Does etomidate increase vasopressor requirements in patients needing mechanical ventilation?
ABSTRACT Single-dose etomidate is used as an induction agent for rapid-sequence intubation and is associated with transient adrenal insufficiency. There is ongoing debate as to the clinical consequences of this transient adrenal insufficiency for critically ill patients.
To determine if the use of etomidate is associated with higher requirements for a vasopressor, relative to other induction agents, at a single time point (24 h after administration of the induction agent) in patients needing mechanical ventilation.
In this retrospective observational study utilizing electronic health records, a convenience sample of 50 patients who had undergone intubation in the emergency department with etomidate were matched (1:1) with patients who had received other induction agents. Matching was based on primary admitting diagnosis relating to the cause of shock, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, age, and sex. All patients were subsequently admitted to critical care areas for management. As a surrogate marker of hemodynamic instability, the vasopressor dose was recorded 24 h after intubation. Vasopressor doses were converted to norepinephrine equivalents for comparison.
The mean dose of vasopressors, in norepinephrine equivalents, was 4 μg/min(-1) for patients receiving etomidate and 3 μg/min(-1) for the control group (mean difference 0.7 μg min(-1), 95% confidence interval [CI] -1.9 to 3.2 μg min(-1), p = 0.61). Twelve of the patients in the etomidate group and 16 of those in the control group required the use of vasopressors at 24 h following intubation (odds ratio 2.3, 95% CI 0.53 to 13.99, p = 0.34).
Single-dose etomidate does not adversely affect hemodynamic stability, as measured by the dose of vasopressors required at 24 h after administration.
Article: Adrenal suppression following a single dose of etomidate for rapid sequence induction: a prospective randomized study.[show abstract] [hide abstract]
ABSTRACT: The administration of etomidate for rapid sequence induction (RSI) has been linked to subsequent adrenocortical insufficiency in nontrauma patients. However, etomidate-related adrenocortical insufficiency has not been well studied in the trauma population. We performed a prospective, randomized, controlled study to assess the effect of one dose of etomidate for RSI on adrenal function and its clinical significance during and after resuscitation in trauma patients. Adult trauma patients admitted to our Level I trauma center requiring RSI were randomized to receive etomidate 0.3 mg/kg and succinylcholine 1 mg/kg (E group) or fentanyl 100 microg, midazolam 5 mg, and succinylcholine 1 mg/kg (FM group) for induction. A baseline serum cortisol level was drawn before RSI. Four to six hours after RSI, a postintubation serum cortisol level was drawn. An ACTH stimulation test was performed. Thirty patients were enrolled: 18 E group patients and 12 FM group patients. No statistical difference was detected between the two groups with respect to age, injury severity score, and baseline serum cortisol. Mean serum cortisol levels were significantly lower in E group patients than in FM group patients 4 to 6 hours after intubation (18.2 vs. 27.8 mug/dL, p < 0.05). Change in serum cortisol between baseline and postintubation levels was different (-12.8 mg/dL +/- 9.6 microg/dL vs. 1.1 microg/dL +/- 7.6 microg/dL, p < 0.01). Patients in the E group had an average increase in cortisol after ACTH administration of 4.2 microg/dL +/- 4.9 microg/dL vs. 11.2 microg/dL +/- 6.1 microg/dL in the FM group, p < 0.001. Patients in the E group required longer ICU lengths of stay (mean, 6.3 days vs. 1.5 days, p < 0.05), more ventilator days (mean, 28 days vs. 17 days, p < 0.01), and longer hospital lengths of stay (mean, 11.6 days vs. 6.4 days, p < 0.01). The use of etomidate for RSI in trauma patients led to chemical evidence of adrenocortical insufficiency and may have contributed to increased hospital and ICU lengths of stay and increased ventilator days. Further studies should be considered to evaluate the safety profile of this drug in trauma patients.The Journal of trauma 10/2008; 65(3):573-9. · 2.48 Impact Factor
Article: Should etomidate be used for rapid-sequence intubation induction in critically ill septic patients?[show abstract] [hide abstract]
ABSTRACT: Etomidate is an agent often used by emergency medicine physicians for rapid-sequence intubation induction of critically ill patients because of its reliable pharmacokinetics and cardiovascular stability. Etomidate is known to inhibit endogenous cortisol production through inhibition of 11beta-hydroxylase. Previous studies in undifferentiated emergency department patients and healthy, elective surgical patients have shown this effect to be only transient and not clinically significant. Recent retrospective studies in the pediatric and adult intensive care literature have shown an association between a single induction dose of etomidate in critically ill septic patients and sustained suppression of the adrenal axis with an increase in mortality. It is unknown at this time if any increase in mortality associated with etomidate-induced adrenal suppression would be offset by concomitant corticosteroid administration. Aggressive resuscitation of septic patients with fluids, antibiotics, and vasopressors has been shown to significantly reduce mortality and may allow for the use of alternative agents that had previously been discouraged because of concern for hemodynamic collapse during intubation. A prospective randomized trial in septic patients of etomidate induction with early corticotropin stimulation testing or corticosteroid supplementation vs the use of alternative induction agents with enough power to detect differences in mortality is needed to further address this clinical dilemma.The American journal of emergency medicine 03/2008; 26(2):229-32. · 1.54 Impact Factor