Does etomidate increase vasopressor requirements in patients needing mechanical ventilation?

, BScPharm, ACPR, is a Clinical Pharmacist with Vancouver General Hospital, Vancouver, British Columbia.
The Canadian journal of hospital pharmacy 07/2012; 65(4):272-6. DOI: 10.4212/cjhp.v65i4.1157
Source: PubMed


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.

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    • "However, neither of these studies was powered to detect a difference in mortality. Several observational or retrospective studies have also evaluated etomidate use in septic patients compared with other RSI agents, and again a significant difference in morbidity and mortality in the etomidate group was not observed [8] [9] [10] [11]. "
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    ABSTRACT: Purpose To characterize risk factors for mortality in septic patients who received etomidate for rapid sequence intubation. Materials and Methods This study was a retrospective cohort conducted at a large, tertiary, urban, academic medical center that included patients with severe sepsis or septic shock who received etomidate between January 1, 2010, and December 31, 2012. Results A total of 169 patients were included with similar baseline characteristics. There were more men in the nonsurvivor group than in the survivor group (67.1% vs 50.6%, P =.03). Septic shock occurred in 91.5% of nonsurvivors and 69% of survivors (P <.01). Nonsurvivors also had a higher initial lactate of (5.1 ± 4.3 mmol/L vs 3.6 ± 3.4 mmol/L, P =.02) and more vasopressor therapy (91.5% vs 69%, P <.01), required a higher number of vasopressors (2.2 ± 1.1 vs 1.3 ± 1, P <.01), and were administered hydrocortisone (53.7% vs 34.5%, P =.01). Abdominal source of sepsis (P =.048) and number of vasopressors (P =.01) were predictive of 30-day mortality. Conclusion An alternative sedative induction agent may be considered for use in rapid sequence intubation in patients on multiple vasopressors or with abdominal source of infection.
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    ABSTRACT: Background: The study aimed to evaluate and compare the effects of a single dose of etomidate and the use of a steroid injection prior to etomidate during rapid sequence intubation on hemodynamics and cortisol levels. Methods: Sixty patients were divided into three groups (n=20). Before intubation, and at 4 and 24 hours, blood samples were taken for cortisol measurements and hemodynamic parameters (systolic-diastolic-mean arterial pressure, heart rate), and SOFA scores were recorded. Intubation was achieved with 0.3 mg/kg etomidate IV in Group I, 0.3 mg/kg etomidate following 2 mg/kg methylprednisolone IV in Group II, and 0.15 mg/kg IV midazolam in Group III. Results: Mean arterial pressure values were lower in Group I at the 24th hour when compared to Groups II and III. In Group I, heart rate values were higher compared to the other Groups. Cortisol levels were lower in Group I at the 4th and at the 24th hour in Groups II and III. Conclusion: Administration of methylprednisolone 2-4 minutes prior to etomidate use in emergency situations can prevent adrenal insufficiency in patients undergoing rapid sequence intubation. Moreover, midazolam can be used in low induction doses as an alternative to etomidate.
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