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Sat Aug 4 17:44:22 BST 2007

Mathias,

this is an excerpt from the attached article...(relates to pts. in septic shock and not hemorrhagic shock, where the suppression is probably less deleterious as far as we know now....)

Another option is the continued use of etomidate in patients with septic shock with the automatic concomitant administration of corticosteroids. This strategy is suboptimal for several reasons. First, and most importantly, administering etomidate instead of using an alternative agent (and assuming an appropriate response to high-dose CST) might actively worsen a patient’s prognostic classification, with an attendant increase in the 28-day mortality rate (from 26 to 67% or 67 to 82%).101 As noted previously, the incidence of adrenal insufficiency (when assessed by high-dose CST) in patients manifesting septic shock who receive etomidate for the induction of intubation may be as high as 94.4%.13 While the 28-day mortality rate reported by Annane et al67 for CST nonresponders who received steroids was equivalent to CST responders who received placebo (53% in each group), there were only 34 patients in the latter category. Second, while there may be a role for low-dose corticosteroid administration in septic shock patients independent of the demonstrated adrenal dysfunction, this role remains unproved. The indiscriminate use of steroids in septic shock patients may not be without risk,102 with the effect on glucose control103 being of particular importance. Third, the dose, timing, and duration of corticosteroid therapy for such an indication would be speculative and might differ considerably from that warranted for a particular patient with vasopressor-dependent septic shock. Acknowledging these limitations, the empiric administration of corticosteroids after etomidate administration while awaiting an assessment of adrenal function or establishing hemodynamic stability (similar to that proposed for adrenal insufficiency in critically ill patients in general57) may be a reasonable, if imperfect, approach if etomidate is administered for induction. Ivan 

> Date: Sat, 4 Aug 2007 14:15:23 +0200> From: listen at doc-kalkum.de> To: trauma-list at trauma.org> Subject: Re: Ketamine vs. Etomidate in head trauma with low BP> > Ivan,> > first to say, thank you for sharing all the information with us.> > You should be aware that, as you have mentioned, the potential dangers> in the head injured are - among others - hypoxia and hypotension. Thus> ketamin was never ment to allow spontaneous breathing or to replace> appropriate airway management (read: to avoid intubation). It *may* be> used as a potential analgesic in certain situations where one has to> make a balanced decision (such as in entrapped patients) - that's all> about it.> > - snip - > > If your mother suffers head trauma and her BP is low are you saying you'll intubate her with Ketamine instead of Etomidate followed by steroids ?? You are not going to tremble that she doesn't herniate on you ?? Really ?? -snip -> > > You are not serious on that steroids stuff, aren't you?> > Mathias> --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/
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Subject: Should We Use Etomidate as an Induction Agent for Endotracheal
	Intubation in Patients With Septic Shock?: A Critical Appraisal
	-- Jackson 127 (3): 1031 -- Chest
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Subject: Adrenocortical Dysfunction Following Etomidate Induction in Emergency
	Department Patients -- Schenarts et al. 8 (1): 1 -- Academic
	Emergency Medicine
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Etomidate & steroid co-administration (in septic shock)