Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock.

Ray DC, McKeown DW.

Crit Care. 2007;11(3):R56.

Department of Anaesthesia, Critical Care & Pain Medicine, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, Scotland, UK. david.ray@luht.scot.nhs.uk

Comment in:

• Crit Care. 2007;11(3):145.

INTRODUCTION:
In seriously ill patients, etomidate gives cardiovascular stability at induction of anaesthesia, but there is concern over possible adrenal suppression. Etomidate could reduce steroid synthesis and increase the need for vasopressor and steroid therapy. The outcome could be worse than in patients given other induction agents.

METHODS:
We reviewed 159 septic shock patients admitted to our intensive care unit (ICU) over a 40-month period to study the association between induction agent and clinical outcome, including vasopressor, inotrope, and steroid therapy. From our records, we retrieved induction agent use; vasopressor administration at induction; vasopressor, inotrope, and steroid administration in the ICU; and hospital outcome.

RESULTS:
Hospital mortality was 65%. The numbers of patients given an induction agent were 74, etomidate; 25, propofol; 26, thiopental; 18, other agent; and 16, no agent. Vasopressor, inotrope, or steroid administration and outcome were not related to the induction agent chosen. Corticosteroid therapy given to patients who received etomidate did not affect outcome. Vasopressor therapy was required less frequently and in smaller doses when etomidate was used to induce anaesthesia. We found no evidence that either clinical outcome or therapy was affected when etomidate was used. Etomidate caused less cardiovascular depression than other induction agents in patients with septic shock.

CONCLUSION:
Etomidate use for critically ill patients should consider all of these issues and not simply the possibility of adrenal suppression, which may not be important when steroid supplements are used.