Is Single-Dose Etomidate Induction Safe in Emergency Intubation of Critically Ill Patients?

doi:10.1016/j.annemergmed.2015.10.006

Annals of Emergency Medicine

Volume 67, Issue 3, March 2016, Pages 399-400

https://doi.org/10.1016/j.annemergmed.2015.10.006 Get rights and content

Section snippets

Results

Outcome	Studies, Number of Patients	Relative Effect (95% CI)	Heterogeneity (I²), %
Mortality	6 studies, 772 patients	OR 1.17 (0.86 to 1.6)	0
Duration of mechanical ventilation, days	3 studies, 621 patients	Avg duration: 1.5–13 days; etomidate effect 2.14 days (–1.67 to 5.95 days)	86
Organ dysfunction (SOFA scores)	1 study, 469 patients	Mean SOFA score: 9.6; etomidate effect 0.7 (0.01 to 1.39)

OR, Odds ratio; SOFA, Sequential Organ Failure Assessment score.

Of 1,395 potential titles screened, 8 studies were

Commentary

Etomidate has been a controversial induction agent in emergency intubation for a number of years because of concerns about adrenal suppression and subsequent adverse outcomes.1, 2 The concern about etomidate safety in septic patients was first raised in an observational substudy of the Corticosteroid Therapy of Septic Shock trial.³ The specific flaws of this study are elaborated elsewhere,⁴ revealing multiple confounding factors and reporting omissions that preclude the erroneous conclusion

References (7)

R.M. Walls et al.
Continue to use etomidate for intubation of patients with septic shock
Ann Emerg Med
(2008)
B.R. Hunter et al.
In patients with severe sepsis, does a single dose of etomidate to facilitate intubation increase mortality?
Ann Emerg Med
(2013)
A. Sacchetti
Etomidate: not worth the risk in septic patients
Ann Emerg Med
(2008)

There are more references available in the full text version of this article.

Cited by (2)

Current status of perioperative hypnotics, role of benzodiazepines, and the case for remimazolam: a narrative review
2021, British Journal of Anaesthesia
Citation Excerpt :
Nevertheless, many anaesthesiologists look to alternative induction agents, notably etomidate66 or ketamine,67 for compromised patients or in emergencies. Etomidate depresses adrenocortical function, even when used in single doses, and argument persists regarding the possible adverse consequences for patients.68–70 This anxiety comes in addition to the propensity of etomidate to extraneous muscle movements and PONV.
Anaesthesiologists and non-anaesthesiologist sedationists have a limited set of available i.v. hypnotics, further reduced by the withdrawal of thiopental in the USA and its near disappearance in Europe. Meanwhile, demand for sedation increases and new clinical groups are using what traditionally are anaesthesiologists' drugs. Improved understanding of the determinants of perioperative morbidity and mortality has spotlighted hypotension as a potent cause of patient harm, and practice must be adjusted to respect this. High-dose propofol sedation may be harmful, and a critical reappraisal of drug choices and doses is needed. The development of remimazolam, initially for procedural sedation, allows reconsideration of benzodiazepines as the hypnotic component of a general anaesthetic even if their characterisation as i.v. anaesthetics is questionable. Early data suggest that a combination of remimazolam and remifentanil can induce and maintain anaesthesia. Further work is needed to define use cases for this technique and to determine the impact on patient outcomes.
Thiopental to desflurane-an anaesthetic journey. Where are we going next?
2017, British Journal of Anaesthesia
Citation Excerpt :
Etomidate use has greatly declined after concerns about adrenocortical depression and the realisation that most patients can be safely managed with propofol provided it is administered cautiously.46 Recently the potential for etomidate induced harm has been challenged.47–50 The two novel hypnotic compounds have recently been progressed into advanced clinical development, remimazolam51 and ABP-70018 were both targeted in the first instance at sedation for gastrointestinal endoscopy.
Development targets in anaesthetic pharmacology have evolved from minimizing harm caused by unwanted effects through an era in which rapid onset and offset of drug effect were prioritised. Today's anaesthetists have access to a library of effective drugs whose characteristics offer controllable hypnosis, analgesia and paralysis with manageable off-target effects. The availability of these agents at generic prices inhibits commercial interest and this is reflected in the limited number of current anaesthetic drug development projects. Recently, questions around neonatal neurotoxicity, delirium and postoperative cognitive dysfunction have stimulated research to characterise these phenomena and explain them in mechanistic terms. Emergent basic science from these enquiries together with exploration of possible effects of anaesthetic drug choice on patient outcomes from cancer surgery may yield new targets for drug discovery.

: Editor’s Note: This is a clinical synopsis, a regular feature of the Annals' Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Bruder EA, Ball IM, Ridi S, et al. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev. 2015;(1):CD010225.

: Michael Brown, MD, MSc, and Alan Jones, MD, serve as editors of the SRS series.

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Airway/systematic review snapshotIs Single-Dose Etomidate Induction Safe in Emergency Intubation of Critically Ill Patients?

Section snippets

Results

Commentary

Ann Emerg Med

Ann Emerg Med

Etomidate: not worth the risk in septic patients

Ann Emerg Med

Airway/systematic review snapshot
Is Single-Dose Etomidate Induction Safe in Emergency Intubation of Critically Ill Patients?