Safety of etomidate bolus administration in patients with septic shock
Reviewed by: Rob Green, BSc, MD, DABEM*; Sean K. Gorman, BSc (Pharm)†
From the *Department of Emergency Medicine, Department of Anesthesia, Division of Critical Care, Queen Elizabeth II Health Sciences Centre; Dalhousie University, Halifax, NS; and †Department of Pharmacy, Capital District Health Authority and College of Pharmacy, Dalhousie University, Halifax, NS. On behalf of the CLAM group (Critical Illness Airway Management; www.theCLAMgroup.ca).
- In critically ill patients with septic shock, does exposure to bolus administration of etomidate increase the risk of inadequate response to corticotropin and mortality compared to no exposure?
- In critically ill patients with septic shock who are exposed to bolus administration of etomidate, does hydrocortisone reduce the risk of death compared to placebo?
Article chosenCuthbertson BH, Sprung CL, Annane D, et al. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock.
Study objectiveThe authors sought to test the hypotheses that bolus doses of etomidate results in an increased proportion of nonresponders to corticotropin and an increase in mortality and that hydrocortisone treatment decreases mortality in patients receiving etomidate.
Etomidate is commonly used to achieve induction-level sedation prior to endotracheal intubation because of its cardiovascular stability, rapid onset and short duration, and cerebroprotective properties.1–3 However, critical illness–related corticosteroid insufficiency has been associated with etomidate after the administration of a single dose.4,5
Critical illness–related corticosteroid insufficiency, commonly referred to as adrenal insufficiency, is defined as inadequate cellular corticosteroid activity for the severity of the patient's illness. It is best diagnosed by a delta serum cortisol of less than 248 nmol/L after administration of cosyntropin 250 μg or a random total serum cortisol of less than 276 nmol/L.6 Adrenal insufficiency has been associated with increased mortality in septic shock.7 Investigations into the utility of hydrocortisone replacement in these patients have yielded mixed results. One study suggested that corticosteroid replacement was beneficial, whereas another demonstrated an equivocal result.8,9 Several guidelines have recommended that corticosteroid replacement therapy be considered in patients with adrenal insufficiency who have refractory septic shock.10,11 The use of etomidate to facilitate emergency endotracheal intubation in patients with septic shock is particularly concerning as the potential for etomidate to contribute to adrenal insufficiency may result in adverse patient outcomes. Etomidate use in this situation may avoid peri-intubation hemodynamic instability in the short term yet result in increased patient mortality in the longer term. There is no study to date demonstrating that the use of etomidate leads to an increase in mortality or morbidity.12
In the study being reviewed, Cuthbertson and colleagues sought to determine whether etomidate exposure in patients with septic shock was associated with an increased incidence of inadequate response to corticotropin and 28-day mortality.13 They also aimed to determine whether corticosteroid replacement reduced mortality in patients exposed to etomidate.
Study Design and Patient Population
This was an a priori substudy of the prospective, randomized, double-blind, placebo-controlled Corticosteroid Therapy of Septic Shock (CORTICUS) study.9 The CORTICUS study randomized 499 adult patients with septic shock to receive hydrocortisone 50 mg IV or placebo every 6 hours. As part of the study design, etomidate use was discouraged because of its potential for adrenal suppressive effects but did not constitute an exclusion criterion. Approximately 90% of patients enrolled required mechanical ventilation. No breakdown was provided in terms of proportions requiring invasive versus noninvasive mechanical ventilation. The study was stopped prematurely (target
The cohort of patients of interest was those who received any dose of etomidate via bolus administration within 72 hours prior to being randomized to receive hydrocortisone or placebo. This time cutoff was prospectively chosen because the authors believed these patients to be most likely to develop an inadequate response to corticotropin, representing adrenal insufficiency. Patients who were exposed to etomidate more than 72 hours prior to trial inclusion were not included as it was assumed that the effects (if any) would not persist beyond 3 days.
Study end points in the etomidate-exposed patients included short corticotropin stimulation test response, 28-day mortality, and 28-day mortality in patients who received hydrocortisone. Inadequate response to corticotropin was defined as a failure of serum cortisol concentrations to increase more than 248 nmol/L after bolus intravenous administration of corticotropin 250 μg.
Ninety-six (96 of 499, 19.2%) patients received etomidate within 72 hours of randomization in the CORTICUS study and were included for analysis. A further 33 (7%) patients who had received etomidate met the exclusion criteria stated above. The median time between etomidate exposure and randomization to hydrocortisone or placebo was 14.5 hours (interquartile range 4.25–28.4), but reasons for etomidate use and total dose administered were not reported.
Baseline characteristics including age, gender, race, severity of illness, and cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score were similar between the etomidate-exposed group and those who were not exposed to the drug. However, baseline serum cortisol concentration appeared lower in the etomidate group (559 nmol l1 vs 713 nmol l1; no
Univariate analysis revealed an association between etomidate exposure and mortality (OR = 1.7, 95% CI 1.07–2.68; NNH 8, 95% CI 4–68;
Etomidate for rapid-sequence induction has gained widespread popularity in emergency medicine owing to its ease of administration in combination with a stable cardiovascular profile.14 Peri-intubation hemodynamic instability is common in the critically ill patient population and is thought to be related in part to medications administered to facilitate intubation.15 Although medications may be one risk factor for the development of peri-intubation hemodynamic instability, other factors are probably also important.16,17
Peri-intubation hemodynamic instability has not been thoroughly evaluated, and little is known about its incidence, risk factors, and impact on patient outcomes.17 Despite this, evidence exists indicating that both sustained and nonsustained hemodynamic instability in the general emergency department patient population are associated with increased mortality.18 Critically ill patients requiring resuscitation and emergency endotracheal intubation commonly present with physiologic derangements. Further hemodynamic instability associated with airway management is likely to be poorly tolerated. In light of this, the avoidance or minimization of peri-intubation hemodynamic instability is an important management principle.
High-quality research examining peri-intubation hemodynamic responses to other induction agents used in emergency airway management is minimal. Ketamine has been shown to be similar to etomidate in terms of offering a stable cardiovascular profile when used to facilitate rapid-sequence intubation in critically ill patients.12 Even though hemodynamic information about other induction agents is lacking, research establishing the risk of etomidate in patients with sepsis should be undertaken.
This was a substudy of a prospective, randomized, placebo-controlled trial and must be interpreted with the cautions associated with observational research. Although in one regression model, an association between etomidate exposure and mortality was established, it does not prove that etomidate caused that increased risk for death. Confounding factors could have accounted for the associated increase in mortality. The patients in this subset were not randomized for this purpose. There was no sample size calculation for this study; given the early termination of the original study, this particular analysis was probably underpowered. There was no description of other medications administered prior to randomization. Unreported patient factors may have contributed to the treating clinician's decision to use etomidate prior to randomization. Reported baseline characteristics between the initial study groups were similar. In this subset of patients determined by criteria (use or nonuse of etomidate) distinct from the original randomization, the two groups were different at baseline. A univariate analysis revealed a modest association between etomidate and 28-day mortality; however, this method of analysis evaluates the relationship between two variables and does not control for interactions with other potential confounding variables.19 Although the result of one of the multiple regression analyses was statistically significant, the result of another was not. In the positive analysis, the association between etomidate exposure and mortality was modest (OR 1.75). Furthermore, the indications for etomidate administration and details of the dosing regimens administered were not reported. The authors of the source study reported that etomidate was used for induction of anesthesia; however, no specific details were provided.9 This study's results are discordant with another underpowered subgroup analysis from an earlier study that revealed treatment with etomidate in septic patients was not associated with increased odds of death when compared to ketamine.12 Both analyses were exploratory and hypothesis generating at best.
A search of ClinicalTrials.gov revealed one actively recruiting prospective, randomized, double-blind, single-centre study comparing etomidate versus midazolam for intubation of patients with sepsis (NCT00441792). Its aims are to determine the difference in mortality and length of stay between the two groups of critically ill septic patients. The results of this study and those of future prospective, randomized, controlled trials will be required to determine the safety of etomidate bolus administration in patients with septic shock.
This study does not provide definitive answers to the clinical questions surrounding risk of use of etomidate for rapid-sequence induction anesthesia in septic shock. The study also does not adequately address the utility of supplemental corticosteroids to counteract potential adverse effects on the hypothalamic-pituitary-adrenal axis.
Zed PJ, Abu-Laban RB, Harrison DW. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Acad Emerg Med 2006;13:378- 83, doi:10.1111/j.1553-2712.2006.tb00313.x.
Bergen JM, Smith DC. A review of etomidate for rapid sequence intubation in the emergency department. J Emerg Med 1997;15:221-30, doi:10.1016/S0736-4679(96)00350-2.
Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest 2005;127:1397- 412, doi:10.1378/chest.127.4.1397.
Jackson WL. Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock? Chest 2005;127:1031-8, doi:10.1378/chest.127.3.1031.
Allolio B, Dorr H, Stuttmann R, et al. Effect of a singlebolus of etomidate upon eight major corticosteroid hormones and plasma ACTH. Clin Endocrinol 1985;22:281-6, doi:10.1111/j.1365-2265.1985.tb03241.x.
Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med 2008;36:1937-49, doi:10.1097/CCM.0b013e31817603ba.
Annane D, Sebille V, Troche G, et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000;283:1038-45.
Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288:862-71, doi:10.1001/jama.288.7.862
Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008; 358:111-24, doi:10.1056/NEJMoa071366.
Delinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296-327, doi:10.1097/01.CCM.0000298158.12101.41.
Green RS, Djogovic D, Gray S, et al. Canadian Association of Emergency Physicians Sepsis Guidelines: the optimal management of severe sepsis in Canadian emergency departments. CJEM 2008;10:443-59.
Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet 2009;374: 293-300, doi:10.1016/S0140-6736(09)60949-1.
Cuthbertson BH, Sprung CL, Annane D, et al. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Intensive Care Med 2009;35:1868- 76, doi:10.1007/s00134-009-1603-4.
Oglesby AJ. Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department? Emerg Med J 2004;21:655-9, doi:10.1136/ emj.2003.009043.
Franklin C, Samuel J, Hu TC. Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation. Am J Emerg Med 1994;12:425-8, doi:10.1016/0735-6757(94)90053-1.
Sivilotti ML, Ducharme J. Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: the SHRED study Ann Emerg Med 1998;31:313-24, doi:10.1016/S0196- 0644(98)70341-5.
Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations—part I. J Intensive Care Med 2007; 22:157-65, doi:10.1177/0885066607299525.
Marchick MR, Kline JA, Jones AE. The significance of nonsustained hypotension in emergency department patients with sepsis. Intensive Care Med 2009;35:1261-4, doi:10.1007/ s00134-009-1448-x.
Katz MH. Multivariable analysis: a practical guide for clinicians. Cambridge (UK): Cambridge University Press; 1999.
Dr. Rob Green, Department of Medicine: Division of Critical Care and Department of Emergency Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, 377 Bethune Building, 1276 South Park Street, Halifax, NS B3H 2Y9; email@example.com