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Mon Aug 18 13:52:35 BST 2008

The results of this small study are interesting. The non-etomidate group however had a distinctly non-standard combination of drugs. Fentanyl /midazolam/sux to my mind do not constitute a rapid sequence induction. I am unsure as to the effects this would have on intracranial pressure and pressor response to intubation. How much of the increase in cortisol could be attributed to an increased stress response following this choice of agents?

Dom Krzanicki 
Dr Dominik Krzanicki 
MBChB(Hons), MRCS (Eng), DIMC (RCSEd)
StR Anaesthetics and Intensive Care  
Tel: +44 (0) 7801 118790
E-mail: dominikkrzanicki at hotmail.com

> > Message: 3> Date: Sun, 17 Aug 2008 20:55:30 -0400> From: Amy Hildreth <amy at hildrethus.com>> Subject: Re: trauma-list Digest, Vol 62, Issue 7 - etomidate and the> trauma patient> To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>> Message-ID: <C4CE40C2.A49%amy at hildrethus.com>> Content-Type: text/plain; charset="ISO-2022-JP"> > All-> > Sorry to enter the conversation so late, but there is some new prospective> data regarding etomidate in the trauma patient that might be of interest.> See abstract below (in press, J Trauma). Our study was obviously not> powered to detect mortality differences, but I think the results are> interesting, nevertheless.> > Amy Hildreth> > Amy Hildreth, M.D. > Assistant Professor> Department of Surgery> Wake Forest University Baptist Medical Center> > > Adrenal Suppression Following a Single Dose of Etomidate For Rapid Sequence> Induction: A Prospective Randomized Study> Amy Hildreth, M.D.; Vicente A Mejia, M.D.; Robert A Maxwell, M.D.; Philip W> Smith, M.D.; Benjamin W Dart, M.D.; Donald E Barker, M.D.> > Introduction: The administration of etomidate for rapid sequence induction> (RSI) has been linked to subsequent adrenocortical insufficiency in> non-trauma patients. However, etomidate- related adrenocortical> insufficiency has not been well studied in the trauma> population.> Purpose: We performed a prospective, randomized, controlled study to assess> the effect of one dose of etomidate for RSI on adrenal function and its> clinical significance during and after resuscitation in trauma patients.> Methods: Adult trauma patients admitted to our Level I trauma center> requiring RSI were randomized to receive etomidate 0.3mg/kg and> succinylcholine 1mg/kg (E group) or fentanyl 100 μg, midazolam 5mg, and> succinylcholine 1mg/kg (FM group) for induction. A baseline serum cortisol> level was drawn prior to RSI. Four to six hours after RSI a postintubation> serum cortisol level was drawn. An ACTH stimulation test (CST)> was performed.> Results: 30 patients were enrolled: 18 E group patients and 12 FM group> patients. No statistical difference was detected between the two groups with> respect to age, injury severity score (ISS), and baseline serum cortisol.> Mean serum cortisol levels were significantly lower in E group patients than> in FM group patients four to six hours after intubation (18.2 vs. 27.8μg/dL,> p<0.05). Change in serum cortisol between baseline and> postintubation levels was different (-12.8 ± 9.6 μg/dL vs 1.1 ± 7.6 μg/dL,> p<0.01).> Patients in the E group had an average increase in cortisol following ACTH> administration of 4.2 ± 4.9 mg/dL vs. 11.2 ± 6.1 mg/dL in the FM group, p <> 0.001. Patients in the E group required longer ICU lengths of stay (mean 6.3> vs. 1.5 days, p<0.05), more ventilator days (mean 28 vs. 17 days, p<0.01),> and longer hospital lengths of stay (mean 11.6 vs. 6.4 days, p<0.01).> Conclusions: The use of etomidate for RSI in trauma patients led to chemical> evidence of adrenocortical insufficiency and may have contributed to> increased hospital and ICU lengths of stay and increased ventilator days.> Further studies should be considered to evaluate the safety profile of this> drug in trauma patients.> > > > > > 
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trauma-list Digest, Vol 62, Issue 17 - etomidate and the trauma patient