Another Retrospective Observational Study Criticizes Etomidate
Daniel J. Pallin, MD, MPH
Yet another attempt to use retrospective methods to discredit a valuable medication
Etomidate is one of the standard agents for induction during rapid sequence intubation when cardiovascular stability is a concern, because it causes minimal hypotension and has a very short duration of action. Randomized trials have not found it to cause any problems (NEJM JW Emerg Med Dec 17 2010 and NEJM JW Emerg Med Jul 2 2009), but a number of observational studies and secondary analyses have associated its use with increased morbidity, even death
In a retrospective analysis of a database of patients who underwent general anesthesia for surgery at the Cleveland Clinic, researchers compared outcomes between 2144 patients who received etomidate and 5233 who received propofol. Only American Society of Anesthesiologists Class III and IV patients were eligible (i.e., seriously ill, multiple comorbidities, or moribund).
Mortality at 30 days was 2.5 times higher in the etomidate group. The investigators had hypothesized that infectious morbidity would be more common with etomidate, but it was not.
The investigators made a serious attempt to control for potentially unknown confounders, but the lack of randomization makes it impossible to account fully for why the anesthesiologists chose etomidate for particular patients – it is quite likely that they felt the patients were more unstable. The mixed picture that has emerged from these retrospective studies of etomidate should not lead us to hesitate to use it for rapid sequence intubation when cardiovascular stability is an acute issue and rapid recovery is desired. Ketamine is also a reasonable option for the hemodynamically unstable patient. When cardiovascular stability is not an acute issue, etomidate, propofol, or ketamine are all reasonable choices.
Komatsu R et al. Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery. Anesth Analg 2013 Dec; 117:1329.
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