BOSTON – Etomidate did not significantly increase vasopressor requirements, compared with midazolam, in a double-blind randomized trial of 122 patients with suspected sepsis who presented to a single emergency department over an 18-month period.
Etomidate is widely used for sedation before endotracheal intubation. One recent post hoc analysis showed that prolonged use of etomidate was associated with increased mortality (N. Engl. J. Med. 2008;358:111-24), while another post hoc analysis demonstrated a significant increase in mortality in septic patients given etomidate for rapid-sequence intubation irrespective of steroid supplementation (Crit. Care Med. 2007;35:1012-8). In a small study, single-dose etomidate use was associated with adrenal suppression that may have contributed to longer hospital length of stay, more ventilator days, and more days in intensive care (J. Trauma 2008;65:573-9).
However, the clinical relevance of the adrenal suppression is not yet clear, and the studies showing increased mortality were not randomized, noted Dr. David Barounis, an emergency physician at Advocate Christ Medical Center, Oak Lawn, Ill.
Dr. David Barounis
In the current study, a post hoc analysis of data from a prospectively randomized double-blind study performed between November 2007 and May 2009 at a single tertiary care center’s emergency department (ED), 303 patients met the enrollment criteria of age greater than 18 years and intubation in the ED with suspected infectious etiology for their illness. Of 122 who could be enrolled in the study, 96 were later confirmed to be septic following intubation. Of those, 45 were randomized to etomidate while 51 received midazolam.
Baseline characteristics did not differ significantly between the two groups, although there was a nonsignificant trend among the etomidate patients toward greater use of vasopressors in the ED (53% vs. 43% of the midazolam group) and total vasopressor use (66% vs. 51%; 95% confidence interval of difference, -4% to 34%). The difference in total number of hours septic patients received vasopressors was not significant: 38 hours with etomidate vs. 32 hours with midazolam (P = .65).
Limiting the analysis to just the 26 etomidate and 23 midazolam patients who received vasopressors within the first 48 hours of ED arrival (95% CI, 7% to 31%) did not change the results, with 58% vasopressor use with etomidate vs. 45% with midazolam (95% CI, -7% to 31%) and with 64 vs. 51 total hours, respectively, of vasopressor use in this subgroup (P = .44).
Norepinephrine was the most common vasopressor used for both groups, and there were no differences in sedative use by type of vasopressor, Dr. Barounis said at the annual meeting of the Society for Academic Emergency Medicine.
"Based on our results, etomidate does not result in a statistically significant increase in length of vasopressor duration when used as a bolus dose during rapid sequence intubation," he said. However, he added, due to the relatively small number of patients who could be enrolled at one center over 18 months, a multicenter prospective trial powered to detect clinically significant mortality and secondary outcome differences should be undertaken.
Dr. Barounis stated that he had no financial disclosures.