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Jan 15, 2009Article Details
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Avoiding etomidate for emergency intubation. Throwing the baby out with the bathwater?
Abstract
Introduction. Recent literature questions the suitability of etomidate as a rapid-sequence intubation (RSI) drug, owing to induced relative adrenal insufficiency (AI) and possible increased mortality. Aim. This paper examines the evidence for and against etomidate in the shocked emergency patient and whether or not its use should be cautiously considered or abandoned in this patient cohort, given the AI effect. The issue is examined from the perspective of the septic shock patient, the child and the trauma patient.
Method. A literature review focusing on the risk-benefit ratio and whether there are mortality differences in the outcome of patients in whom etomidate is used, that are attributable to the relative adrenal suppression with even a single bolus dose.
Discussion. The evidence of relative AI is clear, but the cause-effect relationship of increased mortality is not as clear. Currently, most evidence is in the context of septic shock, with only retrospective studies in the trauma subgroup, with a small or moderate sample size. Conclusion. Etomidate should preferably be avoided as an RSI drug in the septic patient, and cautiously considered in the trauma patient, provided that steroid supplementation is provided in the event that vasopressor-resistant shock occurs.
Southern African Journal of Critical Care Vol. 24 (1) 2008: pp. 13-25
