Etomidate Use for RSI in Septic Patients

Report By: Mary Jo VanOstenberg, MD - Emergency Medicine Resident
Search checked by Jeffrey Jones, MD - Research Director, EM Residency Program
Institution: Grand Rapids Medical Education & Research/Michigan State University
Date Submitted: 6th May 2009
Last Modified: 9th May 2009
Status: Blue (submitted but not checked)

Three Part Question

In [septic patients requiring intubation] does [Etomidate] lead to [increased morbidity and mortality].

Clinical Scenario

A 70-year-old woman presents to the Emergency Department with urosepsis and requires intubation. You consider using Etomidate as an RSI agent, but wonder if it will increase morbidity and mortality secondary to adrenal suppression.

Search Strategy

Medline 1950-04/09 using OVID interface, Cochrane Library (2009), PubMed clinical queries

[(exp etomidate/ or etomidate.mp. or amidate.mp) AND (exp sepsis/ or sepsis.mp.)] Limit to human and English

Search Outcome

35 papers were found of which only two prospective studies were relevant to the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tekwani, K., et al. January 2009 United States of America	106 patients with 2 or more SIRS criteria, suspected or documented infection, and intubation performed in the ED.	nonrandomized, prospective observational study	In-hospital mortality	38% in Etomidate group; 44% in those receiving alternatives	Study nonrandomized. Intubating agents not blinded. Other variables in treatment during hospitalization not measured.
Tekwani, K., et al. January 2009 United States of America		nonrandomized, prospective observational study	Hospital length of stay	10 days in Etomidate group; 7.5 days in those receiving alternatives (p=0.08)
Hildreth, A., et al. September 2008 United States of America	30 trauma patients >18 years old requiring RSI within 48 hours of injury randomized to Etomidate or Fentanyl and Midazolam.	PRCT	Mean cortisol levels 4-6 hrs post intubation	18.2 microgram/dL in Etomidate group vs. 27.8 microgram/dL (p<0.05)	Study not blinded. 31 patients excluded for various reasons. ISS greater in Etomidate group (although not statistically significant). No standardized treatments while inpatient. ICU days, ventilator days, and hospital LOS numbers do not correlate suggesting that these averages may be skewed by outliers.
			Change in serum cortisol	-12.8 microgram/dL in Etomidate group vs. 1.1 microgram/dL (p<0.01)
			Increase cortisol after ACTH	4.2 microgram/dL in Etomidate group vs. 11.2 microgram/dL (p<0.001).
			ICU days	6.3 in Etomidate group vs. 1.5 (p<0.05)
			Ventilator days	28 in Etomidate group vs. 17 (p<0.01)
			Hospital LOS	11.6 days in Etomidate group vs. 6.4 (p<0.01)

Comment(s)

The Hildreth article, while not specific to septic patients, does demonstrate statistically significant decreases in cortisol levels. It is the clinical significance of this decrease that remains in question. With the small number of patients, and inconsistencies among ICU and ventilator days and hospital LOS, it is possible that these morbidity data (expressed in means) are highly influenced by outliers.

Clinical Bottom Line

While evidence exists that Etomidate decreases cortisol levels in critically-ill patients, there is insufficient evidence of subsequent increase in morbidity and mortality to recommend against the use of Etomidate for RSI in septic patients at this time.

References

Tekwani, K., et al. A Prospective Observational Study of the Effect of Etomidate on Septic Patient Mortality and Length of Stay Academic Emergency Medicine January 2009, Vol. 16, No. 1
Hildreth, A., et al. Adrenal Suppression Following a Single Dose of Etomidate For Rapid Sequence Induction: A Prospective Randomized Study The Journal of Trauma, Injury, Infection, and Critical Care September 2008;65:573-579.