A novel use of etomidate for intentional adrenal suppression to control severe hypercortisolemia in childhood

Area of Science:

• Pediatric Endocrinology
• Critical Care Medicine
• Pharmacology

Background:

• Etomidate is commonly used for anesthesia induction in children but is controversial due to its potential for adrenal suppression.
• Severe hypercortisolemia, often due to Cushing's disease, presents a life-threatening condition requiring urgent management.
• Standard treatments for hypercortisolemia, such as metyrapone and ketoconazole, may be ineffective in severe cases.

Observation:

• A case report details the use of continuous intravenous etomidate infusion in a 6-year-old boy with severe hypercortisolemia.
• The patient's condition was refractory to initial medical management, necessitating admission to the pediatric intensive care unit.
• Etomidate infusion was administered prior to bilateral adrenalectomies to deliberately suppress elevated endogenous cortisol levels.

Findings:

• Continuous etomidate infusion at 0.08 mg/kg/hr effectively reduced serum cortisol from 1200 to 250 nmol/L within 48 hours.
• The therapy facilitated stable serum cortisol levels, enabling the successful completion of bilateral laparoscopic adrenalectomies.
• Perioperative cortisol surge was observed but was significantly blunted compared to expected levels without prior etomidate use.

Implications:

• This study suggests a novel therapeutic application for etomidate in critically ill children, leveraging its adrenal suppressive effect.
• Continuous etomidate infusion offers a viable short-term strategy for controlling severe, life-threatening hypercortisolemia in pediatric patients.
• The findings challenge the current perception of etomidate's adrenal suppression as solely a detrimental side effect, highlighting its potential therapeutic benefits.