Tuesday, September 21, 2010

Etomidate in ICU....comes with a price

This is a common scenario in Intensive Care Unit. For those not practicing in US....The ICU is managed by Internal Medicine residents with the help of Anaesthesiologists(only for intubations).
We have had many patients transferred to the ICU for management of Sepsis/Septic shock who would need intubation. A commonly used induction anaesthetic for intubation is Etomidate.It is preferred for its rapid onset action, and a low cardiovascular risk profile! In many of these patients there has been a substantial drop in blood pressure after intubation with Etomidate, which needed fluid boluses &/or vasopressor supprt.


The mechanism behind this is as follows -  Etomidate inhibits 11-beta hydroxylase in the synthesis of corticosteroids. This enzyme converts 11-deoxy cortisol to active cortisol. This was shown in a prospective, observational cohort study of 40 critically ill pt’s without sepsis given etomidate during intubation.ACTH stimultation testing done at 1, 12, 48 and 72 hrs after etomidate.Authors found a reversible adrenal insufficiency following etomidate administration that persisted no longer than 48 hours.80% of patients tested (32) had evidence of adrenal inhibition at 12 hours.(Int Care Med 2008). 
Since Etomidate blocks 11-beta hydroxylase, it can block aldosterone synthesis as well. So a theoretical possibility of Hyperkalemia is on the cards as well.
To add to this problem.....patients on concomitant benzodiazepines and /or opioids (in opioid naive pts) can add to the cortisol suppression by etomidate. BZD inhibits 21 & 17- hydroxylases, and opioid suppresses stress related cortisol production.(Int Care Med 2008)


Based on this..it would be reasonable to administer stress dose steroids (Hydrocortisone 50mg 6th hourly) to patients who have received etomidate. Based on the above observation...give hydrocortisone for atleast 48 hours after etomidate. Also try to minimise use of BZD and opioids in these patients. 
Also try to avoid etomidate in patients with hyperkalemia.

12 comments:

  1. hi suresh, i had used etomidate for single dose induction in one of my patients back home in india,he was in cardiac failure secondary to dilated cardiomyopathy .anyway he was not in sepsis, interesting though, i will keep an eye, thanks for the info. dominic

    ReplyDelete
  2. Hi Domnic...I think it becomes a noticeable issue only in sepsis..as almost half of septic patients have some relative adrenal insufficiency. There is a nice discussion on this in Critical care medicine http://ccforum.com/content/10/4/R105.(ve a look at the response letters too)
    I didnt realise that this is ur area of expertise (I mean Anaesthesia.

    ReplyDelete
  3. well, i am an anaesthetist. now for a year cardiac anaesthetist.i was in icu back home, though mainly surgical,anyway, keep it coming , nice blog.

    ReplyDelete
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