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Etomidate Use for RSI in Septic Patients

Three Part Question

In [septic patients requiring intubation] does [Etomidate] lead to [increased morbidity and mortality].

Clinical Scenario

A 70-year-old woman presents to the Emergency Department with urosepsis and requires intubation. You consider using Etomidate as an RSI agent, but wonder if it will increase morbidity and mortality secondary to adrenal suppression.

Search Strategy

Medline 1950-04/09 using OVID interface, Cochrane Library (2009), PubMed clinical queries

[(exp etomidate/ or or AND (exp sepsis/ or] Limit to human and English

Search Outcome

35 papers were found of which only two prospective studies were relevant to the three part question

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Tekwani, K., et al.
January 2009
United States of America
106 patients with 2 or more SIRS criteria, suspected or documented infection, and intubation performed in the ED.nonrandomized, prospective observational studyIn-hospital mortality38% in Etomidate group; 44% in those receiving alternativesStudy nonrandomized. Intubating agents not blinded. Other variables in treatment during hospitalization not measured.
Hospital length of stay10 days in Etomidate group; 7.5 days in those receiving alternatives (p=0.08)
Hildreth, A., et al.
September 2008
United States of America
30 trauma patients >18 years old requiring RSI within 48 hours of injury randomized to Etomidate or Fentanyl and Midazolam.PRCTMean cortisol levels 4-6 hrs post intubation18.2 microgram/dL in Etomidate group vs. 27.8 microgram/dL (p<0.05) Study not blinded. 31 patients excluded for various reasons. ISS greater in Etomidate group (although not statistically significant). No standardized treatments while inpatient. ICU days, ventilator days, and hospital LOS numbers do not correlate suggesting that these averages may be skewed by outliers.
Change in serum cortisol-12.8 microgram/dL in Etomidate group vs. 1.1 microgram/dL (p<0.01)
Increase cortisol after ACTH4.2 microgram/dL in Etomidate group vs. 11.2 microgram/dL (p<0.001).
ICU days6.3 in Etomidate group vs. 1.5 (p<0.05)
Ventilator days28 in Etomidate group vs. 17 (p<0.01)
Hospital LOS11.6 days in Etomidate group vs. 6.4 (p<0.01)


The Hildreth article, while not specific to septic patients, does demonstrate statistically significant decreases in cortisol levels. It is the clinical significance of this decrease that remains in question. With the small number of patients, and inconsistencies among ICU and ventilator days and hospital LOS, it is possible that these morbidity data (expressed in means) are highly influenced by outliers.

Clinical Bottom Line

While evidence exists that Etomidate decreases cortisol levels in critically-ill patients, there is insufficient evidence of subsequent increase in morbidity and mortality to recommend against the use of Etomidate for RSI in septic patients at this time.


  1. Tekwani, K., et al. A Prospective Observational Study of the Effect of Etomidate on Septic Patient Mortality and Length of Stay Academic Emergency Medicine January 2009, Vol. 16, No. 1
  2. Hildreth, A., et al. Adrenal Suppression Following a Single Dose of Etomidate For Rapid Sequence Induction: A Prospective Randomized Study The Journal of Trauma, Injury, Infection, and Critical Care September 2008;65:573-579.