The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock

@article{Cuthbertson2009TheEO,
  title={The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock},
  author={Brian H. Cuthbertson and Charles L Sprung and Djillali Annane and Sylvie Chevret and Mark Garfield and Sergei Goodman and Pierre-François Laterre and Jean Louis Vincent and Klaus Freivogel and Konrad Reinhart and Mervyn Singer and Didier Payen and Yoram G. Weiss},
  journal={Intensive Care Medicine},
  year={2009},
  volume={35},
  pages={1868-1876}
}
RationaleUse of etomidate in the critically ill is controversial due to its links with an inadequate response to corticotropin and potential for excess mortality. [] Key MethodMethodsAn a-priori sub-study of the CORTICUS multi-centre, randomised, double-blind, placebo-controlled trial of hydrocortisone in septic shock. Use and timing of etomidate administration were collected. Endpoints were corticotropin response and all-cause 28-day mortality in patients receiving etomidate.
Etomidate and mortality in cirrhotic patients with septic shock
TLDR
In this group of septic cirrhotic patients with very high mortality, etomidate increased ICU mortality and subsequent use of hydrocortisone appears to have no benefit beyond decreasing vasopressor requirements.
Corticosteroid after etomidate in critically ill patients: A randomized controlled trial*
TLDR
It is suggested that critically ill patients without septic shock do not benefit from moderate-dose hydrocortisone administered to overcome etomidate-related adrenal insufficiency.
Etomidate increases susceptibility to pneumonia in trauma patients
TLDR
It is suggested that in trauma patients, etomidate is an independent risk factor for HAP and that the administration of hydrocortisone should be considered after Etomidate use.
Effects of Etomidate on Adrenal Suppression: A Review of Intubated Septic Patients
TLDR
Etomidate use for induction of anesthesia during RSI was associated with clinically significant hypotension when compared to other sedatives, and the hypotension was transient and did not translate into statistically significant differences in the secondary clinical endpoints.
Etomidate, Adrenal Function, and Mortality in Critically Ill Patients
TLDR
In this study of critically ill patients requiring endotracheal intubation, etomidate administration was associated with a trend toward a relative increase in mortality, similar to the collective results of smaller randomized trials conducted to date.
Advantages and Disadvantages of Etomidate Use for Intubation of Patients with Sepsis
TLDR
It would be prudent to favor other agents until further conclusive evidence of etomidate safety is available in critically ill patients with sepsis, because of the lack of a clear clinical advantage of Etomidate over other agents used in rapid sequence intubation.
Outcomes of etomidate in severe sepsis and septic shock.
TLDR
Single-dose etomidate used during RSI in critically ill patients with severe sepsis and septic shock was not associated with increased mortality, vasopressor use, ICU-LOS, or number of ventilator days.
Etomidate for critically ill patients. Con: do you really want to weaken the frail?
TLDR
Etomidate is an imidazole-derived hypnotic agent preferentially used for rapid sequence induction of anaesthesia because of its favourable haemodynamic profile, but it causes adrenal dysfunction via 11&bgr;-hydroxylase inhibition, making the drug unsuitable for use in elective interventions.
Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis
TLDR
In septic shock patients treated with hydrocortisone, etomidate did not decrease life-threatening complications following intubation, but when associated with hydrodisone it also did not impair outcome.
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TLDR
It is reasonable to suggest that the effects of etomidate would differ only little in other critically ill patients, and thus the same strategy as for septic shock patients is recommended.
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TLDR
The incidence of relative adrenal insufficiency in etomidate-naïve septic shock patients was lower than observed in the steroid supplementation trial, and in those who fulfilled inclusion criteria for the trial, the incidence was half that reported by the trial.
The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate
TLDR
The incidence of relative adrenal insufficiency in patients with septic shock is increased when the stimulation test is performed after the administration of etomidate.
Adrenal response in patients with septic shock of abdominal origin: relationship to survival
TLDR
In this cohort of patients with abdominal septic shock baseline cortisol level and the response to corticotropin test did not discriminate survivors from nonsurvivors and no deleterious impact of etomidate anesthesia on adrenal function tests and survival was observed.
Adrenal axis function does not appear to be associated with hemodynamic improvement in septic shock patients systematically receiving glucocorticoid therapy
TLDR
In catecholamine-dependent septic shock patients managed with systematic glucocorticoid therapy the results of ACTH stimulation do not predict hemodynamic improvement and relative adrenal insufficiency whatever the definition was not associated with hemodynamic improved.
Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation
TLDR
A single bolus infusion of etomidate could be a major risk factor for the development of relative adrenocortical deficiency in ICU patients for at least 24 h after administration, and female gender is an independent protective factor.
Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock
TLDR
Etomidate use for critically ill patients should consider all of these issues and not simply the possibility of adrenal suppression, which may not be important when steroid supplements are used.
Meta-Analysis: The Effect of Steroids on Survival and Shock during Sepsis Depends on the Dose
TLDR
Recent clinical trials with previous clinical trials of steroid use in patients with sepsis are compared to determine whether administering glucocorticoids in dosages similar to the amount produced physiologically during a stressful state affects outcome in septic patients.
Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock?: a critical appraisal.
TLDR
It is proposed that, pending the performance of a randomized, controlled clinical trial, considerable caution should accompany etomidate administration in patients with evolving or established septic shock.
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