PURPOSE: Etomidate is often used for the emergent intubation of critically ill patients. Continuous infusion of etomidate was associated with increased mortality due to adrenal insufficiency (AI). The safety of a single dose of etomidate used for rapid sequence intubation is unclear. We hypothesized that single dose etomidate increases the occurrence of AI in patients with sepsis.
METHODS: We conducted a meta-analysis of randomized controlled trials (RCTs) published between January 1950 and December 2010. We identified all studies evaluating the effects of etomidate on AI and all-cause mortality. We only examined trials in septic patients. The incidence of AI served as our primary endpoint while all-cause mortality was our secondary endpoint. AI was determined using a cosyntropin stimulation test in all studies. We employed a random effects model for analysis; heterogeneity was assessed with the I2 test. Publication bias was evaluated with Begg’s plot.
RESULTS: Two RCTs were identified that addressed AI in those who received etomidate. A total of 575 subjects were included (mean age: 62.7; male: 65.7%; SAPS II: 48.4). Three RCTs addressed mortality associated with the administration of etomidate; 697 subjects were included (mean age: 65.1; male: 66.0%). Etomidate administration increases the likelihood for developing AI (OR: 1.56; 95% confidence interval [CI]: 1.20-2.03; I2=71.2%; p=0.062). Subjects who received etomidate were also more likely to die (OR: 1.32; 95% CI: 1.06-1.64, I2=0.0%; p=0.802). Mortality assessment was performed at 28 days for 2 studies and at end of hospital stay for the 3rd. There was no evidence of publication bias using Begg’s plot (p=0.251).
CONCLUSIONS: Administration of etomidate for rapid sequence intubation is associated with higher rates of adrenal insufficiency and mortality in patients with sepsis.
CLINICAL IMPLICATIONS: Etomidate should be avoided to induce sedation for intubation in patients with sepsis.
DISCLOSURE: The following authors have nothing to disclose: Chee Chan, Anthony Mitchell, Andrew Shorr
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