Etomidate Use for RSI in Septic Patients
Date First Published:
May 6, 2009
Last Updated:
May 9, 2009
Report by:
Mary Jo VanOstenberg, MD, Emergency Medicine Resident (Grand Rapids Medical Education & Research/Michigan State University)
Search checked by:
Jeffrey Jones, MD, Grand Rapids Medical Education & Research/Michigan State University
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
Search Details:
[(exp etomidate/ or etomidate.mp. or amidate.mp) AND (exp sepsis/ or sepsis.mp.)] Limit to human and English
Outcome:
35 papers were found of which only two prospective studies were relevant to the three part question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A Prospective Observational Study of the Effect of Etomidate on Septic Patient Mortality and Length of Stay Tekwani, K., et al. Jan-09 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. |
| Hospital length of stay | 10 days in Etomidate group; 7.5 days in those receiving alternatives (p=0.08) | ||||
| Adrenal Suppression Following a Single Dose of Etomidate For Rapid Sequence Induction: A Prospective Randomized Study Hildreth, A., et al. Sep-08 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) |
Author Commentary:
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.
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
- Hildreth, A., et al.. Adrenal Suppression Following a Single Dose of Etomidate For Rapid Sequence Induction: A Prospective Randomized Study