Etomidate and General Anesthesia

Abstract

Induction of general anesthesia with control of ventilation remains a routine procedure both in critically ill patients and in those undergoing elective surgery. Etomidate is considered the drug of choice for emergency intubation procedure because of a good perceived benefit/ risk ratio, including hemodynamic stability, and minor side effects such as, myoclonus. Administered in conjunction with a rapid-onset neuromuscular-blocking drug, etomidate remains the preferred drug by most emergency physicians, anesthesiologists, and intensivists for rapid sequence induction of anesthesia. Publication of observational cohort studies suggesting increased mortality with the use of etomidate in septic patients has, however, raised safety concerns. In a systematic review and meta-analysis in septic patients, including randomized controlled trials and observational studies, Chan et al. 1 reported that a single dose of etomidate for induction of anesthesia was associated with increased 28-day mortality (relative risk 1.20, 95% confidence inter val, 1.02–1.4). Similar findings were observed in a post hoc analysis of the Corticosteroid Therapy of Septic Shock (CORTICUS) trial. An increased 28-day mortality rate (43% vs 31%, P = 0.03) was noted in patients who received etomidate compared with patients who did not. 2 However, other authors did not observe such an increased risk of mortality when using etomidate in septic patients 3 and even observed a decreased mortality rate after adjustment for severity of illness. 4 Similarly, randomized controlled trials have not provided evidence for an increased risk of death following a single dose of etomidate in critically ill patients (Fig. 1). 5–8 In the largest multicenter study in the prehospi