BMC Emergency Medicine Journal Club

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BMC Emergency MedicineJournal Club

• Is ED etomidate use in septic patients
• associated with poor outcomes?
• April 2009

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Todays Agenda

• Etomidate and sepsis a safe combination?
• Megan Salinas (PGY3)
• Jason DeLong (PGY2)

BMC EM Journal Club
BMC EM Journal Club
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Etomidate

• C14H16N2O2

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Etomidate

• C14H16N2O2
• From Wikipedia

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BMC Emergency MedicineJournal Club

• Is ED etomidate use in septic patients
• associated with poor outcomes?
• Jason DeLong, MD

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CHEST 2005 1271031-1038
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Background

• Etomidate is commonly used to facilitate
  endotracheal intubation
• Beneficial in hemodynamically unstable patients
• Relative adrenal insufficiency has been observed
  in the critically ill
• Etomidate has been shown to decrease
  corticosteroid production

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Objective

• The use of etomidate for the induction of
  intubation in patients who require critical care
  in general and manifest septic shock in
  particular has come into question. The purpose
  of this article is to explore the basis for such
  concern and to propose management options as the
  evidence dictates

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Methods

• Opinion piece
• Based on literature review
• Single author
• No inclusion or exclusion criteria

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Key Results

• Author groups findings into 5 categories
• - Long term sedation
• - Adrenal insufficiency with induction
• - Additional potential effects
• - Use in septic patients
• - Management alternatives

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Results 1

• Long term sedation
• Mortality rates increased from 25 to 44 in
  1979/1980 and 1981/1982
• Etomidate use became widespread in 1981
• Retrospective study assigning patients to
  benzodiazepine group versus etomidate group
• Etomidate use linked to adrenal insufficiency
• Long term use fell out of favor

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Results 2

• Adrenal insufficiency with induction
• The data suggest that etomidate therapy for the
  induction of intubation may impair the ability to
  maintain vascular homeostasis in patients with
  evolving sepsis and may negatively impact
  mortality
• Literature regarding adrenal suppression from
  induction doses is inadequate for establishing
  safety
• Cortisol levels using CST post-induction with
  etomidate were statistically significantly
  decreased at 4 hrs, but not at 12 and 24 hrs

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Results 3

• Additional potential effects
• Interference with steroid-mediated cellular
  responses (e.g. IL-6, IL-10)
• Inhibition of immune modulators
• Above may be detrimentally affected by one dose
  of etomidate

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Results 4

• Etomidate use in septic patients
• Adrenal insufficiency reported in both relative
  and absolute terms which has created confusion in
  the literature
• Data currently insufficient to determine if the
  absolute adrenal insufficiency post-etomidate
  significantly affects outcomes

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Results 5

• Management alternatives
• The patient with evolving septic shock is most
  likely to require intubation (often emergently)
  in the ED or ICU, where respective providers may
  be less experienced in airway management
• Eliminate etomidate altogether
• Concomitant use of corticosteroids
• Sub-anesthetic doses if etomidate as adjunct

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Authors Conclusion

• The risks of using etomidate outweigh the
  benefits
• Ample evidence suggests etomidate use for
  induction may worsen outcomes
• Consensus agreement on a standardized definition
  for relative adrenal insufficiency in septic
  shock patients, and its optimal diagnosis and
  management should be accompanied by a randomized,
  controlled study examining the use of etomidate
  in this population

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Strengths of Article

• Easy to read
• Numerous references, including non-English
  references
• Not bogged down by extensive statistical analysis
  (sorry, Ward)
• Well organized, logical flow with numerous
  summaries

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Limitations of Article

• Out of 108 References
• - 28 Letters to the editor (gt25 of total)
• - 1 medication packet insert
• - 4 are only abstracts
• No article inclusion/exclusion criteria
• Management alternatives not fully proposed
• Many contradictions

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Read the Editorial
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Final Comments

• Agree that appropriately powered, prospective
  randomized trials are needed
• Current data has only limited ED applicability
• Did not fulfill promise of alternative management
  options
• Has potential to initiate change in practice

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BMC Emergency MedicineJournal Club

• Is ED etomidate use in septic patients
• associated with poor outcomes?
• Megan Salinas, MD

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Acad Emerg Med 20091611

• Advocate Christ Medical Center

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Background

• Prior studies etomidate ? adrenal suppression
• Few small studies have shown increased mortality
• Can the drug we love be detrimental??

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Objective

• To determine whether there was a difference in
  mortality and hospital LOS between those who had
  received etomidate vs another induction agent
• Null hypothesis etomidate other

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Methods

• Prospective, Non-randomized, Observational Cohort
  study
• Feb Oct of 2007
• Enrollment Adults. 2 SIRS. Suspected
  infection. Intubated.

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Methods - Outcomes
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Patient Population
BMC EM Journal Club
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Results

• ETOMIDATE
• In hospital mortality
• 38
• (95CI 28-49)
• LOS
• 8d
• (IQR 3-13d)

• OTHER
• In hospital mortality
• 44
• (95CI 28-61)
• LOS
• 6.5d
• (IQR 3-9.75d)

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A Word on Statistics

• Mortality
• Reported with confidence intervals
• 95 sure the true number is between x and y
• Smaller of pts ? wider CI

BMC EM Journal Club
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Another Word on Statistics

• LOS
• Reported with IQR Inter-Quartile Range
• Because using median
• Using median instead of mean since data is
  skewed septic pts staying longer

BMC EM Journal Club
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Authors Conclusion

• No difference in mortality
• Increased LOS with etomidate
• Not statistically significant
• ? Clinically significant
• Recommendations to discontinue etomidate may be
  unwarranted

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Strengths of Article

• Prospective
• Clearly written
• Acknowledged limitations
• Double checked all eligible were included

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Limitations of Article

• Study Design not randomized, not blinded
• Room for bias
• No power calculation

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Further

• Small sample size

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Final Comments

• Major Limitations
• power
• Hot Topic
• Further study needed

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Upcoming Journal Clubs

• May 12 Musculoskeletal Disorders
• Wrenn Levenberg (EM2)
• Andrea Stanton (EM1)
• June 9 Nervous System Disorders Sullivan and
  Horesji

BMC EM Journal Club
BMC EM Journal Club