Etomidate and mortality in cirrhotic patients with septic shock

Abstract

BackgroundClinical effects and outcomes of a single dose etomidate prior to intubation in the intensive care setting is controversial. The aim of this study is to evaluate the association of a single dose effect of etomidate prior to intubation on the mortality of septic cirrhotic patients and the impact of the subsequent use of low dose hydrocortisone.MethodsThis is a nested-cohort study within a randomized double blind placebo controlled study evaluating the use of low dose hydrocortisone in cirrhotic septic patients. Cirrhotic septic patients ≥ 18 years were included in the study. Patients who received etomidate prior to intubation were compared to those who did not receive etomidate for all cause 28-day mortality as a primary outcome.ResultsSixty two intubated patients out of the 75 patients randomized in the initial trial were eligible for this study. Twenty three of the 62 intubated patients received etomidate dose prior to intubation. Etomidate use was not associated with all cause 28-day mortality or hospital mortality but was associated with significantly higher ICU mortality (91% vs. 64% for etomidate and controls groups, respectively; p = 0.02). Etomidate patients who received subsequent doses of hydrocortisone required lower doses of vasopressors and had more vasopressor-free days but no improvement in mortality.ConclusionsIn this group of septic cirrhotic patients with very high mortality, etomidate increased ICU mortality. Subsequent use of hydrocortisone appears to have no benefit beyond decreasing vasopressor requirements. The lowest mortality was observed in patients who did not receive etomidate but received hydrocortisone.

Etomidate is associated with mortality and adrenal insufficiency in sepsis

“…All studies included in the mortality analysis reported on vital status at discharge. However, only three additionally described 28-day mortality (5,14,22).…”

“…These ten studies reported on 1,623 patients with sepsis or septic shock. Of these ten studies, seven evaluated mortality (5,(14)(15)(16)(17)(18)22) and seven assessed the development of AI (5,14,15,(18)(19)(20)(21) (four studies assessed both). Of the ten studies included for meta-analysis, five studies included data from randomized controlled trials (5,14,16,20,22), two were prospective observational studies (17,21), and three were retrospective observational studies (15,18,19).…”

“…Flowsheet of study selection process. used to assess mortality (5,14,16,17,22). One of these five studies compared etomidate specifically with ketamine (5) and another compared etomidate with midazolam as an induction agent (16).…”

Ketamine-Propofol (Ketofol) as a Viable Alternative in a Septic Patient with Mediastinal Mass Requiring General Anesthesia for Endoscopic Retrograde Cholangio-Pancreatography

“…The choice of the ideal anaesthetic/sedative medication in critically ill patients with aortic aneurysm causing mediastinal compression remains unclear. Etomidate has proven to be efficacious in maintaining stable hemodynamics; however, etomidate is a potent inhibitor of adrenal corticsol secretion and has been associated with increased mortality in critically ill patients [10][11][12][13][14][15] .…”

Etomidate - a review of robust evidence for its use in various clinical scenarios

“…Despite clear endocrinological proof of etomidate's potentially adverse effect and worldwide termination of its repetitive use for sedation, the clinical impact of a single‐dose etomidate administration on adrenal insufficiency‐associated and all‐cause mortality remains controversial. A systematic review with meta‐analysis of five RCTs, two prospective and three retrospective observational studies, focusing exclusively on 865 sepsis patients receiving etomidate for rapid sequence intubation concluded that the administration of a single dose of etomidate increased the risk of adrenal insufficiency (relative risk, 1.33) and all‐cause mortality (relative risk, 1.20) in sepsis. The included studies, however, demonstrate obvious limitations in terms of: 1) heterogeneity; 2) small sample size or only subgroup analysis; 3) variation in the type of comparative sedative, severity of illness score, timing to determine adrenal insufficiency; 4) limited quality of study randomisation, blinding, description of inclusion, and exclusion criteria; and 5) discrepancies in follow‐up and reporting of 28‐day mortality.…”