Etomidate for rapid sequence intubation in the emergency department: Is adrenal suppression a concern?

Abstract

There is significant evidence demonstrating that etomidate, when used as an induction agent to facilitate RSI, causes transient adrenal insufficiency of uncertain clinical effect. As many patients undergoing intubation in the ED are under physiologic stress, this effect could be of concern, particularly for the subgroup of patients with septic shock. However, the clinical relevance in patients receiving this agent for induction of RSI in the ED is uncertain. To date, morbidity and mortality data associated with surrogate outcomes involving the measurement of adrenal activity are limited, and further research is necessary. In the absence of a consensus regarding the clinical significance of transient adrenal insufficiency, we believe a prudent approach is to avoid the use of etomidate in patients with known or suspected septic shock or any other patients who may be harmed by transient adrenal suppression. However, if etomidate is administered to patients with septic shock, we suggest a baseline serum cortisol and a 250-μg CST test. Until the CST results are available, patients should be treated with hydrocortisone 50 mg IV every 6 hours. Patients who have an incremental cortisol response of <250 nmol/L after the 250-μg CST should receive hydrocortisone 50 mg IV every 6 hours ± fludrocortisone 50 μg orally, daily for 7 days.