Etomidate and intensive care physicians

Excerpt

Sir: The concerns expressed by Dr. Annane [1] about the effects of etomidate on outcome are well founded, and his proposal to eschew the use of etomidate in the ICU provides one solution to this problem [1]. However, the solution is only partial in that some intensive care physicians may not follow his advice because of perceived advantages of this agent. The perceived utility of etomidate in critically ill patients is reflected in a recent study which found that over 80% of shocked patients received etomidate prior to enrolment [2]. Indeed other professionals such as anaesthetists and emergency physicians may provide their intensive care colleagues with patients who have already received etomidate prior to ICU admission. The early experience of the Glasgow ICU that first reported etomidate-induced adrenal insufficiency may then be relevant. Their research letters, when combined, are suggestive that steroid replacement confers a survival benefit [3]. Therefore, although it is reasonable to suggest that the use of etomidate should be avoided, intensive care physicians must nevertheless deal with patients who have received this agent. Until there are data to the contrary, we believe intensive care physicians should consider adapting corticosteroid replacement strategies from other settings to deal with their patients who have drug-induced but reversible adrenal insufficiency [4]. Annane and colleagues may be able to confirm whether corticosteroid replacement is beneficial in patients with septic shock as a large subgroup of patients in their multi-centre clinical trial received etomidate and were randomised to receive either hydrocortisone or placebo [5]. …