1) The studies of etomidate in trauma are mixed, but while Banh et al
didn't find any improvements in trauma outcomes subsequent to limiting
etomidate (J Emerg Med 2012 p e277) there were some studies with the same
concerning conclusions as those using etomidate in sepsis: e.g. Hildreth
AN, J Trauma 2008 p573. The mechanism is that the alpha adrenergic
properties of etomidate inhibit the enzyme that yields cortisol, thus can
lead to transiently worse outcomes in patients who happen to be trying to
pump out a little extra cortisol right then. That said, since the initial
"etomidate for trauma is bad" studies had really small sample sizes. The
more recent ones are bigger, and seem to indicate that etomidate for trauma
is not an issue, certainly much less a problem than etomidate for sepsis.
(McPhee LC, Crit Care Med, 2013 p 744)
2) A colleague recently was administering propofol to sedate for an MRI of
a newly diagnosed brain tumor. Before the mass could be fully visualized
the patient started having bradycardia and increasing blood pressure
despite the propofol. When the physician emergently stopped the scan and
propofol, within minutes of the propofol being stopped the patient became
apneic. In this case, the decreased ICP/BP from the propofol seemed to be
protective. Patient intubated hyperventilated and went emergently to the OR.
3) If you have a patient who has Cushing's SYNDROME, actually, you want
less cortisol, so etomidate can be part of your treatment suppressing
cortisol secretion! Heyn J, Pituitary 2012 p 117.
On Fri, Oct 18, 2013 at 4:49 PM, Jay Pershad <[log in to unmask]> wrote:
> Mike et al,
> I am aware that it is controversial since the mortality amongst study
> participant's may have been related to the underlying severity of illness.
> Proving a cause effect relationship will be challenging, to say the least.
> However, if you review a more recent metaanalysis from the critical care
> literature, the association between etomidate for RSI & all cause
> mortality, as well as blunting of adrenal response to an ACTH stimulation
> test, although small, appears to be real. [RR of death 1.20; 95% CI
> 1.02-1.42; RR for adrenal insufficiency 1.33; 95% CI 1.22-1.46]
> Etomidate is associated with mortality and adrenal insufficiency in
> sepsis: a meta-analysis*. Chan CM, Mitchell AL, Shorr AF. Crit Care Med.
> 2012 Nov;40(11):2945-53.
> Since we have other sedatives drugs in our quiver, my practice off late
> has been to avoid Etomidate in the severely ill or injured patients. Would
> love to hear from others as well as more details of your EM JC discussion.
> BTW, "ketamine" myth has been "debunked"!
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
Amy Baxter MD FAAP FACEP
Director of Emergency Research, Scottish Rite
Children's Healthcare of Atlanta
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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