Single-dose etomidate for intubation in the trauma patient

A retrospective data analysis on the induction medications used in trauma rapid sequence intubations and their effects on outcomes

PURPOSE

Rapid sequence intubation (RSI) in trauma patients is common; however, the induction agents used have been debated. We determined which induction medications were used most frequently for adult trauma RSIs and their associations with hemodynamics and outcomes. We hypothesized that etomidate is the most commonly used induction agent and has similar outcomes to other induction agents.

METHODS

This retrospective review at two U.S. level I trauma centers evaluated adult trauma patients undergoing RSI within 24 h of admission, between 01/01/2016 and 12/31/2017. We compared patient characteristics and outcomes by induction agent. Comparisons on the primary outcome of in-hospital mortality and secondary outcomes of peri-intubation hypotension, hospital and ICU length of stay (LOS), ventilator days, and complications used logistic regression or negative binomial regression. Regression models adjusted for hospital site, age, patient severity measures, and intubation location.

RESULTS

Among 1303 trauma patients undergoing RSI within 24 h of admission, 948 (73%) were intubated in the emergency department (ED) and 325 (25%) in the operating room (OR). The most common induction agents were etomidate (68%), propofol (17%), and ketamine (11%). In-hospital mortality was highest in the etomidate group (25.5%), followed by ketamine (17%), and propofol (1.8%).

CONCLUSION

Etomidate was most commonly used in ED intubations; propofol was most used in the OR. Compared to propofol, patients induced with etomidate had higher mortality and complication rates. Findings should be interpreted with caution given limited generalizability and residual confounding by indication.

Pre-hospital emergent intubation in trauma patients: the influence of etomidate on mortality, morbidity and healthcare resource utilization

Background

Due to its favorable hemodynamic characteristics and by providing good intubation conditions etomidate is often used for induction of general anesthesia in trauma patients. It has been linked to temporary adrenal cortical dysfunction. The clinical relevance of this finding after a single-dose is still lacking appropriate evidence.

Methods

This retrospective multi-centre study is based on merged data from a German Helicopter Emergency Medical Service (HEMS) database and a large trauma patient registry. All trauma patients who were intubated prior to hospital admission with a documented Injury Severity Score ≥ 9 between 2008 and 2012 were eligible for analysis. The primary endpoint was hospital mortality. Other outcome measures were organ failures, sepsis, length of ventilation, as well as length of stay in hospital and ICU.

Results

One thousand six hundred ninety seven patients were enrolled into the study. Seven hundred sixty two patients received etomidate and 935 patients received other induction agents. The in-hospital mortality was similar in both groups (18.9% versus 18.2%; p = 0.71). Incidences of organ failures and sepsis were not increased in the etomidate group. However, health care resource utilization parameters were prolonged (after adjusting: + 1.3 days for ICU length of stay, p = 0.062; + 0.8 days for length of ventilation, p = 0.15; + 2,7 days for hospital length of stay, p = 0.034). A multivariable logistic regression analysis did not identify etomidate as an independent predictor of hospital mortality (OR: 1.10, 95% CI: 0.77–1.57; p = 0.60).

Conclusions

This is the largest trial investigating outcome data for trauma patients who had received a single-dose of etomidate for induction of anesthesia. The use of etomidate did not affect mortality. The influence on morbidity and health care resource utilization remains unclear.

Trauma Airway Management: Induction Agents, Rapid Versus Slower Sequence Intubations, and Special Considerations

Trauma patients who require intubation are at higher risk for aspiration, agitation/combativeness, distorted anatomy, hemodynamic instability, an unstable cervical spine, and complicated injuries. Although rapid-sequence intubation is the most common technique in trauma, slow-sequence intubation may reduce the risk for failed intubation and cardiovascular collapse. Providers often choose plans with which they are most comfortable. However, developing a flexible team-based approach, through recognition of complicating factors in trauma patients, improves airway management success.

Collective Review of the Status of Rapid Sequence Intubation Drugs of Choice in Trauma in Low- and Middle-Income Settings (Prehospital, Emergency Department and Operating Room Setting)

INTRODUCTION

Establishing a definitive airway in order to ensure adequate ventilation and oxygenation is an important aspect of resuscitation of the polytrauma patient .

AIM

To review the relevant literature that compares the different drugs used for rapid sequence intubation (RSI) of trauma patients, specifically reviewing: premedication, induction agents and neuromuscular blocking agents across the prehospital, emergency department and operating room setting, and to present the best practices based on the reviewed evidence.

METHOD

A literature review of rapid sequence intubation in the trauma population was carried out, specifically comparison of the drugs used (induction agent, neuromuscular blocking drugs and adjuncts).

DISCUSSION

Studies involving the comparison of drugs used in RSI in, specifically, the trauma patient are sparse. The majority of studies have compared induction agents, etomidate, ketamine and propofol, as well as the neuromuscular blocking agents, succinylcholine and rocuronium.

CONCLUSION

There currently exists great variation in the practice of RSI; however, in trauma the RSI armamentarium is limited to agents that maintain hemodynamic stability, provide adequate intubating conditions in the shortest time period and do not have detrimental effects on cerebral perfusion pressure. Further, multicenter randomized controlled studies to confirm the benefits of the currently used agents in trauma are required.

Developing a trauma curriculum for anesthesiology residents and fellows

PURPOSE OF REVIEW

The board certification process for qualification by the American Board of Anesthesiology is undergoing significant review. A basic sciences examination has been added to the process and the traditional oral examination is evolving into a combined oral interview and practical skills assessment. These recent developments, as well as the growing body of evidence regarding the resuscitation of trauma patients, call for a revision in the curriculum beyond the documentation of participation in the anesthetics of 20 trauma patients.

RECENT FINDINGS

The implications of the 80-h work week are beginning to be appreciated. The development of a new trauma curriculum must take this significant change in residency training into account while incorporating modern educational theory (e.g. simulation) and new data on the resuscitation of trauma patients.

SUMMARY

Currently, the curriculum for trauma anesthesia requires only that residents participate in the anesthetics of 20 trauma patients. There is no plan for, and little literature regarding, a more extensive educational program. This offers a unique opportunity to innovate a novel curriculum in the anesthesiology residency. The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness has designed a curriculum that can serve as a template for this important step forward in anesthesiology education.

Use of propofol as an induction agent in the acutely injured patient

PURPOSE

Etomidate is a commonly used agent for rapid sequence induction (RSI) in trauma due to its limited hemodynamic effects. Given a recent nationwide shortage of etomidate, alternative induction agents may be required. Propofol is a frequent substitute; however, concern exists regarding its potential hypotensive effects. The study attempts to determine the hemodynamic effects of propofol and etomidate following RSI in trauma bay.

METHODS

A retrospective study was performed on 76 consecutive trauma patients requiring RSI at a single academic medical center. Patients were stratified by age, gender, mechanism of injury, Injury Severity Score (ISS), and Glasgow Coma Scale (GCS). Pre-induction and post-induction hemodynamic parameters were evaluated, and a multivariate regression analysis was performed.

RESULTS

The mean age was 42, ISS was 13, and GCS was 9.8. The mean dose of propofol was 127 ± 5 mg and the mean dose of etomidate was 21 ± 6 mg. Patients who received propofol were younger and had a lower ISS. The etomidate group had significantly increased post-induction systolic blood pressure but no difference in mean arterial pressure or heart rate when compared to pre-induction parameters. The propofol group had no significant changes in any post-induction parameter compared to pre-induction parameter.

CONCLUSION

RSI with propofol did not result in hypotension in our patient population, suggesting that a reduced dose of propofol may represent a reasonable alternative to etomidate in hemodynamically stable trauma patient. Further research is warranted to assess the safety of propofol in the acutely injured patient.

The impact of etomidate on mortality in trauma patients

INTRODUCTION

Etomidate has a neutral hemodynamic profile which has made it an attractive medication for emergent intubation. Despite theoretical advantages of etomidate administration in the trauma patient, there are incomplete data to support its use. This study examined the association of etomidate use for emergent intubation in traumatic illness with patient mortality.

METHODS

This is a historical cohort study using the Nova Scotia Trauma Registry. It included all major adult trauma patients who required tracheal intubation at the Queen Elizabeth II Health Sciences Centre in Halifax, Canada from January 23, 2000 to March 25, 2012. Prospectively recorded data were analyzed, including patient demographics, presence of comorbidities, trauma specific variables, admission and discharge vitals, length of stay in the intensive care unit (ICU) and hospital, mechanical ventilation-free days, and mortality. Associations between the use of etomidate and 28-day mortality are presented as odds ratios. Multivariable logistic regression models were created adjusting for age, injury severity score (ISS), sex, comorbidities, presence of traumatic brain injury, and injury type. The effects of etomidate on other relevant outcome variables were assessed using unpaired Student's t-tests.

RESULTS

Three hundred eight patients were included in the study, and there were 42 deaths. Patients receiving etomidate were similar to those who did not, including ISS and pre-intubation blood pressure. The 28-day mortality was 18.7% in the etomidate group and 11.1% in the non-etomidate group (odds ratio = 1.85; 95% confidence interval [CI] 0.96 to 3.57; P = 0.07). After adjustment for age, female sex, ISS, and comorbidity, the odds ratio was 1.94 (95% CI 0.87 to 4.37; P = 0.11). There were no differences between the two groups in ICU length of stay, hospital length of stay, or number of ventilation-free days.

CONCLUSION

The association between use of a single dose of etomidate for emergency tracheal intubation in the trauma patient and mortality is inconclusive. Etomidate administration should be used with caution in trauma patients requiring tracheal intubation. Further data are required to determine the safety and risk-benefit of etomidate use in this patient population.

Pros and cons of etomidate--more discussion than evidence?

PURPOSE OF REVIEW

To evaluate the most recent publications in the long-lived debate over the use of etomidate in critically ill septic and trauma patients.

RECENT FINDINGS

Virtually without controversy is the hemodynamic stability after its use for induction of anesthesia on the one hand, and its negative effect on steroid synthesis on the other. The rating of the relative importance of both phenomena for the outcome of patients is however a highly controversial issue. We will discuss the most recent publications for two patient groups: trauma and critically ill septic patients. New meta-analyses and smaller studies have been published and might help us to weigh pros and cons in our patients. Sufficiently powered randomized controlled trials remain absent. The question whether supplemented corticosteroids after etomidate improve outcome is answered negatively by two recent studies.

SUMMARY

A single dose of etomidate supplies good intubation conditions with hemodynamic stability, but increases the risk for adrenal insufficiency. The relative importance of these characteristics for the patients' outcome remains controversial, as there is a lack of direct evidence. According to the principle 'nihil nocere', reasoning argues against its use, especially in septic patients or in those at major risk to develop septic complications (e.g. trauma patients).

In emergently ventilated trauma patients, low end-tidal CO2 and low cardiac output are associated and correlate with hemodynamic instability, hemorrhage, abnormal pupils, and death

Background

In a smaller experience, the authors previously demonstrated that end-tidal carbon dioxide (PetCO₂) and cardiac output (CO) had a positive association in emergently intubated trauma patients during Emergency Department resuscitation. The aim of this larger study was to reassess the relationship of PetCO₂ with CO and identify patient risk-conditions influencing PetCO₂ and CO values.

Methods

The investigation consists of acutely injured trauma patients requiring emergency tracheal intubation. The study focuses on the prospective collection of PetCO₂ and noninvasive CO monitor (NICOM®) values in the Emergency Department.

Results

From the end of March through August 2011, 73 patients had 318 pairs of PetCO₂ (mm Hg) and CO (L/min.) values. Mean data included Injury Severity Score (ISS) ≥15 in 65.2%, Glasgow Coma Score of 6.4 ± 4.6, hypotension in 19.0%, and death in 34.3%. With PetCO₂ ≤ 25 (15.9 ± 8.0), systolic blood pressure was 77.0 ± 69, CO was 3.2 ± 3.0, cardiac arrest was 60.4%, and mortality was 84.9%. During hypotension, CO was lower with major blood loss (1.9), than without major loss (5.0; P = 0.0008). Low PetCO₂ was associated with low CO (P < 0.0001). Low PetCO₂ was associated (P ≤ 0.0012) with ISS > 20, hypotension, bradycardia, major blood loss, abnormal pupils, cardiac arrest, and death. Low CO was associated (P ≤ 0.0059) with ISS > 20, hypotension, bradycardia, major blood loss, abnormal pupils, cardiac arrest, and death.

Conclusions

During emergency department resuscitation, a decline in PetCO₂ correlates with decreases in noninvasive CO in emergently intubated trauma patients. Decreasing PetCO₂ and declining NICOM CO are associated with hemodynamic instability, hemorrhage, abnormal pupils, and death. The study indicates that NICOM CO values are clinically discriminate and have physiologic validity.

Clinical study of etomidate emulsion combined with remifentanil in general anesthesia

BACKGROUND

The aim of this study was to investigate and evaluate the safety, recovery time, and side effects of general anesthesia with different doses of etomidate emulsion combined with remifentanil.

METHODS

One hundred ten patients of American Society of Anesthesiologists class 1 or 2 who underwent gynecological general anesthesia with a 1-3-hour operation time were randomly divided into the following groups: etomidate emulsion group 1 ([E1] n = 30); etomidate emulsion group 2 ([E2] n = 30); etomidate emulsion group 3 ([E3] n = 20); and propofol group ([P group] n = 30). For induction of anesthesia, 0.3 mg/kg etomidate emulsion, and the continuous remifentanil infusion also to induce anesthesia (0.1~0.3 μg · kg(-1) · min(-1)), was applied in all cases. Afterwards, continuous infusion of etomidate emulsion and remifentanil, respectively (E1: 10 μg · kg(-1) · min(-1) and 0.1 μg · kg(-1) · min(-1); E2: 15 μg · kg(-1) · min(-1) and 0.2 μg · kg(-1) · min(-1); E3: 20 μg · kg(-1) · min(-1) and 0.2 μg · kg(-1) · min(-1)), and propofol (P group: 6~10 mg · kg(-1) · h(-1)) were administered. Changes in blood flow kinetics and adverse reactions were noted and compared between the four groups.

RESULTS

Both arterial blood pressure (BP) and heart rate (HR) decreased after induction of anesthesia (P < 0.05). Systolic (SBP) and diastolic (DBP) BP changed only slightly, and HRs were slightly infected in E1, E2, and E3. SBP, DBP, and HR during the operation all decreased significantly in P group (P < 0.05). Muscle tremor at the time of induction occurred in 13 cases (11.8%). Following etomidate emulsion anesthesia maintenance, postoperative agitation occurred in seven cases (8.75%), lethargy in 20 cases (25%), and vomiting in 19 cases (23.75%). No adverse reactions were found in P group.

CONCLUSION

Continuous infusion of etomidate emulsion at 10 μg · kg(-1) · minute(-1) combined with remifentanil during anesthesia has the advantages of hemodynamic stability, quick wake-up, and few adverse reactions. Increasing the dose of etomidate emulsion increases the incidence of adverse reactions.