Advantages and Disadvantages of Etomidate Use for Intubation of Patients with Sepsis

Abstract

Etomidate is a potent imidazole hypnotic used widely in single doses in the rapid sequence intubation of critically ill patients with sepsis due to its presumed hemodynamic safety, fast onset, and short duration of action. However, the literature is conflicting regarding the hemodynamic advantages of etomidate over other induction agents, and its safety in this population is a matter of strong debate in the critical care community as the drug is associated with suppression of adrenal steroidogenesis, which can last up to 72 hours after a single dose, primarily through potent inhibition of the 11β-hydroxylase enzyme. However, the clinical impact of this adrenal suppressive effect is not certain. The use of continuous-infusion etomidate in critically ill patients was abandoned more than 20 years ago due to reports of increased mortality. Nevertheless, mortality data of single-dose etomidate are still controversial, with no strong evidence of benefit over other agents and a tendency toward harm (keeping in mind the limitations of the available literature). Proponents of single-dose etomidate use in patients with sepsis suggest that the increased mortality associated with etomidate is merely a reflection of the patients' severity of illness and not related to the drug itself, whereas others believe that the drug causes true harm and increases mortality in this population. In view of the lack of a clear clinical advantage of etomidate over other agents used in rapid sequence intubation, it would be prudent to favor other agents until further conclusive evidence of etomidate safety is available in critically ill patients with sepsis.

Comparing Hemodynamic Responses to Diazepam, Propofol and Etomidate During Anesthesia Induction in Patients with Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Graft Surgery: a Double-blind, Randomized Clinical Trial

“…There is a relation between etomidate administration and adrenal insufficiency, which caused by reversible inhibition of cortisol synthesis ( 9 ). Reduced cortisol and aldosterone level following to adrenal suppression almost started in less than 30 minutes after a single dose of etomidate and can last up to 72 hours ( 10 ). On the other hand, it has been shown that relative adrenal insufficiency in septic patients may induce morbidity and mortality ( 9 ).…”

Continuous-Infusion Etomidate in a Patient Receiving Extracorporeal Membrane Oxygenation

“…7 The major side effect and concern in the use of etomidate is its ability to inhibit 11-b-hydroxylase, which decreases cortisol, aldosterone, and corticosterone, leading to adrenal suppression. 8,9 This suppression can last up to 72 hours after a single dose of etomidate. In fact, an adult who received a 20-hour infusion of etomidate (1.3-1.5 mg/kg/hr) had marked adrenocortical suppression that was evident 4 days after etomidate was discontinued.…”

Anästhesiologisches Management von herz- und lungentransplantierten Patienten

“…Patienten mit Sepsis, die bereits eine gestörte Nebennierenrindenfunktion aufweisen können, sind dabei besonders gefährdet. Beim geringsten Anzeichen einer septischen Konstellation ist daher von jeglichem Gebrauch dringend abzuraten [11].…”