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Don’t Give Up on Etomidate for Septic Shock

Outcomes with etomidate were not different from those with other induction agents, calling into question the clinical significance of etomidate-related adrenal insufficiency.

Etomidate’s excellent hemodynamic stability and short duration of action make it an important induction agent for emergent intubation. Recently, etomidate’s use in patients with septic shock has been questioned because it can interfere with adrenal function for 24 to 72 hours after intubation through inhibition of 11ß-hydroxylase. The clinical significance of etomidate-induced adrenal insufficiency remains unclear but has provoked significant controversy.

Researchers conducted a retrospective analysis of data from a prospectively collected database to evaluate whether a single use of various induction agents is associated with adverse outcomes or the need for vasopressors, inotropes, and steroids in patients with septic shock. Among 159 patients for whom complete records were available, the hospital mortality rate was 65%. Etomidate was used in 74 patients, thiopental in 26, propofol in 25, and other agents in 18; no induction agent was used in 16 patients. Severity of illness and mortality rates did not differ significantly among patients given different induction agents. The induction agent used also was not associated with the need for steroids or vasopressors. Patients who received etomidate were less likely to require cardiovascular interventions than were those who received other agents.

Comment: The potential for inducing or worsening hypotension in critically ill patients who require intubation should not be underestimated. Hypotension during induction is a common feature in anesthesia-related deaths. Of the different induction agents, etomidate has one of the most optimal therapeutic profiles for use in an emergent setting. The clinical relevance of etomidate-related adrenal insufficiency is called into question by this and other studies’ findings, and a large prospective trial is needed. Emergency physicians should not abandon the use of etomidate in patients with septic shock, based on our current knowledge. We can debate the significance of the potential transient hormonal effects of etomidate, but, if the patient dies during intubation, the argument is moot.

— Tiffany M. Osborn, MD

Published in Journal Watch Emergency Medicine September 21, 2007

Citation(s):

Ray DC and McKeown DW. Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock. Crit Care 2007 May 16; 11:R56; [e-pub ahead of print]. (http://dx.doi.org/10.1186/cc5916)

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