Adrenal inhibition following a single dose of etomidate in intubated traumatic brain injury victims

Abstract

Background: Etomidate is frequently used to intubate traumatic brain injury (TBI) victims, even though it has been linked to adrenal insufficiency (AI) in some populations. Few studies have explored the risk of prolonged etomidateinduced AI among TBI victims. Objective: To determine the risk and the length of AI induced by etomidate in patients intubated for moderate and severe TBI. Methods: Participants in this observational study were moderate to severe intubated TBI victims aged $ 16 years. The anesthetic used (etomidate versus others) was determined solely by the treating emergency physician. Adrenocorticotropic hormone (ACTH) stimulation tests (250 mg) were performed 24, 48, and 168 hours after intubation. AI was defined as an increase in serum cortisol 1 hour post-ACTH test (delta cortisol) of less than 248.4 nmol/L. Results: Forty subjects (participation 42.6%) underwent ACTH testing. Fifteen received etomidate, and 25 received another anesthetic. There were no statistically significant differences between groups as to the cumulative incidence of AI at any measurement time. However, at 24 hours, exploratory post hoc analyses showed a significant decrease in delta cortisol (adjusted means: etomidate group: 305.1 nmol/L, 95% CI 214.7-384.8 versus other anesthetics: 500.5 nmol/L, 95% CI 441.8-565.7). This decrease was not present at 48 and 168 hours. Conclusion: In TBI victims, although a single dose of etomidate does not increase the cumulative incidence of AI as defined, it seems to decrease the adrenal response to an

Etomidate, but not thiopental, decreases serum cortisol concentration in morbidly obese patients. A randomized controlled trial

“…These observations were confirmed by the results of the short stimulation test performed twenty-four hours after the induction of general anaesthesia. The estimated time of adrenal suppression caused by a single dose of etomidate varies between 12 hours [13] and 48 hours [14]. Our results were within this range.…”

Monitoring sedation during mechanical ventilation

“…7 Etomidate suppresses corticosteroid synthesis in the adrenal cortex by reversibly inhibiting 11β-hydroxylase, an enzyme important in adrenal steroid production, and this leads to primary adrenal suppression. 8,9 Reduced cortisol plasma levels have been reported with induction doses of 0.3 mg/kg etomidate. These persist for approximately 6 to 8 hours and do not reverse with adrenocorticotropic hormone (ACTH) administration.…”

Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients

“…Etomidate is commonly used as an induction agent as part of rapid sequence intubation (RSI) in emergency medicine (EM) due to its reported minimal effects on patient hemodynamics; however, there are concerns regarding associated adrenal suppression. [14][15][16][17] Other agents such as ketamine, fentanyl, midazolam, and propofol are frequently used alone or in combination to facilitate EETI in patients with hemodynamic instability. 18 Rocuronium and succinylcholine are also commonly administered as muscle relaxants for RSI, and debate continues over which is a superior agent for RSI.…”