In reply

Abstract

Dr. McConachie’s concerns regarding potentially significant adrenal suppression with etomidate have, as he notes, been raised many times.1Oglesby A.J. Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department?.Emerg Med J. 2004; 21: 655-659Crossref PubMed Scopus (61) Google Scholar, 2Absalom A. Pledger D. Kong A. Adrenocrotical function in critically ill patients 24h after a single dose of etomidate.Anaesthesia. 1999; 54: 861-867Crossref PubMed Scopus (206) Google Scholar, 3Shirley P.J. McAuley D.F. Etomidate–misused or misunderstood?.Anaesthesia. 2006; 61: 190Crossref PubMed Scopus (2) Google Scholar, 4Jones D. Hayes M. Webb S. et al.Relative adrenal insufficiency in etomidate-naïve patients with septic shock.Anaesth Intesive Care. 2006; 34: 599-605PubMed Google Scholar, 5Mohammad Z. Afessa B. Finkielman J.D. The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate.Crit Care. 2006; 10: R105Crossref PubMed Scopus (67) Google Scholar Indeed, we noted as a limitation that our study design6Jacoby J. Heller M. Nicholas J. et al.Etomidate versus midazolam for out-of-hospital intubation: a prospective, randomized trial.Ann Emerg Med. 2006; 47: 542-544Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar did not allow us to assess the clinical significance of this well-known pharmacologic characteristic. Unfortunately, as Zed et al noted recently, “It is uncertain if this transient adrenal insufficiency results in significant clinical manifestations, as it is still poorly studied.”7Zed P.J. Mabasa V.H. Slavik R.S. et al.Etomidate for rapid sequence intubation in the emergency department: is adrenal suppression a concern?.Can J Emerg Med. 2006; 8: 347-350Google Scholar We agree with Dr. McConachie that “the emergency department, the operating theatre and the ICU should all work together in the interest of the patient” and we heartily support a clinical study that could resolve this issue. We do not agree with the contention that “…all papers discussing etomidate should include…” a discussion of adrenal suppression. Dr. McConachie’s concerns regarding potentially significant adrenal suppression with etomidate have, as he notes, been raised many times.1Oglesby A.J. Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department?.Emerg Med J. 2004; 21: 655-659Crossref PubMed Scopus (61) Google Scholar, 2Absalom A. Pledger D. Kong A. Adrenocrotical function in critically ill patients 24h after a single dose of etomidate.Anaesthesia. 1999; 54: 861-867Crossref PubMed Scopus (206) Google Scholar, 3Shirley P.J. McAuley D.F. Etomidate–misused or misunderstood?.Anaesthesia. 2006; 61: 190Crossref PubMed Scopus (2) Google Scholar, 4Jones D. Hayes M. Webb S. et al.Relative adrenal insufficiency in etomidate-naïve patients with septic shock.Anaesth Intesive Care. 2006; 34: 599-605PubMed Google Scholar, 5Mohammad Z. Afessa B. Finkielman J.D. The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate.Crit Care. 2006; 10: R105Crossref PubMed Scopus (67) Google Scholar Indeed, we noted as a limitation that our study design6Jacoby J. Heller M. Nicholas J. et al.Etomidate versus midazolam for out-of-hospital intubation: a prospective, randomized trial.Ann Emerg Med. 2006; 47: 542-544Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar did not allow us to assess the clinical significance of this well-known pharmacologic characteristic. Unfortunately, as Zed et al noted recently, “It is uncertain if this transient adrenal insufficiency results in significant clinical manifestations, as it is still poorly studied.”7Zed P.J. Mabasa V.H. Slavik R.S. et al.Etomidate for rapid sequence intubation in the emergency department: is adrenal suppression a concern?.Can J Emerg Med. 2006; 8: 347-350Google Scholar We agree with Dr. McConachie that “the emergency department, the operating theatre and the ICU should all work together in the interest of the patient” and we heartily support a clinical study that could resolve this issue. We do not agree with the contention that “…all papers discussing etomidate should include…” a discussion of adrenal suppression. Etomidate Controversies in Emergency MedicineAnnals of Emergency MedicineVol. 50Issue 2PreviewThere seems to be a growing interest in the use of the anaesthetic induction agent, etomidate, in locations other than the operating room and administered by nonanaesthesia personnel. Indeed, Annals of Emergency Medicine has published 3 papers recently examining uses of etomidate in scenarios commonly experienced by emergency medicine personnel. It is not necessarily my place to comment on papers exploring the relative merits of etomidate versus midazolam for intubation or procedural sedation in the emergency department (ED) or in the field. Full-Text PDF