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Critical Appraisal

If your patient is septic and needs intubation, is etomidate appropriate?

Aaron Holley, MD, Critical Care/Intensive Care, 11:32AM Mar 24, 2013



For years etomidate
has been linked to adrenal suppression. I remember back in 2005 when one of the
intensivists who trained me (and inspired me to become a critical care
physician) at the Walter Reed Army Medical Center (WRAMC) wrote a literature
review on using etomidate in the setting of sepsis (CHEST 2005; 127:
1031-1038). His conclusion? Until a randomized controlled trial (RCT) can be
completed, use caution. Over the years I have not heeded his advice. Instead, I
have allowed my comfort with etomidate to prevent me from changing my practice.



               Well, now we have a meta-analysis
of trials (2 of which were RCTs) showing that etomidate does increase adrenal
insufficiency (AI) and more importantly, mortality (Crit Care Med 2012;  40: 2945-2953). Incidentally, the senior author on this study was also one of my mentors WRAMC. A recent review of this
article in the ACP Journal club suggested that it is time to change to ketamine
or midazolam for patients with sepsis (ACP Journal Club 2013; 158(4): JC10),
citing one of the RCTs included in the trial (Lancet 2009; 374: 293-300).



               I spoke with a colleague trained
in anesthesia and critical care who told me that he has not abandoned etomidate
entirely but that he often uses propofol along with phenylephrine as needed. He
told me he rarely uses ketamine because it tends to produce a prolonged effect.
Personally Iím always nervous about propofol when dealing with a patient who is
already hemo-dynamically unstable, but admittedly I havenít really tried it.
What agents are others using for rapid sequence intubation in the setting of
severe sepsis or septic shock? Etomidate, midazolam, propofol, ketamine, or
some other drug?



Poll: What induction agent do you use for rapid-sequence intubation in critically ill patient with sepsis? ketamine|etomidate|midazolam|ketamine|propofol|
About This Blog

The Critical Appraisal blog provides clinical reviews for the practicing ICU physician, and a concise, objective analysis of recently published critical care literature.

Aaron B. Holley, MD, has disclosed no relevant financial relationships.Poll: What induction agent do you use for rapid-sequence intubation in critically ill patient with sepsis? ketamine|etomidate|midazolam|ketamine|propofol|

  • Aaron Holley

    Aaron B. Holley, MD, is a Pulmonary/Sleep and Critical Care Medicine (PSCCM) physician at the Walter Reed National Military Medical Center (WRNMMC) at Bethesda, Maryland. He ran an ICU in a combat support hospital in the Helmand Province while serving in Afghanistan, and is currently the research coordinator for the PSCCM fellowship at WRNMMC.

 


 
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