Division of Endocrinology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO 63104, USA.
Intensive Care Med. 2011 Jun;37(6):901-10. doi: 10.1007/s00134-011-2160-1. Epub 2011 Mar 4.
Although etomidate is a preferred anesthetic agent for rapid sequence intubation (RSI) in critical illness, as an inhibitor of cortisol synthesis (11β-hydroxylase), it may be associated with adrenal dysfunction. The objectives are to review the effects of etomidate versus comparator anesthetics in critical illness for: primary outcome of mortality and secondary outcome of adrenal insufficiency (AI).
Studies were extracted using MEDLINE and SCOPUS, regardless of language, between 1983 and 2010 using the keywords etomidate, intensive care units (ICU), critical illness, intensive care, glucocorticoids, and adrenal insufficiency. Studies of single dose etomidate versus comparator anesthetics with outcomes of adrenal function and/or mortality were included. All reviewers performed electronic data searches. One reviewer extracted data, which were checked by the other reviewers. Authors of trials were contacted for supplemental data. Primary outcome was 28-day mortality. AI was defined per article.
Two hundred sixty-three articles were screened, and 21 articles (19 independent data sets) were evaluated. Meta-analysis comparing etomidate versus non-etomidate anesthesia demonstrated an increased risk ratio (RR) for AI of 1.64 (range 1.52-1.77; 14 studies, 2,854 patients, P<0.0001, I(2)=88%) and an increased RR for mortality of 1.19 (1.10-1.30; 14 studies, 3,516 patients, P<0.0001, I(2)=64%). Significance of re-analysis for mortality within the subset of sepsis was maintained [RR 1.22 (1.11-1.35), 7 studies, n=1,767, I(2)=74%, P<0.0001], but not for trials without sepsis [RR=1.15 (0.97-1.35), 7 studies, n=1,749, I(2)=53%, P=0.10].
There is an increased rate of AI and mortality in critically ill patients who received etomidate.
虽然依托咪酯是急危重症患者快速序贯诱导插管（RSI）的首选麻醉剂，但作为皮质醇合成抑制剂（11β-羟化酶），它可能与肾上腺功能障碍有关。本研究旨在综述急危重症患者中依托咪酯与对照麻醉剂的作用：主要结局为死亡率，次要结局为肾上腺功能不全（AI）。
检索了 1983 年至 2010 年间 MEDLINE 和 SCOPUS 中的文献，使用的关键词有依托咪酯、重症监护病房（ICU）、危重病、重症监护、糖皮质激素和肾上腺功能不全。纳入了依托咪酯与对照麻醉剂单剂量比较，以及评估肾上腺功能和/或死亡率的研究。所有评审员均进行了电子数据检索。一位评审员提取数据，另一位评审员进行核对。对于试验补充数据，与试验作者进行了联系。主要结局为 28 天死亡率。AI 根据文章进行定义。
共筛选了 263 篇文章，评估了 21 篇文章（19 个独立数据集）。与非依托咪酯麻醉相比，依托咪酯与麻醉比较的荟萃分析显示 AI 的风险比（RR）增加了 1.64（范围为 1.52-1.77；14 项研究，2854 例患者，P<0.0001，I(2)=88%），死亡率的 RR 增加了 1.19（1.10-1.30；14 项研究，3516 例患者，P<0.0001，I(2)=64%）。在脓毒症亚组内，死亡率重新分析的意义仍然存在[RR 1.22（1.11-1.35），7 项研究，n=1767，I(2)=74%，P<0.0001]，但在无脓毒症的试验中则不然[RR=1.15（0.97-1.35），7 项研究，n=1749，I(2)=53%，P=0.10]。
接受依托咪酯的急危重症患者 AI 和死亡率增加。
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