The Case for Etomidate

Todd Fraser on 15-12-2010

The haemodynamic perils of induction of anaesthesia in severely compromised patients has long been recognised. Few anaesthetic agents can be used in this setting without the potential for significant haemodynamic effects. Etomidate has been touted as the solution, though concerns remain regarding the impact of its known interaction with corticosteroid synthesis. A recent study however suggests that the impact may be less than previously thought. A retrospective analysis of 224 patients in the USA found that the risk of death, vasopressor use and ventilation times were not related to whether or not etomidate was used for induction. The study by Dmello et al, published online by CHEST, is limited by its retrospective and unblinded nature, but provides further cause for consideration of its use. These findings support those of a systematic analysis by Hohl et al, published in the Annals of Emergency Medicine earlier this year. The time appears right for a large scale trial in sepsis and septic shock.

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Todd Fraser wrote 03-29-2011 07:03:01 pm
An interesting aside to the recently released HYPOLYTE study was that over 70% of patients in the study were deemed "relatively hypoadrenal" - a strikingly high number for a relatively well group of patients (overall mortality in the control arm was just 5%). The vast majority of patients also received Etomidate as their induction agent, with Synacthen testing occuring no less than 8 hours after induction.

But then again, despite such a huge number of adrenal insufficiency, the mortality was incredibly small!

Perhaps this leads to the hypothesis that RAI associated with etomidate poisoning (!) is a different beast to other forms...

AMIT KANSAL wrote 12-17-2010 03:41:20 pm
There is no compelling evidence to support serious harm with use of etomidate for induction. Declines in serum cortisol concentrations were more prevalent among etomidate recipients than those who did not receive etomidate in the large majority of studies, but did not persist beyond hours (2010 systemic review). There is some recommendation (EXPERT OPINION) to cover etomidate use with steroids for 12-24 hrs anyways more so if there is refractory shock.
So, r we still scared?

Todd Fraser wrote 12-17-2010 04:27:00 pm
I agree Amit. But scared or not, some areas of the world, including Australia, do not currently have access to it. I guess the question is, should we?

Nick Simpson wrote 03-27-2011 03:46:36 pm
I always felt that etomidate was unfairly dealt with in Australia. The evidence suggesting poorer outcomes was association at best - sicker patients got intubated with etomidate and did worse - surprise, surprise. I don't imagine that the hypotension associated with commonly used anaesthetic agents is all that good for you either. Etomidate has been extensively (and often preferentially) used in the US and Europe for many years. It would be great to have it in our armamentarium.

BongoICU from Australia wrote 12-29-2012 02:37:18 pm
Etomidate makes the news again - http://www.crit-iq.com/index.php/Journal_Club/Previous_Journals/2012/11