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Increased Risk of Adrenal Insufficiency Following Etomidate Exposure in Critically Injured Patients—Invited Critique

Increased Risk of Adrenal Insufficiency Following Etomidate Exposure in Critically Injured... The prevalence and impact of AI in critical illness has gained considerable attention recently such that guidelines for the diagnosis and treatment of AI in sepsis have been established.1 Although AI is known to occur in critically ill trauma patients in the early postinjury period, its contribution to patient outcomes and its causes are not well understood. Also underappreciated is the potential contribution of commonly used pharmacologic agents on adrenal function. One such agent is etomidate, a sedative commonly used during rapid-sequence intubation in the initial treatment of severely injured patients. Etomidate has a known impact on adrenal function by blocking mitochondrial hydroxylase activity and, hence, steroidogenesis. This effect was thought to be short-lived after a single dose and therefore of little consequence in the trauma setting. In a retrospective study, the authors of this report have provided evidence that AI, assessed 48 hours after intubation, occurs more frequently in severely injured patients who received etomidate than in those who did not (54% vs 30%). Furthermore, AI was associated with longer hospital stay, more ventilator days, and longer stays in the intensive care unit. However, AI also occurred more frequently in the setting of hemorrhagic shock and in patients who developed coagulopathy. These observations raise intriguing questions. For example, does shock render patients more susceptible to prolonged adrenal dysfunction due to delayed recovery of the enzyme system inhibited by etomidate? Is the initial interpretation of refractory hemorrhagic shock actually a manifestation of early profound adrenal dysfunction? The results of this study are of obvious importance. The authors are to be commended for the cautious interpretation of their results and for clearly articulating the limitations of the study. They wisely refrain from making firm recommendations for changes in induction algorithms in trauma patients and instead conclude that these observations provide the basis for proceeding with a more comprehensive prospective evaluation of the impact of etomidate on adrenal function in the trauma population. It is clear that such a study should be carried out and the importance of AI in the trauma setting rigorously evaluated. Financial Disclosure: None reported. References 1. Dellinger RPCarlet JMMasur H et al. Surviving Sepsis Campaign Management Guidelines Committee, Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32 (3) 858- 873[published corrections appear in Crit Care Med. 2004;32(6):1448; and Crit Care Med. 2004;32(10):2169-2170]PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Increased Risk of Adrenal Insufficiency Following Etomidate Exposure in Critically Injured Patients—Invited Critique

Archives of Surgery , Volume 143 (1) – Jan 1, 2008

Increased Risk of Adrenal Insufficiency Following Etomidate Exposure in Critically Injured Patients—Invited Critique

Abstract

The prevalence and impact of AI in critical illness has gained considerable attention recently such that guidelines for the diagnosis and treatment of AI in sepsis have been established.1 Although AI is known to occur in critically ill trauma patients in the early postinjury period, its contribution to patient outcomes and its causes are not well understood. Also underappreciated is the potential contribution of commonly used pharmacologic agents on adrenal function. One such agent is...
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Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2007.19
Publisher site
See Article on Publisher Site

Abstract

The prevalence and impact of AI in critical illness has gained considerable attention recently such that guidelines for the diagnosis and treatment of AI in sepsis have been established.1 Although AI is known to occur in critically ill trauma patients in the early postinjury period, its contribution to patient outcomes and its causes are not well understood. Also underappreciated is the potential contribution of commonly used pharmacologic agents on adrenal function. One such agent is etomidate, a sedative commonly used during rapid-sequence intubation in the initial treatment of severely injured patients. Etomidate has a known impact on adrenal function by blocking mitochondrial hydroxylase activity and, hence, steroidogenesis. This effect was thought to be short-lived after a single dose and therefore of little consequence in the trauma setting. In a retrospective study, the authors of this report have provided evidence that AI, assessed 48 hours after intubation, occurs more frequently in severely injured patients who received etomidate than in those who did not (54% vs 30%). Furthermore, AI was associated with longer hospital stay, more ventilator days, and longer stays in the intensive care unit. However, AI also occurred more frequently in the setting of hemorrhagic shock and in patients who developed coagulopathy. These observations raise intriguing questions. For example, does shock render patients more susceptible to prolonged adrenal dysfunction due to delayed recovery of the enzyme system inhibited by etomidate? Is the initial interpretation of refractory hemorrhagic shock actually a manifestation of early profound adrenal dysfunction? The results of this study are of obvious importance. The authors are to be commended for the cautious interpretation of their results and for clearly articulating the limitations of the study. They wisely refrain from making firm recommendations for changes in induction algorithms in trauma patients and instead conclude that these observations provide the basis for proceeding with a more comprehensive prospective evaluation of the impact of etomidate on adrenal function in the trauma population. It is clear that such a study should be carried out and the importance of AI in the trauma setting rigorously evaluated. Financial Disclosure: None reported. References 1. Dellinger RPCarlet JMMasur H et al. Surviving Sepsis Campaign Management Guidelines Committee, Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32 (3) 858- 873[published corrections appear in Crit Care Med. 2004;32(6):1448; and Crit Care Med. 2004;32(10):2169-2170]PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Jan 1, 2008

Keywords: adrenal gland hypofunction,etomidate

References