Etomidate, pharmacological adrenalectomy and the critically ill a matter of vital importance.docVIP

Available online /content/10/4/161 Commentary Etomidate, pharmacological adrenalectomy and the critically ill: a matter of vital importance Roxanna Bloomfield and David W Noble Intensive Care Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK Corresponding author: David W Noble, d.noble@ Published: 29 August 2006 Critical Care 2006, 10:161 (doi:10.1186/cc5020) This article is online at /content/10/4/161 ? 2006 BioMed Central Ltd See related research by Mohammad et al., /content/10/4/R105 Abstract the excess mortality was not statistically significant. The study size and design preclude inferences on mortality. Etomidate is a potent suppressant of adrenal steroidogenesis, effectively inducing reversible pharmacological adrenalectomy. Recent evidence suggests that for every five patients with septic shock given etomidate without corticosteroid supplementation, one patient will die as a consequence. Other critically ill patients are also at possible risk, and this risk requires further exploration. Etomidate will also confound investigations into the effects of disease states on adrenal function, and should therefore be avoided. A moratorium on the use of etomidate in critically ill patients outside clinical trials may be prudent until its safety is established. The results of Mohammad and colleagues add to a prospective observational study of critically ill, mechanically ventilated patients that found a single bolus of etomidate given 24 hours before a standard cosyntropin test to be the most important predictor of relative adrenal insufficiency – and overall nonresponders to cosyntropin had a significantly higher mortality [8]. Further evidence comes from an observational study of 60 children with meningococcal sepsis, none of whom received corticosteroid supplemen- tation [9]. Adrenal dysfunc