Nor are there any statistical differences between the two groups in regard to the secondary endpoints or need for or duration of vasopressor support, hospital or ICU length of stay, receipt of corticosteroids or mechanical ventilation days. The discrepancy between the above-mentioned studies stimulated this current investigation. There is additional literature challenging the mortality effect of etomidate. Most recently, Jabre et al. A retrospective study by Dmello et al.
To date, this is the largest retrospective study to specifically evaluate the mortality impact of etomidate on the severe sepsis and septic shock population. This study presents over twice the number of patients provided by the Annane and Sprung negative subset analyses [ 4 , 8 ].
The prospective Jabre study [ 11 ] presents data for only 76 sepsis patients. The supportive Ray study [ 10 ] has data involving patients. The equally positive Dmello study [ 12 ] has a comparable cohort with patients. The Dmello manuscript does have a substantially larger non-etomidate cohort. Unlike some of the previously mentioned studies [ 4 , 7 , 8 ], this study includes both severe sepsis and septic shock patients. This might be considered a potential limitation.
The decision to include this population is further validated as both the etomidate and non-etomidate groups had mortality comparable to the study by Sprung [ 8 ]. The investigation includes data from two separate institutions; which separates it from the majority of the current literature and strengthens the data. There are several limitations in this study. This is a retrospective study and suffers from the characteristic weaknesses of such analysis. The data from UMass and Yale were collected in different formats.
The data from Yale was obtained from a registry with extensive clinical inclusion criteria. The UMass data collection first identified patients by ICD-9 code and then reviewed clinical criteria. Potential patients may have been missed as institutional data collection patterns differed.
There were significant differences in gender and intubation location between the etomidate and non-etomidate cohorts. The Malerba article [ 6 ] suggests that female gender may be a protective aspect. The lack of evenly matched genders does affect the study.
The discrepancy in intubation location is partially explained by the ED focus of the Yale sepsis registry. Both institutions differed in degree of data collected. The Yale registry has more available laboratory data than the UMass collection.
The UMass data set has adrenal insufficiency data available while the Yale registry does not yield this information. Difference in available information limited reportable results. The data also includes patients who did not receive any medication to facilitate intubation. In reviewing the data, several patients were intubated by emergency medical services EMS personnel. Certain EMS services may not use medication.
One may hypothesize that patients did not receive medication due to the severity of their clinical condition. Etomidate use in this large multi-center cohort of severe sepsis and septic shock patients does not increase mortality in comparison to the non-etomidate patient group with similar acuity. As a retrospective study, this work cannot suffice to be the final treatise on etomidate use in sepsis. Given the large sample size, this investigation does suggest that the movement to eradicate etomidate use in this patient population is premature.
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Morley P. Support Center Support Center. External link. Please review our privacy policy. Increased deoxycorticosterone in patients receiving etomidate. Cortisol level after CST after 24 hrs of ventilation. Lower cortisol levels in patients given etomidate OR Consecutive patients presenting to the ED requiring intubation. Cortisol level after CST at 4, 12, and 24 hours post-induction. Decreased cortisol response at 4 hrs after etomidate.
Lower cortisol levels in patients given etomidate. We can debate the significance of the potential transient hormonal effects of etomidate, but, if the patient dies during intubation, the argument is moot.
Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock. Crit Care May 16; R56; [e-pub ahead of print]. Crit Care May 16 Outcomes with etomidate were not different from those with other induction agents, calling into question the clinical significance of etomidate-related adrenal insufficiency.
Comment The potential for inducing or worsening hypotension in critically ill patients who require intubation should not be underestimated. By continuing to use our site, you accept the use of these cookies.
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