Another Attempt to Link Etomidate to Sepsis Mortality

Abstract

In this of heterogeneous, mostly methodologically flawed studies, the authors suggest a weak link between etomidate use and mortality. A single dose of etomidate can suppress cortisol response for up to 48 hours, but study results and opinions as to whether this effect has clinical relevance are conflicting. Researchers conducted a of 19 studies that compared rates of adrenal insufficiency, mortality, or both between critically ill adult patients who received a single dose of etomidate and those who received a comparator (thiopentone, fentanyl, midazolam, or ketamine) for rapid sequence intubation in intensive care units and emergency departments. The included eight retrospective studies, seven randomized controlled trials, and four observational studies with a combined total of 3715 patients. Use of etomidate was associated with increased risk for adrenal insufficiency (risk ratio, 1.64) and for all-cause mortality at 28 days (RR, 1.19). The authors note that whereas evidence for an association between etomidate and adrenal insufficiency is strong, evidence for an association between etomidate and increased mortality is weak, as most trials were nonrandomized and heterogeneous. Comment: Three 7-year-olds do not make a 21-year-old. Unfortunately, combining uncontrolled studies does not improve their quality, and this meta-analysis provides no new or useful information or guidance. No convincing evidence exists that etomidate increases mortality or morbidity in patients with sepsis, and unless a rigorous, prospective study provides clear evidence to the contrary, etomidate is an appropriate agent for induction of critically ill patients, including those with sepsis.