November - 2012
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Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysisChan Chee, Mitchell Anthony L, Shorr Andrew F Crit Care Med, 2012, 0:2945–2953 This page is only available to Crit-IQ subscribers. To view the rest of this review and gain access to our vast array of critical care teaching tools including podcasts, vodcasts, modules, exam preparation tools, teaching aids and much more, login here, or Become a Member to register |
November |
Previous Comments
| Didnt we know this several years ago? Does anyone actually use Etomidate these days? These guys must have a lot of time on their hands !! | |
| Hmmmm !!-16 Nov, 2012 06:02:29 PM | |
| No, I'm not sure that we do - this has been discussed previously on the blog, and a number of comments suggest that this is not universally accepted. The definition of adrenal insufficiency remains incredibly nebulous, so I'm not sure it is an appropriate end-point. It is well and truly past due for a study in critical illness. | |
| Todd Fraser-17 Nov, 2012 03:12:42 AM | |
| The blog can be found here - http://crit-iq.com/index.php/blog/single/The-Case-for-Etomidate | |
| Todd Fraser-17 Nov, 2012 03:13:31 AM | |
| So in that case we need to work on a new definition of adrenal insufficiency. Why not just stop using Etomidate? There are far better drugs these days. Its been almost 20 years since Ive used etomidate. I am surprised it is still being used. | |
| Hmmmm!!-18 Nov, 2012 06:02:54 PM | |
| Hello Hmmmmmmm, Interesting to hear that you are using other drugs. I've never used etomidate because its not available here. Everyone I speak to who has used it swear by its stable haemodynamic profile. I can't think of any other drug in practice that can boast that - even ketamine, when used in patients with severe shock, will dump blood pressure into the floor. What do you use in these circumstances? Agreed, we need a new definition of adrenal insufficiency. Jeremy Cohen's podcast highlights the total turbidity of this area. I don't think we have the first clue on how to define it yet. | |
| Todd Fraser-18 Nov, 2012 08:57:45 PM | |
| Yes I have not used etomide for a long long while. In patients with shock, no matter what you use, you will most certainly get a drop in BP. The key is to use just "enough" drug rather tnan the mg/kg dose that you would otherwise use in a stable patient. Also, I teach my registrars to always prime such patients with a small dose of vasopressor prior to induction. Most often such unstable patients require negligible amounts of drug to induce them. So the choice is opiates with small dose benzos or Ketamine provided you prime those patients with a vasopressor ( Aramine commonly) Even Etomidate, when used in a septic shocked patient, has caused a drop in BP. Any sedative will affect the sympathetic tone in those patients dependant on that protective phenomenon. | |
| Hmmmmm!!-19 Nov, 2012 04:02:16 PM | |
| Just out of curiosity, how many Intensivists/ Anesthetists actually have access to and use Etomidate in their practice? I am really curious ! | |
| Hmmmmmmm!-19 Nov, 2012 04:05:21 PM | |
| There's a few options here. One is to use almost nothing, and to explain to the patient (who may or may not be cognisant enough to remember it later) that they may feel something, sorry about that, but its better than you dying... A little local anaesthetic, perhaps even nebulised, can sometimes help. Agreed, putting in a CVC if possible, or running an inoconstrictor infusion peripherally, even if low dose initially, is a good idea. Also, preloading with fluids, if you think you can get away with it, may mitigate the BP drop somewhat. | |
| Nigel-20 Nov, 2012 09:22:08 PM | |
| Well done Nigel. Nice explanation. We were just discussing Etomidate and exploring if there were any other drugs that could be used safely in the critically ill patients. I am glad you have also introduced the options of alternative methods. What worries me is that there is this pursuit of the "holy grail of EBM". To try and prove what?? To determine if etomidate really suppresses adrenal function?? Why can't we simply dump Etomidate and use other drugs or methods like you have described instead of this "hot pursuit" of the truth? Wouldn't that be simple and much more practical? To determine if Etomidate suppresses adrenal function or not will be a huge undertaking a) Firstly we would have to define normal response vs abnormal response (values) b) then we would need to determine whats normal and abnormal response (values) in sepsis and septic shock c) once that is done we would then have to determine if the use of Etomidate actually does what it is claimed to do. d) finally how would one get ethical approval, knowing fully well that some patients will suffer from suppression of adrenals. Why are we so obsessed with randomised controlled trials when in fact we should be using simple logic and possibly use alternative means if there are possible drastic side effects of certain drugs. Trials can lead to more confusion and I think we lay too much emphasis on crunching numbers. Thankfully I have worked in the UK and I have used a lot of stuff that only recently has made its way into Australia. Etomide also can cause haemodynamic instability in really sick patients. Protective sympathetic tone WILL be knocked off with any sedative. | |
| Hmmmmm!-21 Nov, 2012 12:39:40 AM | |
Comment
The issue of etomidate induced adrenal insufficiency is well described, and led to criticisms of European low-dose steroids in sepsis trials because of its confounding effect.
This systematic analysis of the effect of single-dose etomidate used for intubation induction, on...