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Etomidate is commonly used for the facilitation of endotracheal intubation. While etomidate possesses multiple qualities that are beneficial in hemodynamically unstable patients who require a sedative or amnestic, its potential to negatively impact corticosteroid production is well-documented. Given the frequency of relative adrenal insufficiency observed in the critically ill and the increasing use of corticosteroids in patients with septic shock, an appraisal of the status of etomidate as an induction agent in patients with evolving or established septic shock is indicated. A review of the relevant literature suggests that its use in this setting may be harmful. It is proposed that, pending the performance of a randomized, controlled clinical trial, considerable caution should accompany its administration in patients with evolving or established septic shock. The potential role for concomitant empiric steroid replacement and the comparability of alternative induction regimens are also discussed. (CHEST 2005; 127:1031-1038)
Key words: adrenal insufficiency; endotracheal intubation; etomidate; sepsis; septic shock
Abbreviations: APACHE = acute physiology and chronic health evaluation; CST = cosyntropin stimulation testing; ED = emergency department
Etomidate is an imidazole derivative that is widely used as an IV induction agent to facilitate endotracheal intubation. It possesses several characteristics that are particularly advantageous in the critical care setting, including rapid, predictable onset of action and recovery, relative cardiovascular stability, limited suppression of ventilation, lack of histamine release, and favorable safety profile.1 However, etomidate is known to inhibit adrenal mitochondrial hydroxylase activity,2 with a resultant observable decrease in steroidogenesis after administration by both single-bolus3 and maintenance infusion.4 Importantly, the normal response to stress states such as trauma, burns, surgery, and infection is characterized by a proportional increase in cortisol production and release.5 Given the renewed interest and debate concerning the evaluation of relative adrenal insufficiency in critically ill patients5-7 and the value of corticosteroid administration in septic shock patients,8,9 as well as the increasing prevalence10 and established lethality11 of septic shock, conditions that affect the hypothalamic-pituitary-adrenal response to stress and may deleteriously impact patient survival are being increasingly scrutinized.
Consequently, the use of etomidate for the induction of intubation in patients who require critical care in general12 and manifest septic shock in particular13 has come into question. The purpose of this article is to explore the basis for such...