In reply

Abstract

Dr. Mittal's letter raises some interesting points in the debate over etomidate's use to facilitate endotracheal intubations. Fortunately, the very concerns he raises reinforce the premise that etomidate should not be used in septic patients at this time. The CORTICUS study he cites provides some of the strongest evidence yet of the role the adrenal gland plays in sepsis survival.1Sprung C.L. Annane D. Didier K. et al.Hydrocortisone therapy for patients with septic shock.N Engl J Med. 2008; 358: 111-124Crossref PubMed Scopus (1606) Google Scholar The mortality rate for patients responsive to adrenocorticotropic hormone (28.7%-28.8%) was significantly less than that of patients not responding to corticotrophin (36.1%-39.2%) More importantly, the study demonstrated that supplemental hydrocortisone did not affect the mortality rates in patients with adrenal suppression. This single study reinforced 2 points, one an intact pituitary-adrenal axis increases a patient's chances for survival from sepsis; and two, supplemental hydrocortisone does not offset the impact of a non-responsive adrenal gland. Given this premise, one has to question the wisdom of iatrogenic suppression of the adrenal gland when no effective pharmacologic substitute exists. It is also dangerous to summarily dismiss den Brinker's findings regarding etomidate and meningococcal sepsis.2den Brinker M. Joosten K.F. Liem O. et al.Adrenal insufficiency in meningococcal sepsis: bioavailable cortisol levels and impact of interleukin-6 levels and intubation with etomidate on adrenal function and mortality.J Clin. Endocrinol Metab. 2005; 90: 5110-5117Crossref PubMed Scopus (152) Google Scholar The intent of den Brinker's work was to study the effect of meningococcemia on adrenal function and not to examine any effects of etomidate. It was only on further analysis that den Brinker's team demonstrated the correlation between etomidate use, depressed adrenal function and mortality. To ignore this finding simply because it was not the initial objective of the study would needlessly place patients at risk in the name of academic arrogance. It should be pointed out that a fair number of Nobel prizes resulted from curious investigators pursuing incidental observations in a research project. den Brinker's work does not confirm etomidate's role in these patient's deaths, but does indicate the need for caution in the use of this drug until further evaluation is completed. To be clear, none of the other articles cited by Dr. Mittal has the scientific credentials to confirm etomidate's risks in the septic patient. A recent randomized trial has demonstrated increased morbidity with etomidate's use in rapid sequence intubation, although this study had a relatively small number of patients enrolled.3Hildreth A.N. Mejia V.A. Maxwell R.A. et al.Adrenal suppression following a single dose of etomidate for rapid sequence induction: A prospective randomized study.J Trauma. 2008; 65: 573-579Crossref PubMed Scopus (151) Google Scholar Regardless of how anyone views the quality of etomidate-related articles, there can be no argument about the existence of a potential connection between etomidate use and adverse outcomes in critically ill patients. Given these circumstances and the existence of multiple alternative medications, it is difficult to justify the continued use of this drug pending publication of the methodologically perfect study. Etomidate: Not Worth the Risk in Septic PatientsAnnals of Emergency MedicineVol. 52Issue 1PreviewA 3-year-old boy presents to the emergency department (ED) with a 1-day history of fever, a coalescing petechial rash, and a blood pressure of 40 mm Hg. A 75-year-old febrile nursing home patient has a pulse rate of 120 beats/min, blood pressure of 80 mm Hg, and a grossly infected urinary catheter. The child is lethargic and fatigued, whereas the nursing home patient has agonal respirations. Both of these patients are obviously septic, both have a 50% chance of having adrenal insufficiency, and in North America, both will almost certainly undergo rapid sequence intubation with etomidate. Full-Text PDF Etomidate as an Induction Agent for Endotracheal Intubation in Patients With SepsisAnnals of Emergency MedicineVol. 53Issue 3PreviewI was excited to read the feature “Clinical Controversies: Etomidate as an induction agent for endotracheal intubation in patients with sepsis” as this relates to one's everyday practice if working at a busy emergency department (ED).1,2 I want to make a few points in response to the commentary: “Etomidate: not worth the risk in septic patients.”2 The assertion in the body of the paper, and then again in the concluding paragraph, that response to adrenocorticotropic hormone and performance of adrenal glands affects outcome including survival in sepsis (based on a small cohort study with only 9 nonsurvivors, and 2 editorials/review articles) seems to be in conflict with the result of the CORTICUS study, the largest randomized trial of patients with sepsis and septic shock which showed that there was no significant difference in mortality between patients who did or did not have a response to corticotrophin. 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