Effect of etomidate combined with propofol on pulmonary complications and quality of recovery after laparoscopic abdominal surgery in elderly patients: a clinical, randomized, controlled study

doi:10.21203/rs.3.rs-4896217/v1

Purpose

To observe the effect of etomidate combined with propofol on pulmonary complications and quality of recovery after laparoscopic abdominal surgery in elderly patients.

Methods

Ninety patients undergoing elective laparoscopic abdominal surgery, aged 65 ~ 87 years, American society of anesthesiologists (ASA) physical status II or III, were randomly allocated into three groups: propofol group (group P), etomidate group (group E) and etomidate combined with propofol group (group EP), 30 patients in each group. Group P received 2.5 mg/kg propofol for anesthesia induction, followed by 6 ~ 8 mg·kg^− 1·h^− 1 propofol to maintain anesthesia. Group E received 0.3 mg/kg etomidate for anesthesia induction, followed by 0.4 ~ 0.7 mg·kg^− 1·h^− 1 etomidate to maintain anesthesia. Group EP received 0.2 mg/kg etomidate combined with 1 mg/kg propofol for anesthesia induction, followed by 0.2 ~ 0.4 mg·kg^− 1·h^− 1 etomidate combined with 4 ~ 6 mg·kg^− 1·h^− 1 propofol to maintain anesthesia. The incidence of postoperative pulmonary complications (PPCs) was recorded as the primary indicator. Secondary indicators included mean arterial pressure (MAP) and heart rate (HR) before anesthesia induction (T0), after tracheal intubation (T1), 30min after anesthesia induction (T2), and at the end of surgery (T3), the levels of IL-6 and TNF-α before anesthesia induction (T0), at the end of surgery (T3), and 24 hours after surgery (T4), awakening time, time to tracheal extubation, postoperative nausea and vomiting (PONV) and quality of recovery-15 (QoR-15) scale scores 1 day before and after surgery.

Results

The incidence of PPCs in group EP and group E was significantly lower than that in group P (P < 0.05). Compare with T0, the MAP and HR at T2 and T3 were more stable in group EP (P < 0.05). The levels of IL-6 and TNF-α in groups EP and E were lower than those in group P at T3 and T4 (P < 0.05). Compared with group E, the incidence of PONV was significantly lower in group EP and group P (P < 0.05). The QoR-15 scale scores in group EP were higher than that in group P and group E (P < 0.05).

Conclusion

Combination of etomidate and propofol for anesthesia can reduce the incidence of PPCs, alleviate inflammatory response, achieved better hemodynamic stability, reduce the incidence of PONV and improve the postoperative recovery quality in elderly patients undergoing laparoscopic abdominal surgery.

Trial registration

ChiCTR2200065117.

etomidate

propofol

postoperative pulmonary complications

elderly

postoperative recovery

laparoscopy

Laparoscopic techniques are increasingly becoming a mainstay of surgical management, offering many benefits to patients, including improved cosmetic outcomes with smaller incisions, improved perioperative morbidity, reduced postoperative pain, and faster recovery^[1]. In laparoscopic surgery, carbon dioxide insufflations may have significant ventilatory consequences such as elevated intra-abdominal pressure and hypercarbia. Ventilatory consequences secondary to increased intra-abdominal pressure include increased airway pressure and decreased pulmonary compliance, which increases the incidence of postoperative pulmonary complications^{[2, 3]}. Age is one of the independent risk factors for PPCs. The older the patient, the higher the incidence of PPCs^[4]. Perioperative inflammation reaction can also increase the incidence of PPCs^[5]. PCCs can lead to prolong postoperative hospitalization and increase morbidity and mortality, so how to reduce PPCs is very important, especially for elderly patients.

Propofol is an alkylphenol compound, has been a transformative anesthetic since its introduction 40 years ago and is still considered a near-ideal anesthetic. Its success in the clinical setting is due to its rapid onset of action, short duration of action, rapid attainment of depth of sedation, and complete recovery^[6–8]. Etomidate is an imidazole derivative and a potent short-acting hypnotic intravenous anesthetic agent used in clinical medicine since 1972. It has the advantages of fast onset, short duration of action, minor effects on the respiratory and circulatory systems, and rapid recovery^{[9, 10]}. Yu et al found that propofol had protective effects on experimental rat neonatal acute lung injury^[11]. Li et al reported that etomidate might effectively decrease hyperoxia-induced acute lung injury (HALI) model by inhibiting inflammatory responses, improving antioxidant capacity, and upregulating the Nrf2/HO-1 pathway^[12]. Several studies have reported that the stimulation by etomidate combined with propofol can have a certain impact on the immune function in the body of humans^{[13, 14]}. And it has been shown that etomidate and propofol can be administrated in mixture without adversely affecting product characteristics^[15]. However, the effect of etomidate combined with propofol on PPCs and quality of recovery in laparoscopic abdominal surgery in elderly patients is unclear. Therefore, this study aims to observe the effects of etomidate plus propofol infusion on PPCs and quality of recovery in laparoscopic abdominal surgery in elderly patients.

Design and Patients

This study was approved by the Anqing Municipal Hospital Ethics Committee (Medical Ethics Approval No: 2022053) and registered in the Chinese Clinical Trial Registry (ChiCTR2200065117) following the Helsinki Declaration. Before surgery, all patients signed the informed consent form.

Ninety elderly patients undergoing general anesthesia for laparoscopic abdominal surgery were included in this study. The following inclusion criteria were applied: aged between 65 and 87 years old, Body Mass Index (BMI) between 19.2 and 26.8 kg/m², ASA physical status II-III, independent communication skills. Exclusion standards were as follows: upper respiratory tract infection within one month before surgery, history of surgery or mechanical ventilation within two weeks before surgery, history of thoracic surgery; comorbidities such as bronchial asthma, chronic obstructive pulmonary disease, thoracic and spinal deformities; treatment with radiotherapy and corticosteroids, significant cardiovascular and cerebral vascular disease, allergies to anesthesia medications used in the study, duration of the surgery < 2 hours, more than 1000 ml of bleeding during surgery, or refusal to participate in the trial.

Randomization and masking

A total of 90 patients were randomly divided into three groups using a random number table method based on their time of admission to the hospital: propofol group (group P), etomidate group (group E) and etomidate combined with propofol group (group EP), with 30 patients in each group. Due to differences in the rate of infusion of anesthetic agent, the anesthetists were aware of the group allocation. But they were not involved in the follow-up evaluation. Patient grouping information and anesthesia protocols were hidden in the envelopes and were not known to the assessors who performed the follow-up.

Anesthesia method

Before surgery, patients in three groups were required to fast for eight hours. No preoperative medication was given to all patients. Upon entering the operating room, venous access was established, preoxygenation was administered using a mask, and oxygen flow rate was set at 6 L/min. The patient's HR, MAP, peripheral oxygen saturation (SpO₂), bispectral index (BIS), train-of-four stimulation (TOF), temperature and partial pressure of end-tidal carbon dioxide (P_ETCO₂) were monitored using a multifunctional Philips-MP 40 monitor (Netherlands). Group P received 0.02 ~ 0.05 mg/kg midazolam (Jiangsu Nhwa Pharmaceutical Company, China, Lot No. H10980025), 0.5 µg/kg sufentanil (Yichang Renfu Pharmaceutical Company, China, Lot No. H20054171), 1.0 mg/kg rocuronium (Zhejiang Xianju Pharmaceutical Company, China, Lot No. H20093186), and 2.5 mg/kg propofol (Xi'an Lipan Pharmaceutical Company, China, Lot No. H20123318) for anesthesia induction, followed by 6 ~ 8 mg·kg^− 1·h^− 1 propofol and 6 ~ 15 µg·kg^− 1·h^− 1 remifentanil (Yichang Renfu Pharmaceutical Company, China, Lot No. H20030197) to maintain anesthesia. Group E received 0.02 ~ 0.05 mg/kg midazolam, 0.5 µg/kg sufentanil, 1.0 mg/kg rocuronium, and 0.3 mg/kg etomidate (Jiangsu Nhwa Pharmaceutical Company, China, Lot No. H20020511) for anesthesia induction, followed by 0.4 ~ 0.7 mg·kg^− 1·h^− 1 etomidate and 6 ~ 15 µg·kg^− 1·h^− 1 remifentanil to maintain anesthesia. Group EP received 0.02 ~ 0.05 mg/kg midazolam, 0.5 µg/kg sufentanil, 1.0 mg/kg rocuronium, and 0.2 mg/kg etomidate combined with 1 mg/kg propofol for anesthesia induction, followed by 0.2 ~ 0.4 mg·kg^− 1·h^− 1 etomidate combined with 4 ~ 6 mg·kg^− 1·h^− 1 propofol and 6 ~ 15 µg·kg^− 1·h^− 1 remifentanil to maintain anesthesia. After the patients were rendered unconscious, muscle relaxation was satisfied and the BIS value was 45 ~ 60, endotracheal intubation was performed using a portable video laryngoscope. Observe the waveform of P_ETCO₂ and auscultate both lungs to confirm the position of the tracheal tube, and then the Fabius Plus anesthesia machine (Germany) was connected, the volume control ventilation (VCV) was used, with the following settings: Tidal volume (VT) of 6 ~ 8 ml/kg, inspiration time/expiration time (I: E) of 1:2, and respiratory rate (RR) of 12 ~ 16 beats/min. Intraoperative CO₂ pneumoperitoneal pressure was set at 8 ~ 10 mmHg, P_ETCO₂ and BIS value were maintained at 35 ~ 45 mmHg and 45 ~ 60, respectively. Cis-atracurium 1 ~ 2 mg was administered according to the TOF ratio or surgical requirements. If MAP < 60 mmHg or HR < 45 beats/min occurred during the intraoperative period, ephedrine 6 mg and atropine 0.3 ~ 0.5 mg were given, respectively. Propofol, etomidate, and remifentanil were discontinued at the end of skin suture, ondansetron 4 mg was used intravenously as a prophylactic measure for postoperative nausea and vomiting. Postoperative analgesia was provided by patient-controlled intravenous analgesia (PCIA) with sufentanil 2 µg/kg plus 0.9% normal saline to make 100 mL (basal rate 2 ml/h, bolus 2 ml, and lockout time 15 min), meanwhile, sufentanil 0.1 µg/kg was injected 30 minutes before the end of surgery. Subsequently, the patient was transferred to the post-anesthesia care unit (PACU) with the tracheal tube retained. When BIS > 80, tidal volume > 6 ml/kg, TOF ratio ≥ 0.9, and respiratory rate > 13/min, postoperative extubation was performed, the patients were observed for 30 min before being transported back to their hospital room. Vital signs were closely monitored throughout the surgery, the patient's temperature was maintained between 36℃ ~ 37℃ by thermal insulation blanket.

Primary indicator

The incidence of postoperative pulmonary complications, including pulmonary infection, respiratory failure, pleural effusion, pulmonary atelectasis, and pneumothorax, should documented from the end of surgery until discharge from the hospital.

Secondary indicators

HR and MAP were monitored and recorded at several time points throughout the perioperative period, the detection time points included before anesthesia induction (T0), after tracheal intubation (T1), 30 min after anesthesia induction (T2), and at the end of surgery (T3). A total of 3 ml venous blood from the elbow was collected from the non-intravenous infusion side before anesthesia induction (T0), at the end of surgery (T3), 24 hours after surgery (T4), and centrifuged at 3,000×g for 10 min to separate the serum. The levels of IL-6 (BeJing Hotgen Biotech Co., Ltd, Batch No: C22110108) and TNF-α (Hotgen Langfang Biotech Co., Ltd, Batch No: C22120109) were detected by magnetic particle chemiluminescence immunoassay. Besides, the duration of operation, awakening time (defined as the time from the end of surgery to the call to open eyes), extubation time (defined as the time from end of surgery to tracheal tube extraction), postoperative nausea and vomiting were all recorded in three groups. The patients were evaluated by the same anesthesiologist using the QoR-15 scale 1 day before and after surgery. QoR-15 incorporates five dimensions of the patient's health (support, comfort, emotions, physical independence, and pain). It includes 15 items with scores ranging from 0 to 10, resulting in a maximum of 150 points, the higher the score, the better the quality of the recovery. In addition, patient demographic and clinical information such as age, sex, BMI, ASA physical status were gathered.

Sample size calculation

The sample size was calculated using PASS 11.0 according to the primary endpoint of the present study. This trial was a three-way comparison, and all pairwise comparisons were of interest. The results of our pilot study showed that the incidence of PPCs in all three groups were 7%, 9%, and 45%, respectively. Therefore, 27 patients in each group were required with an α of 0.05, and β = 0.1. Considering a dropout frequency of 10%, 30 patients per group were recruited (a total of 90 patients).

Statistical analysis

Continuous data were examined for normality with the Shapiro–Wilk test. Measures conforming to normal distribution were presented as mean values and standard deviations and analyzed using one-way analysis of variance (ANOVA). The nonparametric distribution of data were expressed as median and interquartile range (IQR) and analyzed using the Kruskal-Wallis test. Categorical data were summarized with counts and frequencies and compared using the chi-square test; a simulated chi-square test was employed in case of low cell entries.

A total of 98 participants were recruited for the study. Five participants did not meet the inclusion criteria, three refused to participate in the study, and 90 participants completed the study (Fig. 1).

There were no differences in age, sex, ASA grade, BMI, operation time, awaking time, extubation time, and type of surgery among the three groups (Table 1).

Table 1

Clinical Data of Patients
	Group E (n = 30)	Group P (n = 30)	Group EP (n = 30)	p value
Sex (male/female)	15/15	16/14	16/14	0.956
Age (years)	73.0 ± 6.6	71.6 ± 5.9	72.2 ± 5.5	0.653
ASA (Ⅱ/Ⅲ)	16/14	19/11	22/8	0.275
BMI(kg/m²)	22.9 ± 1.3	22.6 ± 1.5	22.9 ± 1.6	0.675
Operation time (min)	220.0 ± 39.5	213.8 ± 40.4	229.5 ± 39.9	0.315
Awaking time (min)	9.2 ± 1.5	8.7 ± 0.8	8.9 ± 1.1	0.348
Extubation time (min)	14.5 ± 1.3	15.1 ± 1.6	15.2 ± 1.4	0.110
Type of surgery, n
Gastrointestinal surgery, n (%)	19(63.3)	16(53.3)	15(50)	0.557
Liver surgery, n (%)	1(3.3)	1(3.3)	2(6.7)	0.770
Biliary surgery, n (%)	10(33.3)	13(43.3)	13(43.3)	0.659
Notes: Data are present as mean ± standard deviation or number (%).

Abbreviations: Group E, etomidate group; Group P, propofol group; Group EP, etomidate combined with propofol group; ASA, American Society of Anesthesiologists; BMI, Body mass index.

The incidence of PPCs in groups E and EP was significantly lower than that in group P (P < 0.05), and the incidence of postoperative nausea and vomiting in groups P and EP was significantly lower than that in group E (P < 0.05) (Table 2).

Table 2 Comparison of the incidence of postoperative pulmonary complications and nausea and vomiting among the three groups

	Group E (n=30)	Group P (n=30)	Group EP (n=30)	p value
Respiratory infection, n (%)	1(3.3)	6(20)	1(3.3)	0.032
Respiratory failure, n (%)	0(0)	1(3.3)	0(0)	0.364
Pleural effusion, n (%)	1(3.3)	4(13.3)	1(3.3)	0.200
Atelectasis, n (%)	1(3.3)	2(6.7)	0(0)	0.355
Pneumothorax, n (%)	0(0)	0(0)	0(0)
Total (PPCs), n (%)	3(10)^a	13(43.3)	2(6.7)^a	0.000
Nausea and vomiting, n (%)	11(36.7)	2(6.7)^b	3(10)^b	0.004

Notes: ^aP versus Group P and ^bP versus Group E, P < 0.05. Data are present as number (%).

Abbreviations: Group E, etomidate group; Group P, propofol group; Group EP, etomidate combined with propofol group; PPCs, postoperative pulmonary complications.

There was no significant difference in serum IL-6 and TNF-α concentrations among the three groups at T0(P > 0.05).Compared with T0, the serum IL-6 and TNF-α concentrations were significantly increased at T3 and T4 in the three groups (P < 0.05). Serum IL-6 and TNF-α concentrations in group E and group EP were significantly lower than those in group P at T3 and T4 (P < 0.05) (Table 3).

Table 3 Comparison of serum IL-6 and TNF-α concentrations at different time points among the three groups

	IL-6 (ng/L)			TNF-α (ng/L)
	T0	T3	T4	T0	T3	T4
Group E (n=30)	38.0±2.0	120.1±2.5^ab	87.9±2.7^ab	5.4±1.3	29.6±1.6^ab	13.9±1.1^ab
Group P (n=30)	38.7±2.1	145.0±1.9^b	115.3±2.2^b	5.2±1.3	45.1±1.9^b	27.1±1.1^b
Group EP (n=30)	38.2±2.1	119.9±2.1^ab	88.2±2.9^ab	5.4±1.1	29.9±1.3^ab	14.5±1.2^ab
p value	0.361	0.000	0.000	0.794	0.000	0.000

Notes: ^aP versus Group P, P < 0.05, ^bP versus T0, P < 0.05. Data are present as mean ± standard deviation.

Abbreviations: Group E, etomidate group; Group P, propofol group; Group EP, propofol combined with etomidate group; T0, before anesthesia induction; T3, the end of surgery; T4, 24 hours after surgery.

Compared with T0, MAP and HR of the three groups were significantly increased at T1(P < 0.05). Compared with T0, there was no significant difference in MAP and HR in group EP at T2 and T3 (P > 0.05). Compared with T0, MAP and HR in group P significantly decreased, and in group E significantly increased at T2 and T3 (P < 0.05) (Figure 2).

There was no difference in QoR-15 scores among the three groups one day before surgery (P > 0.05). The QoR-15 scores of the group EP was significantly higher than that of the groups E and P one day after surgery (P < 0.05) (Table 4).

Table 4 Comparison of QoR-15 scores at 1 day before and after operation

	Group E (n=30)	Group P (n=30)	Group EP (n=30)	p value
QoR-15 scores one day before surgery	127.5(126.0-130.0)	128.0(126.0-130.0)	128.0(126.0-129.0)	0.578
QoR-15 scores one day after surgery	110.0(109.0-111.0)	110.0(109.0-111.0)	118.0(117.0-119.0)^a	0.000

Notes: ^aP versus Group E and Group P, P < 0.05. Data are present as median (interquartile range).

Abbreviations: Group E, etomidate group; Group P, propofol group; Group EP, etomidate combined with propofol group.

The results of this study showed that combination of etomidate and propofol for anesthesia could reduce the incidence of PPCs, alleviate inflammatory response, achieved better hemodynamic stability, reduce the incidence of postoperative nausea and vomiting after laparoscopic abdominal surgery in elderly patients and improve the postoperative recovery quality.

The deterioration of physical reserve function and compensatory stress capacity in elderly individuals can lead to a decreased tolerance to anesthesia and surgery^[16]. Furthermore, postoperative adverse effects tend to increase in this population. PPCs are common, costly, and increase patient mortality^[17]. PPCs include respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm and aspiration pneumonitis according to European joint taskforce published guidelines for perioperative clinical outcome (EPCO) definitions^[18]. Surgery inevitably leads to inflammation due to tissue damage; patients with high levels of inflammatory factors may have systemic inflammatory response syndrome, which may further develop into multiple organ dysfunction such as lung injury^[19,20]. IL-6 and TNF-α are acute inflammatory regulatory factors that have a favorable effect on the body's immunity and inflammatory response. They can reflect the degree of lung injury in the early stage, and their concentrations are directly proportional to the degree of lung function injury^[21-24]. Our results found that IL-6 and TNF-α in three groups increased after operation, and then decreased gradually at 24 h, which was due to the release of pro-inflammatory factors caused by the stimulation of operation, and then the body began to adjust gradually. Karacaer et al showed that propofol provided better anti-inflammatory effect than sevoflurane in children with cyanotic congenital heart disease^[25]. Roh et al found that propofol attenuated inflammatory reaction in patients undergoing robot-assisted laparoscopic radical prostatectomy^[26]. Zheng et al discovered that compared with propofol, etomidate could improve the inflammatory response in patients undergoing lung adenocarcinoma resection^[27]. Tian et al reported that etomidate combined with propofol could effectively decrease the levels of inflammatory factors in gastric cancer patients^[28]. The present study observed that the levels of IL-6 and TNF-α at T3 and T4 were significantly lower in the groups E and EP than in the group P. It suggested that etomidate or etomidate combined with propofol further attenuated the body's inflammatory response, which might help to reduce the incidence of PPCs by alleviating inflammation-induced acute lung injury.

The stability of hemodynamics during perioperative anesthesia helps to reduce the incidence of cardiovascular and cerebrovascular complications in elderly patients^[29]. Propofol can act on vascular smooth muscle or cause sympathetic nerve activity to weaken and cause vasodilation, which leads to hypotension. Etomidate can not inhibit sympathetic nerve tension and myocardial function, so it has good stability on cardiovascular function and hemodynamics^[30,31]. Dhingra et al found that etomidate offered better hemodynamic and respiratory stability than propofol^[32]. The results of this study found that MAP and HR were more stable in the group EP at T2 and T3 compared with the groups E and P. It suggested that etomidate combined with propofol could better maintain the stability of hemodynamics in elderly patients, which may be related to the small effect of etomidate itself on hemodynamics and the reduction of propofol dosage.

PONV is one of the common complications after surgical procedures, it not only leads to subjective discomfort in patients but also increases the risk of water and electrolyte imbalance disorder, aspiration pneumonia, suture tension, and esophageal rupture. In addition, it may also prolong the length of hospital stay, pay additional medical expenses, and affect the postoperative recovery of patients^[33]. In recent years, the anti-nausea and vomiting effects of propofol have been found and confirmed^[34]. Compared with traditional anti-nausea and vomiting drugs, propofol can not only reduce the incidence of nausea and vomiting but also has an anti-anxiety effect^[35]. The exact mechanism of propofol in the prevention and treatment of nausea and vomiting is still unknown. The possible mechanism of action is the inhibition of the central nervous system (CNS), which acts on the chemical trigger band of the post-polar region, including the enhancement of γ-aminobutyric acid (GABA), anti-dopamine, anti-5-HT₃ effect, and the indirect effects of sedation^[36-38]. In our study, we found that the incidence of PONV was significantly lower in groups P and EP than that in group E, However, there was no significant difference between group P and group EP, This may be related to the anti-nausea and vomiting effects of propofol.

Current perioperative treatment for improving surgical patients' recovery emphasizes the patient's subjective postoperative experience rather than just morbidity endpoints in light of the remarkable advancements in sedation, pain control, and surgical methods. The quality of recovery (QoR) score is an objective measure of patient-centered general health status after surgery and anesthesia. Its latest version, QoR-15, is characterized by time efficiency and a high rate of response and completion, and it has validity in patients undergoing various surgical procedures^[39]. Reducing postoperative PONV was important factor for improving the quality of recovery after surgery^[40]. Study have shown that intraoperative intravenous s-ketamine can attenuate the postoperative inflammatory response of patients, thus improving the quality of recovery^[41]. The results of this study showed that the total QoR-15 score in group EP was higher than that in groups E and P 1 day after surgery, indicating that etomidate combined with propofol can improve the quality of postoperative recovery of patients. This may be related to the fact that etomidate combined with propofol reduces nausea and vomiting and attenuate inflammatory response.

Our study has certain limitations that need to be acknowledged. Firstly, the sample size is small, and the study was conducted at a single center. As such, larger sample sizes and multi-center participation are necessary to obtain more reliable and generalizable results. Secondly, our study only observed the quality of recovery on the first day after surgery, and the quality of recovery for a further period postoperatively was not evaluated, nor was the length of postoperative hospitalization and hospitalization costs observed, which needs further research.

Combination of etomidate and propofol for anesthesia can reduce the incidence of postoperative pulmonary complications (PPCs), alleviate inflammatory response, achieved better hemodynamic stability, reduce the incidence of postoperative nausea and vomiting and improve the postoperative recovery quality in elderly patients undergoing laparoscopic abdominal surgery. These findings suggest that etomidate combined with propofol may be a superior choice for anesthesia in elderly patients.

ASA: American society of anesthesiologists; PPCs: postoperative pulmonary complications; MAP: mean arterial pressure; HR: heart rate; PONV: postoperative nausea and vomiting; QoR-15: Quality of recovery-15; HALI: hyperoxia-induced acute lung injury; BMI: Body Mass Index; SpO₂: peripheral oxygen saturation; BIS: bispectral index; TOF: train-of-four stimulation; P_ETCO₂: partial pressure of end-tidal carbon dioxide; VCV: volume control ventilation; VT: Tidal volume; RR: respiratory rate; PCIA: patient-controlled intravenous analgesia; PACU: post-anesthesia care unit; ANOVA: one-way analysis of variance; IQR: interquartile range; EPCO: perioperative clinical outcome; CNS: central nervous system; GABA: γ-aminobutyric acid.

Ethics approval and consent to participate:

This study was approved by the Anqing Municipal Hospital Ethics Committee (Medical Ethics Approval No: 2022053) and registered in the Chinese Clinical Trial Registry (ChiCTR2200065117) following the Helsinki Declaration. Before surgery, all patients signed the informed consent form.

Consent for publication:

Not applicable.

Availability of data and materials:

The datasets used and/or analyzed during the current study are available from the corresponding author (Shengbin Wang, [email protected]) on reasonable request.

Competing interests:

The authors declare that they have no competing interests.

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions:

Xing Wang, Xia Ju, Siqi Xu, Shengbin Wang designed the study. Xing Wang, Xia Ju, Jinjuan Duan and Teng Shu collected the data. Xing Wang and Shengbin Wang revised the manuscript. Siqi Xu and Shengbin Wang interpreted the data. All authors read and approved the final version of the manuscript.

Acknowledgements:

Not applicable.

Authors' information:

¹Department of Anesthesiology, Affiliated Anqing Medical Centre of Anhui Medical University, Anqing Municipal Hospital, Anqing, China. Xing Wang, Email: [email protected]; Xia Ju, Email: [email protected]; Jinjuan Duan, Email: [email protected]; Teng Shu, Email: [email protected].

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No competing interests reported.

Effect of etomidate combined with propofol on pulmonary complications and quality of recovery after laparoscopic abdominal surgery in elderly patients: a clinical, randomized, controlled study

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Trial registration

Figures

Introduction

Data and Methods

Design and Patients

Randomization and masking

Anesthesia method

Primary indicator

Secondary indicators

Sample size calculation

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1