Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu-HME, University Hospital of Nantes, Nantes, France.
Intensive Care Med. 2012 Oct;38(10):1673-82. doi: 10.1007/s00134-012-2619-8. Epub 2012 Jul 10.
To investigate the impact of etomidate on the rate of hospital-acquired pneumonia (HAP) in trauma patients and the effects of hydrocortisone in etomidate-treated patients.
This was a sub-study of the HYPOLYTE multi-centre, randomized, double-blind, placebo-controlled trial of hydrocortisone in trauma patients (NCT00563303). Inclusion criterion was trauma patient with mechanical ventilation (MV) of ≥48 h. The use of etomidate was prospectively collected. Endpoints were the results of the cosyntropin test and rate of HAP on day 28 of follow-up.
Of the 149 patients enrolled in the study, 95 (64 %) received etomidate within 36 h prior to inclusion. 79 (83 %) of 95 patients receiving etomidate and 34 of the 54 (63 %) not receiving etomidate had corticosteroid insufficiency (p = 0.006). The administration of etomidate did not alter basal cortisolemia (p = 0.73), but it did decrease the delta of cortisolemia at 60 min (p = 0.007). There was a correlation between time from etomidate injection to inclusion in the study and sensitivity to corticotropin (R (2) = 0.19; p = 0.001). Forty-nine (51.6 %) patients with etomidate and 16 (29.6 %) patients without etomidate developed HAP by day 28 (p = 0.009). Etomidate was associated with HAP on day 28 in the multivariate analysis (hazard ratio 2.48; 95 % confidence interval 1.19-5.18; p = 0.016). Duration of MV with or without etomidate was not significantly different (p = 0.278). Among etomidate-exposed patients, 18 (40 %) treated with hydrocortisone developed HAP compared with 31 (62 %) treated with placebo (p = 0.032). Etomidate-exposed patients treated with hydrocortisone had fewer ventilator days (p < 0.001).
Among the patients enrolled in the study, etomidate did not alter basal cortisolemia, but it did decrease reactivity to corticotropin. We suggest that in trauma patients, etomidate is an independent risk factor for HAP and that the administration of hydrocortisone should be considered after etomidate use.
研究依托咪酯对创伤患者医院获得性肺炎（HAP）发生率的影响，以及氢化可的松对依托咪酯治疗患者的作用。
这是一项多中心、随机、双盲、安慰剂对照的氢化可的松治疗创伤患者的 HYPOLYTE 研究的亚研究（NCT00563303）。纳入标准为机械通气（MV）时间≥48 h 的创伤患者。依托咪酯的使用是前瞻性收集的。终点是促皮质素试验的结果和第 28 天的 HAP 发生率。
在纳入研究的 149 例患者中，95 例（64%）在纳入前 36 小时内接受了依托咪酯。在接受依托咪酯的 95 例患者中，有 79 例（83%）和未接受依托咪酯的 54 例患者中的 34 例（63%）存在皮质激素功能不全（p=0.006）。依托咪酯的使用并未改变基础皮质醇水平（p=0.73），但确实降低了 60 分钟时皮质醇的变化（p=0.007）。依托咪酯注射至纳入研究的时间与对促皮质素的敏感性之间存在相关性（R²=0.19；p=0.001）。在第 28 天，49 例接受依托咪酯的患者和 16 例未接受依托咪酯的患者发生 HAP（p=0.009）。多变量分析显示，依托咪酯与第 28 天的 HAP 相关（风险比 2.48；95%置信区间 1.19-5.18；p=0.016）。接受依托咪酯或不接受依托咪酯的 MV 持续时间无显著差异（p=0.278）。在接受依托咪酯治疗的患者中，18 例（40%）接受氢化可的松治疗的患者发生 HAP，而 31 例（62%）接受安慰剂治疗的患者发生 HAP（p=0.032）。接受依托咪酯治疗的接受氢化可的松治疗的患者呼吸机使用天数更少（p<0.001）。
在纳入研究的患者中，依托咪酯并未改变基础皮质醇水平，但确实降低了对促皮质素的反应性。我们建议，在创伤患者中，依托咪酯是 HAP 的独立危险因素，应在使用依托咪酯后考虑给予氢化可的松治疗。
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