Etomidate – there is always a downside

January 14, 2014 by  
Filed under All Updates, ICU

By Norwegian intensivist/anaesthetist/HEMS Physician Dr Per Bredmose.

[Warning - Rant level: Viking]

Etomidate has for a long time been known in some countries as the “drug of choice” for RSI in unstable/fragile patients. This is due to the fact that induction with etomidate is fairly cardiovascularly stable. However, there is a down side: a subsequent suppression of adrenal function. This was initially discovered after etomidate was used for sedation infusions on ICU.

It has for a long time been debated whether this is a side effect with clinical implications after a single dose induction… and yes it has.

A recent Japanese study demonstrates this(1). This is a large propensity based study. Now, propensity based statistics are pretty complex to explain. In short, it is an advanced method to strengthen the statistics when comparing groups in non-cross over studies.

In this study 2616 patients receiving etomidate for induction and a volatile agent for maintenance are included.
This showed an increased OR for 30-days mortality with a factor of 2.5 and 1.5 times greater chance for a major cardiovascular event in hospital. Interestingly enough, there were no significant differences in either perioperative vasopressor use or infections complications during hospital stay.

What does this mean?
In my mind and experience, it strengthens the fact that there is no wonder drug. And also that there seems to be a reason for why etomidate is de-registered in many countries.
Also, it tells me that for a safe prehospital RSI we need physicians capable of clinical judgment and “decision making” to tailor an (any) induction agent to the specific individual patient. In my mind, there is no room for an etomidate-only (dose / weight) induction protocol!

1. Komatsu R, You J, Mascha EJ, Sessler DI, Kasuya Y, Turan A.
Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery.
Anesth Analg. 2013 Dec;117(6):1329-37

Comments

3 Responses to “Etomidate – there is always a downside”

  1. Cliff on January 14th, 2014 23:53

    Thanks Viking One. Another study showing correlation but not necessarily causation, but ammunition for the anti-etomidate camp.

    To me this is an OR-based study and although they were ASA physical status III and IV patients this doesn’t automatically translate to the EM/ICM/PHARM environment. The lack of increase in vasopressor use does undermine the adrenal mechanism for harm doesn’t it?

    We don’t have etomidate, but I discarded it long before I left the UK in favour of ketamine. I don’t think etomidate will be buried unless a proper RCT provides compelling evidence for harm.

    Thanks for posting

    Cliff

  2. Dr Abu Galib on January 17th, 2014 00:14

    So what is is the current choices in RSI? Propofol/Ketamine/Midazolam?

  3. Jens Michelsen on January 27th, 2014 19:27

    I agree with Cliff. The study just shows that anesthetists are good at predicting who is going to die. They use etomidate for the dying and propofol for the living. Fancy statistics can’t correct for good intuition. We need randomized trials.

    I think the induction agent depends on the patient,

    propofol/thiopental for high ICP, seizures or tox patients
    ketamin for shock
    etomidate for bad hearts???