Etomidate-propofol combination in painless gastrointestinal endoscopy for elderly patients: A comparative study

Abstract

BACKGROUND

Elderly patients often display age-related physiological decline, which increases their susceptibility to complications during medical procedures. Therefore, it is clinically imperative to refine anesthetic protocols for painless gastroscopy in this vulnerable population.

AIM

To explore the effects of the etomidate-propofol combination on anesthesia quality, compliance, and adverse reactions in elderly patients undergoing painless gastrointestinal endoscopy.

METHODS

A total of 103 elderly patients scheduled for painless gastrointestinal endoscopy at the Hospital of Wuhan Economic and Technological Development Zone (Hannan District) between October 2022 and October 2024 were enrolled. The participants were divided into a control group (n = 50) receiving propofol anesthesia and an observation group (n = 53) that received a combination of etomidate and propofol anesthesia. The anesthesia quality (including induction time, recovery time, and orientation recovery time), compliance, hemodynamic parameters (heart rate, oxygen saturation, systolic/diastolic blood pressure), adverse reactions (muscle tremors, injection pain, respiratory depression, hypotension, and nausea/vomiting), and analgesic and sedative effects [evaluated using the visual analog scale (VAS) and Ramsay score] were comparatively analyzed.

RESULTS

The observation group had significantly shorter anesthesia induction, recovery, and orientation recovery times than the control group. Moreover, the observation group showed higher compliance; greater hemodynamic stability at preanesthesia (T0), during anesthesia (T1), and postrecovery (T2) time points; and a significantly lower incidence of adverse reactions. The VAS and Ramsay scores at 5, 30, and 60 minutes after anesthesia recovery were also significantly lower in the observation group than in the control group.

CONCLUSION

The etomidate-propofol combination for painless gastrointestinal endoscopy in elderly patients may provide superior anesthesia quality and improved compliance and safety, making it a promising approach for clinical application.

Key Words: Etomidate; Propofol; Painless gastrointestinal endoscopy; Anesthesia quality; Compliance; Adverse reactions

Core Tip: The choice of anesthesia plays a pivotal role in ensuring both safety and efficacy during painless gastroscopy. This study enrolled 103 elderly patients scheduled for painless gastrointestinal endoscopy and systematically compared propofol monotherapy with a combined etomidate-propofol regimen. Comprehensive evaluations of anesthesia quality, patient compliance, hemodynamic stability, adverse events, and sedation-analgesia efficacy demonstrated that the etomidate-propofol combination provides distinct clinical advantages for such patients. These results support its adoption as a preferred anesthetic strategy for elderly patients undergoing painless gastrointestinal endoscopy.

INTRODUCTION

Painless gastrointestinal endoscopy, a widely adopted diagnostic and therapeutic modality, is extensively used for the screening and diagnosis of various gastrointestinal disorders, such as reflux esophagitis, esophageal carcinoma, gastric and duodenal ulcers, and gastric malignancies, facilitating the timely and accurate identification of gastrointestinal pathologies[1]. Worldwide, millions of such procedures are performed annually[2]. Conventional gastrointestinal endoscopy without anesthesia is associated with significant physiological stress, potentially causing adverse events such as asphyxia, nausea, vomiting, increased catecholamine secretion, tachycardia, cerebral hemorrhage, and myocardial ischemia, thereby causing considerable discomfort and distress to patients[3]. Conversely, painless gastrointestinal endoscopy, which involves the administration of anesthesia to induce a state of unconsciousness, effectively mitigates these adverse physiological responses and reduces the risk of complications, such as bleeding and perforation, resulting from poor patient compliance[4-6]. This approach aligns with the increasing emphasis on patient comfort and satisfaction in modern medical practice[7]. Consequently, the selection of safe and effective anesthetic agents is of paramount importance for optimizing the outcomes of painless gastroscopy.

Elderly patients, who often face a higher risk of complications due to age-related physiological decline and comorbidities, continue to experience higher rates of morbidity and mortality despite advancements in anesthetic techniques[8]. Hence, refining anesthesia management for painless gastroscopy in elderly patients is a critical clinical priority[9]. Propofol, a widely used intravenous anesthetic, is favored for its rapid onset, short duration of action, and quick recovery profile, making it a common choice for painless gastrointestinal endoscopy[10]. Nevertheless, its use is associated with drawbacks, such as injection pain, respiratory depression, and inadequate anesthetic depth, which may result in involuntary patient movements, thus limiting its clinical utility[11,12]. Etomidate, another commonly used intravenous anesthetic, provides distinct advantages, such as rapid response speed, short response time, and high safety, with minimal effect on the respiratory and circulatory systems, making it a suitable alternative, particularly in high-risk populations[13]. According to a study by Hong and Park[14], etomidate may serve as a viable alternative to propofol in gastrointestinal endoscopy, particularly for hemodynamically unstable patients or elderly patients undergoing gastrointestinal endoscopy, due to its favorable safety profile.

Despite these insights, research on the etomidate-propofol combination in elderly patients undergoing painless gastrointestinal endoscopy is limited, particularly regarding its effect on anesthesia quality, patient compliance, and the incidence of adverse reactions. Therefore, this study was conducted to address this gap by investigating the efficacy and safety of this combined anesthetic approach, with the aim of providing a more effective and safe option for anesthesia management in such patients.

MATERIALS AND METHODS

Case selection

A cohort of 103 elderly patients scheduled for painless gastrointestinal endoscopy at the Hospital of Wuhan Economic and Technological Development Zone (Hannan District) was enrolled in this study. The recruitment period was extended from October 2022 to October 2024. Participants were divided into the control group (n = 50), which received propofol anesthesia, and the observation group (n = 53), which received a combined regimen of etomidate and propofol anesthesia.

Inclusion and exclusion criteria

Inclusion criteria: Patients indicated for painless gastrointestinal endoscopy with American Society of Anesthesiologists (ASA) physical status classification of I-II[15], clear clinical indications for both gastrointestinal endoscopy and anesthesia[16], normal auditory and verbal communication abilities, no history of surgical anesthesia within the previous month, nonemergency cases, excluding conditions such as acute gastrointestinal hemorrhage, and availability of complete clinical documentation were included.

Exclusion criteria: Patients with hypersensitivity to propofol, etomidate, or related anesthetic agents; active asthma exacerbation or pulmonary heart disease; history of cerebrovascular disorders, traumatic brain injury, or intracranial surgery; immune system dysfunction; concurrent diagnosis of other malignant neoplasms; impaired cardiac function (e.g., heart failure); documented history of anesthesia-related allergic reactions; severe metabolic or endocrine dysfunction; primary cognitive impairment or dementia; and history of chronic alcoholism or psychiatric disorders were excluded.

Anesthesia and examination procedures

One day before gastrointestinal endoscopy, patients were advised to adopt a semiliquid diet and complete all necessary preprocedural preparations. A fasting period of 8-12 hours was enforced, during which patients abstained from both food and fluids. Upon arrival, patients were positioned in the left lateral decubitus position, and intravenous access was established. Oxygen supplementation was provided using a face mask, and the vital signs was continuously monitoring throughout the procedure.

Patients in the control group received propofol as the sole anesthetic agent, which was administered intravenously at a dosage of 1-1.5 mg/kg administered over a period of 60 seconds.

Patients in the observation group received a combined anesthetic regimen consisting of etomidate and propofol. The anesthesia protocol was implemented as follows: First, an intravenous infusion of a mixture containing fentanyl (50 µg) and lidocaine (30 mg) was administered, and then propofol was dripped at a dosage of 1-1.5 mg/kg for 60 seconds. Next, intravenous administration of etomidate was provided at a dosage of 0.15-0.3 mg/kg. All medications were administered via slow intravenous injection. The depth of anesthesia was evaluated by the loss of the eyelash reflex and the absence of response to verbal commands, which served as indicators of successful anesthesia induction. After achieving these criteria, gastroscopy was started. In the event of intraoperative complications, such as coughing, body movement, and other signs of inadequate anesthesia, supplemental doses of propofol were administered to maintain the desired anesthetic depth.

Outcome measures

Anesthesia quality: Anesthesia quality was evaluated by measuring and recording the anesthesia induction, recovery, and orientation recovery times for both groups.

Compliance: Patient compliance was evaluated using a standardized, institution-developed questionnaire. Healthcare providers objectively evaluated patient compliance during the procedure, categorizing it as follows: Full compliance (80-100 points), wherein patients demonstrated complete cooperation; partial compliance (60-79 points), wherein patients showed moderate cooperation; and noncompliance (≤ 59 points), wherein patients demonstrated poor cooperation. The overall compliance rate was calculated as the percentage of patients achieving full or partial compliance compared with the total cohort.

Hemodynamic parameters: Hemodynamic stability was monitored using a patient monitoring system at the following three predefined time points: Preanesthesia (T0), during anesthesia (T1), and postrecovery (T2). The parameters measured were heart rate (HR), oxygen saturation (SpO₂), systolic blood pressure (SBP), and diastolic blood pressure (DBP).

Adverse reactions: The incidence of adverse reactions, including muscle tremors, injection pain, respiratory depression, hypotension, and nausea/vomiting, was documented for both groups, after which the total adverse reaction rate was calculated.

Analgesic and sedative effects: Analgesic and sedative effects were evaluated at 5, 30, and 60 minutes postanesthesia recovery. Analgesia was evaluated using the visual analog scale (VAS), with scores ranging from 0 (no pain) to 10 (worst pain), with higher scores indicating inferior analgesic efficacy. Sedation levels were measured using the Ramsay Sedation Scale, which was scored as follows: 1 point: Agitated or restless; 2 points: Cooperative and calm; 3 points: Drowsy but responsive to commands; 4 points: Asleep but easily aroused; 5 points: Sluggish response to stimuli; and 6 points: Deeply asleep, unarousable. A score of 2-4 was classified as satisfactory sedation, whereas a score of > 4 indicated oversedation[17].

Statistical analysis

Continuous variables are expressed as mean ± SEM. Intergroup comparisons of continuous data were performed using independent samples t-tests, and intragroup comparisons (e.g., pretreatment and posttreatment) were performed using paired t-tests. Categorical variables were expressed as proportions (percentages), and intergroup comparisons were conducted using χ² tests. All statistical analyses were performed using SPSS version 20.0. P < 0.05 indicated a statistically significant difference.

RESULTS

Comparison of baseline characteristics between groups

Baseline characteristics, including sex, age, weight, body mass index, and ASA classification, were comparable between the observation and control groups (P > 0.05). The detailed data are summarized in Table 1.

Table 1 Comparison of baseline characteristics.

Baseline characteristics	Control group (n = 50)	Observation group (n = 53)	χ2/t	P value
Gender (male/female)	26/24	31/22	0.439	0.508
Age (years)	68.56 ± 4.90	69.55 ± 6.14	0.901	0.370
Weight (kg)	69.74 ± 10.55	69.30 ± 10.47	0.212	0.832
BMI (kg/m2)	23.58 ± 2.23	23.19 ± 2.44	0.845	0.400
ASA classification (I/II)	28/22	29/24	0.017	0.896

BMI: Body mass index; ASA: American Society of Anesthesiologists.

Comparison of anesthesia quality between groups

Significant differences in anesthesia quality were observed between the two groups. The observation group exhibited markedly shorter anesthesia induction, recovery, and orientation recovery times than the control group (P < 0.01). These data are illustrated in Figure 1.

Figure 1 Comparison of anesthesia quality. A: Comparison of anesthesia induction time; B: Comparison of recovery time; C: Comparison of orientation recovery time. ^bP < 0.01, compared to the control group.

Comparison of compliance between groups

Compliance rates were significantly different between the two groups. In the control group, 18 patients showed full compliance, 20 demonstrated partial compliance, and 12 were noncompliant. In contrast, 28 patients showed full compliance, 22 exhibited partial compliance, and only 3 were noncompliant in the observation group. The overall compliance rate was significantly higher in the observation group (P < 0.05). The detailed results are presented in Table 2.

Table 2 Comparison of compliance, n (%).

Compliance	Control group (n = 50)	Observation group (n = 53)	χ2	P value
Full compliance	18 (36.00)	28 (52.83)
Partial compliance	20 (40.00)	22 (41.51)
Non-compliance	12 (24.00)	3 (5.66)
Patient compliance	38 (76.00)	50 (94.34)	6.955	0.008

Comparison of hemodynamic parameters between groups

Regarding hemodynamic stability, there were no significant intergroup differences in HR, SpO₂, SBP, or DBP at T0 (P > 0.05). In the control group, all hemodynamic parameters significantly declined at T1 (P < 0.05) and partially recovered at T2 (except for SpO₂, P < 0.05). Conversely, the observation group maintained stable hemodynamic parameters at T1 and T2 compared with those at T0 (P > 0.05). Remarkably, the observation group demonstrated significantly higher hemodynamic values at T1 and higher SpO₂ and SBP at T0 than the control group (P < 0.05). These data are depicted in Figure 2.

Figure 2 Comparison of hemodynamic parameters. A: Heart rate levels across time points; B: Oxygen saturation levels across time points; C: Systolic blood pressure levels across time points; D: Diastolic blood pressure levels across time points. ^aP < 0.05 compared to T0; ^bP < 0.01 compared to T0; ^cP < 0.05, compared to the control group; HR: Heart rate; SpO₂: Oxygen saturation; SBP: Systolic blood pressure; DBP: Diastolic blood pressure.

Comparison of adverse reactions between groups

Adverse events in the control group included muscle tremors (4 cases), injection pain (5 cases), respiratory depression (2 cases), hypotension (3 cases), and nausea/vomiting (4 cases). These events were less frequent in the observation group, with 1 case of muscle tremors, 3 cases of injection pain, 0 cases of respiratory depression, 1 case of hypotension, and 2 cases of nausea/vomiting. The total adverse reaction rate was significantly lower in the observation group than in the control group (P < 0.05). Table 3 presents the detailed results.

Table 3 Comparison of adverse reactions, n (%).

Adverse reactions	Control group (n = 50)	Observation group (n = 53)	χ2	P value
Muscle tremors	4 (8.00)	1 (1.89)
Injection pain	5 (10.00)	3 (5.66)
Respiratory depression	2 (4.00)	0 (0.00)
Hypotension	3 (6.00)	1 (1.89)
Nausea/vomiting	4 (8.00)	2 (3.77)
Total	18 (36.00)	7 (13.21)	7.272	0.007

Comparison of the analgesic and sedative effects between groups

The analgesic and sedative effects were evaluated at 5, 30, and 60 minutes postanesthesia. The observation group consistently achieved significantly lower VAS and Ramsay scores than the control group (P < 0.01). These findings are depicted in Figure 3.

Figure 3 Comparison of analgesic and sedative effects. A: Visual analog scale scores across time points; B: Ramsay scores across time points. ^bP < 0.01, compared to the control group; VAS: Visual analog scale.

DISCUSSION

Elderly patients, who are characterized by compromised respiratory function and a high prevalence of comorbidities, are particularly vulnerable to significant discomfort (e.g., reflexive spasms, nausea, and vomiting) during painless gastrointestinal endoscopy. These adverse reactions often engender fear and reluctance toward the procedure, thereby substantially diminishing patient compliance[18]. Consequently, the selection of an optimal anesthetic regimen is imperative to ensure both efficacy and safety in this demographic population.

The present study demonstrated that the etomidate-propofol combination confers superior anesthetic quality for elderly patients undergoing painless gastrointestinal endoscopy. Specifically, this regimen is associated with significantly reduced anesthesia induction time, recovery time, and orientation recovery time compared with propofol monotherapy. Furthermore, patients receiving the combined regimen exhibited improved procedural compliance. Hemodynamically, the etomidate-propofol combination demonstrated greater stability than propofol alone, maintaining more consistent hemodynamic parameters throughout the procedure. From a safety perspective, the incidence of adverse reactions-such as myoclonus, injection pain, respiratory depression, hypotension, nausea, and vomiting-was markedly lower in the etomidate-propofol group. Moreover, the combined regimen provided superior analgesic and sedative effects at 5, 30, and 60 minutes postanesthesia. The clinical efficacy of etomidate can be partially attributed to its active metabolite, hydroxyimidazole carboxylic acid, which mitigates respiratory depression and promotes hemodynamic stability, which partially explains the clinical advantages of etomidate anesthesia for elderly patients undergoing painless gastrointestinal endoscopy[19-21]. In addition, the etomidate-propofol combination allows for a reduction in the required dosage of each agent. The 20% medium- and long-chain triglycerides in etomidate effectively dilute the propofol concentration and inhibit bradykinin release, thereby minimizing vascular irritation. This combination also attenuates the cardiovascular and respiratory suppression associated with high-dose propofol administration, contributing to improved hemodynamic stability and overall safety during anesthesia[22,23]. Supporting our findings, Luo et al[24] reported that the etomidate-propofol combination in patients undergoing bidirectional endoscopy reduced propofol dosage, decreased the incidence of cardiovascular adverse events and respiratory depression, and improved satisfaction among patients, endoscopists, and anesthesiologists. Similarly, Zhang et al[25] observed that the etomidate-propofol combination provided superior hemodynamic stability compared with remimazolam besylate monotherapy in ASA I-II elderly patients undergoing gastrointestinal endoscopy, consistent with our results. Liu et al[26] further highlighted the favorable hemodynamic profile of the etomidate-propofol mixture in patients undergoing radical gastrectomy under general anesthesia, further corroborating our findings. Furthermore, evidence has demonstrated that a 1:1 mixture of 10 mL etomidate and 10 mL propofol, when combined with dezocine, provides stable hemodynamics and high clinical safety in painless gastroscopy, emphasizing the potential advantages of this anesthetic combination[27]. Another study reported a significantly lower incidence of injection pain with the etomidate-propofol combination, suggesting its intrinsic analgesic properties, which is consistent with our observations[28]. Zhou et al[29] also reported that the sedative efficacy of the etomidate-propofol combination during gastroscopy surpassed that of propofol alone, further validating our findings.

This study provides three significant advances in geriatric anesthesia practice: First, the findings establish a clinically superior anesthetic approach for elderly patients undergoing painless gastrointestinal endoscopy, providing practitioners with an evidence-based alternative to conventional protocols. Second, the demonstrated reduction in postoperative pain and agitation with the combined regimen translates into measurable improvements in patient compliance, comfort, and procedural tolerance, improving patient experience and increasing the acceptance of gastrointestinal endoscopy in this population. Most importantly, this study addresses a critical knowledge gap in literature on geriatric anesthesia by providing robust clinical data to guide decision-making for this vulnerable patient group. However, several limitations should be acknowledged. First, the moderate sample size (n = 103), although adequate for initial evaluation, warrants expansion in subsequent multicenter trials to confirm generalizability across diverse clinical settings and evaluate the long-term effects of the anesthesia regimen on delayed adverse reactions or cognitive function. Second, our study design did not incorporate dose-response analyses; future investigations should systematically investigate optimal etomidate-propofol ratios and develop precision dosing algorithms tailored to individual patient characteristics. Perhaps most remarkably, the mechanistic aspects of our observed clinical benefits-particularly regarding stress response modulation and inflammatory pathway regulation-remain to be fully characterized. These knowledge gaps represent important directions for our ongoing research programs.

CONCLUSION

The etomidate-propofol combination is a superior anesthetic strategy for elderly patients undergoing painless gastrointestinal endoscopy than propofol monotherapy. This approach not only shortens anesthesia induction, recovery, and orientation recovery times but also ensures hemodynamic stability and improves procedural compliance and clinical safety. Moreover, this combination facilitates rapid cognitive recovery, making it a highly effective and safe option for this vulnerable patient population. Considering these compelling findings, we strongly advocate for the inclusion of etomidate-propofol combination therapy as a recommended option in clinical practice guidelines for anesthesia management during painless gastrointestinal endoscopy in geriatric populations. Should subsequent cost-benefit evaluations confirm the economic advantages of this combined regimen, proactive measures should be implemented to incorporate it into national health insurance coverage policies, thereby improving patient access and alleviating financial constraints associated with endoscopic procedures.