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Objectives: Etomidate is known to cause adrenal suppression after single-bolus administration. Some studies suggest that when etomidate is used as an induction agent for intubation of septic patients in the emergency department (ED), this adrenal suppression leads to increased mortality, vasopressor requirements, and length of hospital stay. The authors sought to determine differences in the in-hospital mortality and hospital length of stay (LOS) between septic patients given etomidate and patients given alternative or no induction agents for rapid-sequence intubation in our ED.Methods: This was a nonrandomized, prospective observational study of all patients meeting sepsis criteria who were intubated in an ED over a 9-month period. Times of patient presentation, intubation, admission, discharge, and ⁄ or death were recorded, as well as the intubation agent used, if any, and corticosteroid use. The authors also recorded relevant laboratory and demographic variables to determine severity of illness using the Mortality in Emergency Department Sepsis (MEDS) score. Mortality and survivor LOS between the patients given etomidate and those given alternative or no induction agents were compared.Results: A total of 106 patients with sepsis were intubated over the study period. Of these, 74 patients received etomidate, while 32 patients received ketamine, benzodiazepines, propofol, or no induction agents. Age in years (median = 78; interquartile range [IQR] = 67 to 83), gender (45% male), MEDS score (median = 13; IQR = 10 to 15), and receipt of supplemental corticosteroids (56%) were statistically similar between the two groups. In-hospital mortality of patients given etomidate (38%; 95% confidence interval [CI] = 28% to 49%) was similar to those receiving alternatives (44%; 95% CI = 28% to 61%). Surviving patients had a median hospital LOS after receiving etomidate of 10 days compared to those receiving alternatives (7.5 days; p = 0.08). Conclusions:No statistically significant increase in hospital LOS or mortality in patients given etomidate for rapid-sequence intubation was found. Suggestions that the use of etomidate for intubation in the ED be abandoned are not supported by these data.

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Background Warfarin-associated major hemorrhage is frequently treated with prothrombin complex concentrates to correct international normalized ratio (INR). Objective This article aims to investigate the efficacy of activated prothrombin complex concentrate (aPCC) versus 4-factor prothrombin complex concentrate (4PCC) for vitamin K antagonist reversal in patients with warfarin-associated major hemorrhage. Materials and Methods This was a multicenter, retrospective cohort study. Patients included were age ≥ 18 years with pretreatment INR of > 1.5. Exclusion criteria were patients treated for urgent procedures without hemorrhage, treated but not taking warfarin, unavailable INR values, and pregnant patients. Patients were stratified into two groups: aPCC or 4PCC. The primary outcome was achievement of INR ≤ 1.5 at the posttreatment INR sampling. Secondary outcomes focused on thrombotic events and mortality. Results Of 342 patients, 237 patients received aPCC and 105 patients received 4PCC. After 1:1 propensity score matching, 86 patients remained in each group. In the matched cohort, the proportion of patients who achieved target INR ≤ 1.5 was greater with 4PCC (aPCC = 61 [70.9%] vs. 4PCC = 76 [88.4%]; 95% confidence interval [CI] –29.2% to –5.7%) and groups had comparable in-hospital thrombotic events and mortality. In the unmatched cohort, achievement of target INR ≤ 1.5 was greater with 4PCC (aPCC = 151 [63.7%] vs. 4PCC = 92 [87.6%]; 95% CI –32.7% to –15.1%). Conclusion In the treatment of warfarin-associated major hemorrhage, 4PCC compared with aPCC was associated with greater achievement of INR ≤ 1.5 with comparable thrombotic events and mortality. Further controlled studies are needed to confirm these findings and determine the optimal dosing strategy that maximizes efficacy and safety.