Bad news for etomidate from CORTICUS

In an a priori substudy of the CORTICUS multi-centre, randomised, double-blind, placebo-controlled trial of hydrocortisone in septic shock, the use and timing of etomidate administration was examined in relation to outcome.
Of 499 analysable patients, 96 (19.2%) received etomidate within the 72 h prior to inclusion. The proportion of non-responders to ACTH was significantly higher in patients who were given etomidate than in other patients (61.0 vs. 44.6%, P = 0.004). Etomidate therapy was associated with a higher 28-day mortality in univariate analysis (P = 0.02) and after correction for severity of illness (42.7 vs. 30.5%; P=0.06 and P=0.03) in two multi-variant models. Hydrocortisone administration did not change the mortality of patients receiving etomidate (45 vs. 40%).
Some of the previous attacks on etomidate have not been founded on the most rigorous evidence. However this study adds further to the difficulty in justifying etomidate’s use when a perfectly acceptable alternative (ketamine) exists for rapid sequence induction in the haemodynamically unstable septic patient.
The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock.
Intensive Care Med. 2009 Nov;35(11):1868-76