Controversies surrounding the use of etomidate for rapid sequence intubation in patients with suspected sepsis

To evaluate the risk of adrenal insufficiency following a single dose of etomidate in patients with suspected sepsis requiring rapid sequence intubation.

A literature search was conducted using PubMed, MEDLINE, EMBASE, and International Pharmaceutical Abstracts from the dates of database inception until April 2010, utilizing the terms adrenal insufficiency, etomidate, and sepsis.

Data were synthesized in a qualitative manner, as variable study designs were identified. All studies that evaluated the clinical association between etomidate-induced adrenal insufficiency and sepsis in adults were reviewed and included.

A search of the literature revealed 7 studies that specifically evaluated clinical endpoints in septic adults receiving etomidate for induction prior to intubation. Three of the studies evaluated risk factors associated with adrenal insufficiency in critically ill patients. Each of these studies determined that etomidate exposure was independently associated with an inappropriate response to cosyntropin stimulation testing (CST). Two studies found no significant difference in hospital mortality rates when evaluating patients receiving induction with etomidate compared with alternative regimens. Three studies found an increased risk of adrenal insufficiency in patients exposed to etomidate. The majority of studies that evaluated the use of etomidate in sepsis were underpowered, leading to difficulty in establishing a causal relationship between drug-related adrenal insufficiency, morbidity, and mortality.

Until further studies are available, etomidate should be reserved for hemodynamically unstable patients who cannot tolerate an alternative induction agent despite the administration of fluids or vasoactive agents.