Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, IL.
West J Emerg Med. 2010 May;11(2):161-72.
Despite its widespread use in North America and many other parts of the world, the safety of etomidate as an induction agent for rapid sequence intubation in septic patients is still debated. In this article, we evaluate the current literature on etomidate, review its clinical history, and discuss the controversy regarding its use, especially in sepsis. We address eight questions: (i) When did concern over the safety of etomidate first arise? (ii) What is the mechanism by which etomidate is thought to affect the adrenal axis? (iii) How has adrenal insufficiency in relation to etomidate use been defined or identified in the literature? (iv) What is the evidence that single dose etomidate is associated with subsequent adrenal-cortisol dysfunction? (v) What is the clinical significance of adrenal insufficiency or dysfunction associated with single dose etomidate, and where are the data that support or refute the contention that single-dose etomidate is associated with increased mortality or important post emergency department (ED) clinical outcomes? (vi) How should etomidate's effects in septic patients best be measured? (vii) What are alternative induction agents and what are the advantages and disadvantages of these agents relative to etomidate? (viii) What future work is needed to further clarify the characteristics of etomidate as it is currently used in patients with sepsis? We conclude that the observational nature of almost all available data suggesting adverse outcomes from etomidate does not support abandoning its use for rapid sequence induction. However, because we see a need to balance theoretical harms and benefits in the presence of data supporting the non-inferiority of alternative agents without similar theoretical risks associated with them, we suggest that the burden of proof to support continued widespread use may rest with the proponents of etomidate. We further suggest that practitioners become familiar with the use of more than one agent while awaiting further definitive data.
尽管依托咪酯在北美和世界许多其他地区广泛使用，但作为快速序贯诱导插管在脓毒症患者中的诱导剂的安全性仍存在争议。在本文中，我们评估了依托咪酯的现有文献，回顾了其临床历史，并讨论了关于其使用的争议，特别是在脓毒症中。我们回答了八个问题：（i）何时首次出现对依托咪酯安全性的担忧？（ii）依托咪酯被认为如何影响肾上腺轴的机制？（iii）文献中如何定义或识别与依托咪酯使用相关的肾上腺功能不全？（iv）单剂量依托咪酯与随后的肾上腺皮质醇功能障碍相关的证据是什么？（v）与单剂量依托咪酯相关的肾上腺功能不全或功能障碍的临床意义是什么，支持或反驳单剂量依托咪酯与死亡率增加或重要急诊部门（ED）临床结局相关的观点的数据在哪里？（vi）如何最好地衡量依托咪酯在脓毒症患者中的作用？（vii）替代诱导剂有哪些，这些药物相对于依托咪酯的优缺点是什么？（viii）为了进一步阐明依托咪酯在当前脓毒症患者中的使用特性，还需要开展哪些未来工作？我们得出结论，几乎所有可用数据都表明依托咪酯会带来不良后果，这些数据的观察性质并不能支持放弃其在快速序贯诱导中的使用。然而，由于我们看到需要在支持替代药物非劣效性的同时平衡理论上的危害和益处，而这些替代药物与依托咪酯没有类似的理论风险，因此我们建议继续广泛使用依托咪酯的证据负担可能在于依托咪酯的支持者。我们进一步建议，在等待进一步明确数据的同时，从业者应熟悉使用多种药物。
