This is an off shoot from another thread about Etomidate.

Mil mentioned that he has noticed mortality and Etomidate go hand in hand - so what came first the chicken or the egg? His observations mirror the Watts 1984 study.

Which begs the question about how we appreciate the adrenocortical impact of Etomidate and its decision on its use.

So.. how do you decide on Etomidate to use & how do you recognize a potential patient that have reduction in adrenocortical function? If you recognize this issue - do you do anything about it in the limited time you have the patient? Does the reduction in adrenocortical function (for 24 hours) really mean anything to you rather than to variable hemodynamic responses you might get in "testing" their stress response?

I for one - see major surgery as a traumatic event that the body endures. More the case in critically ill patients - where there stress response has been pushed to the max. Rivers et al showed that vasopressor support and adrenal insufficiency(AI) occurs concurrently in ICU patients, as well as a host of other traumatic events ( Hem Shock and TBI). Supplementation of steroid (commonly hydrocortisone) in other studies have been shown to decrease mortality. So enter Etomidate - the decision is still up in the air - Ray et al. & Riche et al (both in 2007) showed that Etomidates was a non issue in critical pts while Cotton et al (2008) found that the use of Etomidate has been linked to increased incidence of adrenal insufficiency (AI) and increased vasopressor support. This reflects the findings of several other studies (see below). Darrouj (2009) - found infusions, rather than single doses of Etomidate - can lead to a deterioration of circulatory stability. It is a mixed bag....but many small studies are asking for a good randomized control trial study for conclusive evidence on its effect and benefit of steroidal supplementation ...

These are just my rambling ...This is not a quiz... for I certainly do not know the answers.... this is another open discussion on the "whys" of practice rather than the "hows"...

Im curious of everyone elses thoughts.... So what does Reduction in Adrenocortical Function Really mean to you - other than just a pimp/board question?



For you reference junkies............

Hoen S, Asehnoune K, Brailly-Tabard S; et al. Cortisol response to corticotropin stimulation in trauma patients: influence of hemorrhagic shock. Anesthesiology. 2002;97(4):807-813

Cohan P, Wang C, McArthur DL; et al. Acute secondary adrenal insufficiency after traumatic brain injury: a prospective study. Crit Care Med. 2005;33(10):2358-2366.

Murray H, Marik PE. Etomidate for endotracheal intubation in sepsis: acknowledging the good while accepting the bad. Chest. 2005;127(3):707-709.

Watt I and Ledingham IM. Mortality amongst multiple trauma patients admitted to an intensive therapy unit. Anaesthesia 1984 Oct; 39:973.

Ray DC and McKeown DW. Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock. Crit Care 2007 May 16; 11:R56.

Annane D et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002 Aug 21; 288:862.

Riché FC et al. Adrenal response in patients with septic shock of abdominal origin: Relationship to survival. Intensive Care Med 2007 Oct; 33:1761.

Bryan et al. Increased Risk of Adrenal Insufficiency Following Etomidate Exposure in Critically Injured Patients. Arch Surg. 2008;143(1):62-67.

Kamp, R. and J.P. Kress, Etomidate, sepsis, and adrenal function: not as bad as we thought? Crit Care, 2007. 11(3): p. 145.

Lipiner-Friedman, D., et al., Adrenal function in sepsis: the retrospective Corticus cohort study. Crit Care Med, 2007. 35(4): p. 1012-8.

Mohammad, Z., B. Afessa, and J.D. Finkielman, The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate. Crit Care, 2006. 10(4): p. R105.

Jones, D., et al., Relative adrenal insufficiency in etomidate-naive patients with septic shock. Anaesth Intensive Care, 2006. 34(5): p. 599-605.

Darrouj, J., L. Karma, and R. Arora, Cardiovascular Manifestations of Sedatives and Analgesics in the Critical Care Unit. Am J Ther, 2009.