Etomidate, adrenal function, and mortality in critically ill patients

Jacob E. Sunshine, Steven Deem, Noel S. Weiss, Norbert Yanez, Stephen Daniel, Katherine Keech, Marcia Brown, Miriam Treggiari

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

BACKGROUND: In critically ill patients, induction with etomidate is hypothesized to be associated with an increased risk of mortality. Previous randomized studies suggest a modest trend toward an increased risk of death among etomidate recipients; however, this relationship has not been measured with great statistical precision. We aimed to test whether etomidate is associated with risk of hospital mortality and other clinical outcomes in critically ill patients. METHODS: We conducted a retrospective cohort study from January 1, 2001, to December 31, 2005, of 824 subjects requiring mechanical ventilation, who underwent adrenal function testing in the ICUs of 2 academic medical centers. The primary outcome was in-hospital mortality, comparing subjects given etomidate (n = 452) to those given an alternative induction agent (n = 372). The secondary outcome was diagnosis of critical illness-related corticosteroid insufficiency following etomidate exposure. RESULTS: Overall mortality was 34.3%. After adjustment for age, sex, and baseline illness severity, the relative risk of death among the etomidate recipients was higher than that of subjects given an alternative agent (relative risk 1.20, 95% CI 0.99-1.45). Among subjects whose adrenal function was assessed within the 48 hours following intubation, the adjusted risk of meeting the criteria for critical illness-related corticosteroid insufficiency was 1.37 (95% CI 1.12-1.66), comparing etomidate recipients to subjects given another induction agent. CONCLUSIONS: In this study of critically ill patients requiring endotracheal intubation, etomidate administration was associated with a trend toward a relative increase in mortality, similar to the collective results of smaller randomized trials conducted to date. If a small relative increased risk is truly present, though previous trials have been underpowered to detect it, in absolute terms the number of deaths associated with etomidate in this high-risk population would be considerable. Large, prospective controlled trials are needed to finalize the role of etomidate in critically ill patients.

Original languageEnglish (US)
Pages (from-to)639-646
Number of pages8
JournalRespiratory Care
Volume58
Issue number4
DOIs
StatePublished - Apr 1 2013
Externally publishedYes

Fingerprint

Etomidate
Critical Illness
Mortality
Hospital Mortality
Adrenal Cortex Hormones
Intratracheal Intubation
Artificial Respiration
Intubation
Cohort Studies
Retrospective Studies

Keywords

  • Adrenal function
  • Etomidate
  • ICU
  • Mortality
  • Rapid sequence induction
  • Sepsis

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine

Cite this

Etomidate, adrenal function, and mortality in critically ill patients. / Sunshine, Jacob E.; Deem, Steven; Weiss, Noel S.; Yanez, Norbert; Daniel, Stephen; Keech, Katherine; Brown, Marcia; Treggiari, Miriam.

In: Respiratory Care, Vol. 58, No. 4, 01.04.2013, p. 639-646.

Research output: Contribution to journalArticle

Sunshine, JE, Deem, S, Weiss, NS, Yanez, N, Daniel, S, Keech, K, Brown, M & Treggiari, M 2013, 'Etomidate, adrenal function, and mortality in critically ill patients', Respiratory Care, vol. 58, no. 4, pp. 639-646. https://doi.org/10.4187/respcare.01956
Sunshine, Jacob E. ; Deem, Steven ; Weiss, Noel S. ; Yanez, Norbert ; Daniel, Stephen ; Keech, Katherine ; Brown, Marcia ; Treggiari, Miriam. / Etomidate, adrenal function, and mortality in critically ill patients. In: Respiratory Care. 2013 ; Vol. 58, No. 4. pp. 639-646.
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abstract = "BACKGROUND: In critically ill patients, induction with etomidate is hypothesized to be associated with an increased risk of mortality. Previous randomized studies suggest a modest trend toward an increased risk of death among etomidate recipients; however, this relationship has not been measured with great statistical precision. We aimed to test whether etomidate is associated with risk of hospital mortality and other clinical outcomes in critically ill patients. METHODS: We conducted a retrospective cohort study from January 1, 2001, to December 31, 2005, of 824 subjects requiring mechanical ventilation, who underwent adrenal function testing in the ICUs of 2 academic medical centers. The primary outcome was in-hospital mortality, comparing subjects given etomidate (n = 452) to those given an alternative induction agent (n = 372). The secondary outcome was diagnosis of critical illness-related corticosteroid insufficiency following etomidate exposure. RESULTS: Overall mortality was 34.3{\%}. After adjustment for age, sex, and baseline illness severity, the relative risk of death among the etomidate recipients was higher than that of subjects given an alternative agent (relative risk 1.20, 95{\%} CI 0.99-1.45). Among subjects whose adrenal function was assessed within the 48 hours following intubation, the adjusted risk of meeting the criteria for critical illness-related corticosteroid insufficiency was 1.37 (95{\%} CI 1.12-1.66), comparing etomidate recipients to subjects given another induction agent. CONCLUSIONS: In this study of critically ill patients requiring endotracheal intubation, etomidate administration was associated with a trend toward a relative increase in mortality, similar to the collective results of smaller randomized trials conducted to date. If a small relative increased risk is truly present, though previous trials have been underpowered to detect it, in absolute terms the number of deaths associated with etomidate in this high-risk population would be considerable. Large, prospective controlled trials are needed to finalize the role of etomidate in critically ill patients.",
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AU - Sunshine, Jacob E.

AU - Deem, Steven

AU - Weiss, Noel S.

AU - Yanez, Norbert

AU - Daniel, Stephen

AU - Keech, Katherine

AU - Brown, Marcia

AU - Treggiari, Miriam

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N2 - BACKGROUND: In critically ill patients, induction with etomidate is hypothesized to be associated with an increased risk of mortality. Previous randomized studies suggest a modest trend toward an increased risk of death among etomidate recipients; however, this relationship has not been measured with great statistical precision. We aimed to test whether etomidate is associated with risk of hospital mortality and other clinical outcomes in critically ill patients. METHODS: We conducted a retrospective cohort study from January 1, 2001, to December 31, 2005, of 824 subjects requiring mechanical ventilation, who underwent adrenal function testing in the ICUs of 2 academic medical centers. The primary outcome was in-hospital mortality, comparing subjects given etomidate (n = 452) to those given an alternative induction agent (n = 372). The secondary outcome was diagnosis of critical illness-related corticosteroid insufficiency following etomidate exposure. RESULTS: Overall mortality was 34.3%. After adjustment for age, sex, and baseline illness severity, the relative risk of death among the etomidate recipients was higher than that of subjects given an alternative agent (relative risk 1.20, 95% CI 0.99-1.45). Among subjects whose adrenal function was assessed within the 48 hours following intubation, the adjusted risk of meeting the criteria for critical illness-related corticosteroid insufficiency was 1.37 (95% CI 1.12-1.66), comparing etomidate recipients to subjects given another induction agent. CONCLUSIONS: In this study of critically ill patients requiring endotracheal intubation, etomidate administration was associated with a trend toward a relative increase in mortality, similar to the collective results of smaller randomized trials conducted to date. If a small relative increased risk is truly present, though previous trials have been underpowered to detect it, in absolute terms the number of deaths associated with etomidate in this high-risk population would be considerable. Large, prospective controlled trials are needed to finalize the role of etomidate in critically ill patients.

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