣. 齊齊哈爾醫學院學報, 2009, 30(11):1287-1288.
16.	吳隆巖, 金光輝. 右美托咪定與咪達唑侖預處理對麻醉誘導期依托咪酯所致肌陣攣的影響. 山東醫藥, 2012, 52(18):92-93.
17.	孫艷紅, 劉海梅, 趙蕓慧, 等. 依托咪酯麻醉誘導期對血流動力學及不同給藥順序對肌陣攣的影響. 中國醫科大學學報, 2010, 39(12):1058-1060.
18.	康振明, 謝文欽, 謝文吉, 等. 右美托咪定與咪達唑侖對依托咪酯全麻誘導時肌陣攣影響的對比研究. 中國醫學創新, 2014, 10(5): 11-13.
19.	廖朝輝, 幸標, 沈嫻文. 咪唑安定和芬太尼對依托咪酯所致肌陣攣的影響. 臨床麻醉學雜志, 2010, 26(2):129-131.
20.	李銀宏, 王祖謙, 趙世軍. 咪唑安定預處理減少依托咪酯所致肌陣攣. 青海醫藥雜志, 2009, 39(6):10-11.
21.	王彬, 程慶好, 李蕾. 右美托咪定或咪達唑侖對依托咪酯鎮靜時肌陣攣的影響. 中國煤炭工業醫學雜志, 2014, 17(4):522-525.
22.	王潤. 小劑量咪唑安定聯合依托咪酯對全麻誘導中減輕肌陣攣的臨床作用探討. 西部醫學, 2012, 24(1):104-106.
23.	魏嶸, 王春, 章賽吉, 等. 芬太尼和咪達唑侖給藥順序對小兒麻醉誘導期依托咪酯所致肌陣攣的影響. 上海醫學, 2013, 36(8):670-672.
24.	Rosenberg MS. The File-drawer problem revisited:a general weighted method for calculating fail-safe numbers in meta-analysis. Evolution, 2005, 59(2):464-468.
25.	Grant IS, Hutchison G. Epileptiform seizures during prolonged etomidate sedation. Lancet, 1983, 2(8348):511-512.
26.	Reddy RV, Moorthy SS, Dierdorf SF, et al. Excitatory effects and electroencephalographic correlation of etomidate, thiopental, methohexital and propofol. Anesth Analg, 1993, 77(5):1008-1011.
27.	Voss LJ, Sleigh JW, Barnard JP, et al. The howling cortex:seizures and general anesthetic drugs. Anesth Analg, 2008, 107(5):1689-1703.
28.	Kugler J, Doenicke A, Laub M. The EEG after etomidate. Anaesthesiol Resusc, 1977, 106(7):31-48.
29.	王新華, 劉樹孝, 王景陽, 等. 依托咪酯引起肌震顫與腦內多巴胺受體關系的實驗研究. 中華麻醉學雜志, 1991, 11(3):147-148.
30.	Mizrak A, Koruk S, Bilgi M, et al. Pretreatment with dexmedetomidine or thiopental decreases myoclonus after etomidate:A randomized, double-blind controlled trial. J Surg Res, 2010, 159(1):e11-e16.
31.	陳金仙, 顧曉霞, 蔡樹云, 等. 右美托咪定滴鼻預處理對全麻誘導期依托咪酯不良反應的影響. 贛南醫學院學報, 2014, 34(3):381-383.

1. Doenicke A, Roizen MF, Nebauer AE, et al. A comparison of two formulations for etomidate, 2-hydroxypropyl-beta-cyclodextrin (HPCD) and propylene glycol. Anesth Analg, 1994, 79(5):933-939.
2. Doenicke AW, Roizen MF, Kugler J, et al. Reducing myoclonus after etomidate. Anesthesiology, 1999, 90(1):113-119.
3. Hüter L, Schwarzkopf K, Simon M, et al. Pretreatment with sufentanil reduces myoclonus after etomidate. Acta Anaesthesiol Scand, 2003, 47(4):482-484.
4. Berry JM, Merin RG. Etomidate myoclonus and the open globe. Anesth Analg, 1989, 69(2):256-259.
5. Shulman MS, Edelmann R. Use of etomidate for elective cardioversion. Anesthesiology, 1988, 68(4):656.
6. Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med, 2003, 21(7):556-558.
7. Ebrahim ZY, DeBoer GE, Luders H, et al. Effect of etomidate on the electroencephalogram of patients with epilepsy. Anesth Analg, 1986, 65(10):1004-1006.
8. Gancher S, Laxer KD, Krieger W. Activation of epileptogenic activity by etomidate. Anesthesiology, 1984, 61(5):616-618.
9. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0[updated March 2011]. The Cochrane Collaboration, 2011. Available at:www.cochrane-handbook.org.
10. Isitemiz I, Uzman S, Topta? M, et al. Prevention of etomidateinduced myoclonus:Which is superior:Fentanyl, midazolam, or a combination? A retrospective comparative study. Med Sci Monit, 2014, 20(1):262-267.
11. Hwang JY, Kim JH, Oh AY, et al. A comparison of midazolam with remifentanil for the prevention of myoclonic movements following etomidate injection. J Int Med Res, 2008, 36(1):17-22.
12. Schwarzkopf KR, Hueter L, Simon M, et al. Midazolam pretreatment reduces etomidate-induced myoclonic movement. Anaesth Intensive Care, 2003, 31(1):18-20.
13. Hüter L, Schreiber T, Gugel M, et al. Low-dose intravenous midazolam reduces etomidate-induced myoclonus:A prospective, randomized study in patients undergoing elective cardioversion. Anesth Analg, 2007, 105(5):1298-1302.
14. Gunes Y, Aktolga S, Gündüz M, et al. A comparison of midazolam or dexmedetomidine for the prevention of myoclonic movements and injection pain following etomidate injection. J Anaesthesiol Clin Pharmacol, 2010:162-166.
15. 盧吉燦, 劉超, 賈燕. 咪達唑侖預處理減少依托咪酯所致的肌陣攣. 齊齊哈爾醫學院學報, 2009, 30(11):1287-1288.
16. 吳隆巖, 金光輝. 右美托咪定與咪達唑侖預處理對麻醉誘導期依托咪酯所致肌陣攣的影響. 山東醫藥, 2012, 52(18):92-93.
17. 孫艷紅, 劉海梅, 趙蕓慧, 等. 依托咪酯麻醉誘導期對血流動力學及不同給藥順序對肌陣攣的影響. 中國醫科大學學報, 2010, 39(12):1058-1060.
18. 康振明, 謝文欽, 謝文吉, 等. 右美托咪定與咪達唑侖對依托咪酯全麻誘導時肌陣攣影響的對比研究. 中國醫學創新, 2014, 10(5): 11-13.
19. 廖朝輝, 幸標, 沈嫻文. 咪唑安定和芬太尼對依托咪酯所致肌陣攣的影響. 臨床麻醉學雜志, 2010, 26(2):129-131.
20. 李銀宏, 王祖謙, 趙世軍. 咪唑安定預處理減少依托咪酯所致肌陣攣. 青海醫藥雜志, 2009, 39(6):10-11.
21. 王彬, 程慶好, 李蕾. 右美托咪定或咪達唑侖對依托咪酯鎮靜時肌陣攣的影響. 中國煤炭工業醫學雜志, 2014, 17(4):522-525.
22. 王潤. 小劑量咪唑安定聯合依托咪酯對全麻誘導中減輕肌陣攣的臨床作用探討. 西部醫學, 2012, 24(1):104-106.
23. 魏嶸, 王春, 章賽吉, 等. 芬太尼和咪達唑侖給藥順序對小兒麻醉誘導期依托咪酯所致肌陣攣的影響. 上海醫學, 2013, 36(8):670-672.
24. Rosenberg MS. The File-drawer problem revisited:a general weighted method for calculating fail-safe numbers in meta-analysis. Evolution, 2005, 59(2):464-468.
25. Grant IS, Hutchison G. Epileptiform seizures during prolonged etomidate sedation. Lancet, 1983, 2(8348):511-512.
26. Reddy RV, Moorthy SS, Dierdorf SF, et al. Excitatory effects and electroencephalographic correlation of etomidate, thiopental, methohexital and propofol. Anesth Analg, 1993, 77(5):1008-1011.
27. Voss LJ, Sleigh JW, Barnard JP, et al. The howling cortex:seizures and general anesthetic drugs. Anesth Analg, 2008, 107(5):1689-1703.
28. Kugler J, Doenicke A, Laub M. The EEG after etomidate. Anaesthesiol Resusc, 1977, 106(7):31-48.
29. 王新華, 劉樹孝, 王景陽, 等. 依托咪酯引起肌震顫與腦內多巴胺受體關系的實驗研究. 中華麻醉學雜志, 1991, 11(3):147-148.
30. Mizrak A, Koruk S, Bilgi M, et al. Pretreatment with dexmedetomidine or thiopental decreases myoclonus after etomidate:A randomized, double-blind controlled trial. J Surg Res, 2010, 159(1):e11-e16.
31. 陳金仙, 顧曉霞, 蔡樹云, 等. 右美托咪定滴鼻預處理對全麻誘導期依托咪酯不良反應的影響. 贛南醫學院學報, 2014, 34(3):381-383.

Chinese Journal of Evidence-Based Medicine

Efficacy and Safety of Midazolam in the Prevention of Etomidate-induced Myoclonus: A Meta-analysis

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