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Could Etomidate..

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Etomidate is the most frequently used sedative hypnotic for rapid sequence intubation and is commonly used in the emergency department. However, the use of etomidate remains controversial in critically ill patients.1,2,3 Multiple clinical trials have frequently reported an increased rate of adrenal insufficiency and an increased risk of death with etomidate use.4    

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Asehnoune and colleagues5 sought to investigate the impact of etomidate on the rate of hospital-acquired pneumonia (HAP) in trauma patients and the effects of hydrocortisone in etomidate-treated patients. This is a subset study of the HYPOLYTE multi-centre, randomized, double blind, placebo-controlled trial of hydrocortisone in trauma patients. The study endpoints were the results of the cosyntropin test and rate of HAP on day 28 of follow-up.         

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The authors demonstrated that out of the 149 patients enrolled in the study, 95 (64 %) received etomidate within 36 h prior to inclusion. Corticosteroid insufficiency occurred in (79/95 patients (83 %) who received etomidate and 34/54 (63 %) patients not receiving etomidate (p = 0.006). A total of 49 (51.6 %) patients with etomidate and 16 (29.6 %) patients without etomidate developed HAP by day 28 (p = 0.009). Etomidate was also associated with HAP on day 28 in the multivariate analysis (hazard ratio 2.48; 95 % CI: 1.19–5.18; p = 0.016).         

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While 18 patients in the etomidate group (40 %) treated with hydrocortisone developed HAP compared with 31 (62 %) treated with placebo (p = 0.032), duration of MV with or without etomidate was not significantly different (p = 0.278).

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The authors concluded that etomidate is an independent risk factor for HAP and that the administration of hydrocortisone should be considered after etomidate use.

1. Doenicke A. Etomidate. A new intravenous hypnotic. Acta Anaesthesiol Belg. 1974;25:307–315.   [PubMed: 4143092]
2. Patschke D, Bruckner JB, Gethmann JW, et al. Comparison of the immediate effects of etomidate, propanidid, thiopentone on haemodynamics, coronary blood flow and myocardial oxygen consumption. Acta Anaesthesiol Belg. 1975;26:112–119.   [PubMed: 1224940]
3. Annane D. ICU physicians should abandon the use of etomidate! Intensive Care Med. 2005;31:325–326.   [PubMed: 15750800]
4. Vinclair M, Broux C, Faure P, et al. Duration of adrenal inhibition following a single dose of etomidate in critically ill patients. Intensive Care Med. 2007;34:714–719.   [PubMed: 18092151]
5. Asehnoune K, Mahe PJ, Seguin P, et al. Etomidate increases susceptibility to pneumonia in trauma patients. Intensive Care Med. 2012 Jul 10. [Epub ahead of print]    [PubMed: 22777514]

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