Controversies Surrounding the Use of Etomidate for Rapid Sequence Intubation in Patients with Suspected Sepsis

Rapid Sequence Intubation, is it Time to Find an Alternative Induction Agent? A Narrative Review

Objective: To review the efficacy, safety, and place in therapy of fentanyl as an induction agent for rapid sequence intubation (RSI) in critically ill patients. Data Sources: A comprehensive search of PubMed, EMBASE, and clinical trial registries (1964-June 2021) was performed utilizing the keywords fentanyl, rapid sequence intubation, intubation, induction, anesthesia, hemodynamics, operating room (OR), and emergency. Study Selection and Data Extraction: Only primary literature evaluating fentanyl in combination with a sedative or as the sole induction agent was included in the final analysis. Primary literature included peer-reviewed publications and results posted on ClinicalTrials.gov actively recruiting participants. Data Synthesis: Fentanyl has been used for decades as an adjunct, and sole induction agent in the OR. Questions surrounding the use of fentanyl as a sole induction agent include optimal dosing and safety in critically ill patients as evaluation in non-OR settings remain limited. Relevance to Patient Care and Clinical Practice: Commonly used induction agents (eg, etomidate and ketamine) are associated with adverse events that may increase risk of morbidity and mortality. Fentanyl, a high-potency opioid could serve as an alternative induction agent for RSI due to its neutral hemodynamic response and fast onset of action. This paper compiles and describes existing data on the use of fentanyl as an induction agent for RSI. Conclusion: Fentanyl in combination with sedatives provides optimal intubating conditions with minimal impact on hemodynamic parameters. Future studies should focus on safety and impact of awareness during paralysis before fentanyl can be considered as a sole induction agent.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation

INTRODUCTION

Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate.

METHODS

A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension.

RESULTS

A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension.

CONCLUSION

In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.

(R)-Ketamine ameliorates lethal inflammatory responses and multi-organ injury in mice induced by cecum ligation and puncture

AIMS

Sepsis is a life-threatening organ dysfunction syndrome arising from infection-induced uncontrolled systemic inflammatory responses. Patients surviving severe sepsis also exhibit increased mortality due to enhanced vulnerability to infections. In this study, we examined whether (R)-ketamine could prevent against lethal sepsis-induced systemic inflammation and inflammatory organ injury.

MAIN METHODS

Septic model was induced by cecal ligation and puncture (CLP) surgery on adult mice. (R)-ketamine (10 or 15 mg/kg) was administrated intraperitoneally (i.p.) 24 h before and/or immediately after CLP.

KEY FINDINGS

Combined prophylactic and therapeutic use of (R)-ketamine (10 mg/kg), as well as either prophylactic or therapeutic use of (R)-ketamine at a single dose of 15 mg/kg did not reduce 14-day mortality after CLP. However, combined prophylactic and therapeutic use of (R)-ketamine (15 mg/kg) significantly increased 14-day survival rate, attenuated sepsis-induced marked drop in the rectal temperature and increase in the plasma levels of inflammatory cytokines [i.e., interleukin (IL)-6, IL-17A, tumor necrosis factor (TNF)-α, IL-1β, and IL-10] 12 h after CLP. Furthermore, (R)-ketamine alleviated sepsis-induced increase in the organ injury markers such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), myocardial kinase (CK-MB), and creatinine 24 h after CLP. Moreover, the increased lung wet/dry weight ratio, pulmonary morphological injury and the pulmonary levels of inflammatory cytokines were also attenuated by (R)-ketamine.

SIGNIFICANCE

Combined prophylactic and therapeutic use of (R)-ketamine could attenuate systemic inflammation and inflammatory multi-organ injury in mice after CLP-induced lethal sepsis. Therefore, (R)-ketamine would be a potential prophylactic and therapeutic drug for patients prone to sepsis.

Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study

OBJECTIVE

The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis.

METHODS

This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine.

RESULTS

A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed.

CONCLUSIONS

Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis.

Etomidate as an Induction Agent in Sepsis

Sepsis is a life-threatening response to infection often times requiring endotracheal intubation in critically ill patients. Etomidate is routinely used as an intravenous induction agent to provide sedation and amnesia before placing an endotracheal tube. Although etomidate has many favorable qualities, there is a major concern regarding the predictable adrenal insufficiency that follows its use. Controversy continues to this day as to whether etomidate should be avoided in the setting of sepsis or septic shock.

Pharmacologic studies on ET-26 hydrochloride in a rat model of lipopolysaccharide-induced sepsis

BACKGROUND

ET-26 hydrochloride (ET-26 HCl) is a promising sedation-hypnotic compound with stable hemodynamic features that elicits virtually no adrenocortical suppression. However, whether it preserves better pharmacologic characteristics in a rat model of sepsis is not known. This study compared the survival rate, levels of corticosterone and pro-inflammatory cytokines, and histologic injury in the lungs and kidneys of rats suffering from sepsis treated with ET-26 HCl, etomidate, or normal saline (NS).

METHODS

Rats were given lipopolysaccharide (1mg/kg body weight, i.v.) to establish a sepsis model. Thirty minutes after lipopolysaccharide administration, ET-26 HCl, etomidate or NS were given as a bolus injection at equivalent doses. Plasma levels of corticosterone, interleukin-1β, interleukin-6, interleukin-10, and tumor necrosis factor-α were measured 1, 2, 4, 6 and 24h after administration. Histologic injury was observed at the time of death or 24h after drug administration.

RESULTS

The survival rate for rats in the etomidate, ET-26 HCl and NS groups was 40%, 90% and 90%, respectively. Corticosterone concentrations in the etomidate group were lower than those in the other groups 1h after administration of hypnotic compounds. Concentrations of pro-inflammatory cytokines in the ET-26 HCl group and NS group were not significantly different, but were significantly lower than those in the etomidate group. The injury scores of kidneys and lungs in the etomidate group were higher than those in ET-26 HCl and NS groups.

CONCLUSIONS

ET-26 HCl showed virtually no suppression of corticosterone synthesis, lower concentrations of pro-inflammatory cytokines, higher survival rate, and less organ injury in rats suffering from sepsis compared with the etomidate group. It may be safer to induce anesthesia using ET-26 HCl, rather than etomidate, in patients suffering from sepsis.

ET-26 hydrochloride (ET-26 HCl) has similar hemodynamic stability to that of etomidate in normal and uncontrolled hemorrhagic shock (UHS) rats

Objective

ET-26 HCl is a promising sedative–hypnotic anesthetic with virtually no effect on adrenocortical steroid synthesis. However, whether or not ET-26 HCl also has a sufficiently wide safety margin and hemodynamic stability similar to that of etomidate and related compounds remains unknown. In this study, the effects of ET-26 HCl, etomidate and propofol on therapeutic index, heart rate (HR), mean arterial pressure (MAP), maximal rate for left ventricular pressure rise (D_max/t), and maximal rate for left ventricular pressure decline (D_min/t) were investigated in healthy rats and a rat model of uncontrolled hemorrhagic shock (UHS).

Methods

50% effective dose (ED₅₀) and 50% lethal dose (LD₅₀) were determined after single bolus doses of propofol, etomidate, or ET-26 HCl using the Bliss method and the up and down method, respectively. All rats were divided into either the normal group and received either etomidate, ET-26 HCl or propofol, (n = 6 per group) or the UHS group and received either etomidate, ET-26 HCl or propofol, (n = 6 per group). In the normal group, after preparation for hemodynamic and heart-function monitoring, rats were administered a dose of one of the test agents twofold-higher than the established ED₅₀, followed by hemodynamic and heart-function monitoring. Rats in the UHS group underwent experimentally induced UHS with a target arterial pressure of 40 mmHg for 1 hour, followed by administration of an ED₅₀ dose of one of the experimental agents. Blood-gas analysis was conducted on samples obtained during equilibration with the experimental setup and at the end of the experiment.

Results

In the normal group, no significant differences in HR, MAP, D_max/t and D_min/t (all P > 0.05) were observed at any time point between the etomidate and ET-26 HCl groups, whereas HR, MAP and D_max/t decreased briefly and D_min/t increased following propofol administration. In the UHS group, no significant differences in HR, MAP, D_max/t and D_min/t were observed before and after administration of etomidate or ET-26 HCl at ED₅₀ doses (all P > 0.05). Administration of propofol resulted in brief, statistically significant reductions in HR and D_max/t, with a brief increase in D_min/t (P ˂ 0.05), while no significant differences in MAP were observed among the three groups. The blood-lactate concentrations of rats in the ET-26 HCl group were significantly lower than those in etomidate and propofol groups (P ˂ 0.05).

Conclusions

ET-26 HCl provides a similar level of hemodynamic stability to that obtained with etomidate in both healthy rats, and rat models of UHS. ET-26 HCl has the potential to be a novel induction anesthetic for use in critically ill patients.

The use of etomidate for rapid sequence induction in septic patients

There is continued debate about the clinical ramifications of single-dose etomidate for rapid sequence induction (RSI) in patients with sepsis. This history of this debate includes early studies identifying an association between etomidate infusions and mortality with adrenal suppression as a hypothesized mechanism. More recent data describing the high prevalence of adrenal insufficiency in patients with sepsis has prompted additional investigation as to the clinical effects of single-dose etomidate when utilized as an agent in RSI. Acknowledging the small number and heterogeneity of studies on this topic, we feel that the recent meta-analysis by Gu et al. provides an accurate and complete assessment of the existing literature on this topic. We continue to utilize etomidate for the purposes of RSI in this critically ill patient population and feel that the current data supports this position.

Etomidate in pediatric anesthesiology: Where are we now?

Etomidate is an intravenous anesthetic agent released for clinical use in the United States in 1972. Its popularity in clinical practice is the result of its beneficial effects on intracerebral dynamics with limited effects on hemodynamic function. These properties have made it a safe and effective anesthetic induction agent in both adult and pediatric patients with altered myocardial performance, congenial heart disease, or hypovolemia. However, recent concern has been expressed regarding its effects on the endogenous production of corticosteroids and the impact of that effect on patient outcomes. The following manuscript reviews clinical reports regarding etomidate use in the pediatric population and discusses recent concerns regarding its effects on corticosteroid metabolism and the implications of such effects for clinical use.

Advancing novel anesthetics: pharmacodynamic and pharmacokinetic studies of cyclopropyl-methoxycarbonyl metomidate in dogs

BACKGROUND

Cyclopropyl-methoxycarbonyl metomidate (CPMM, also known as ABP-700) is a second-generation "soft" (i.e., metabolically labile) etomidate analogue. The purpose of this study was to characterize CPMM's pharmacology in beagle dogs in preparation for potential first in human phase 1 clinical trials.

METHODS

CPMM's and etomidate's hypnotic activity and duration of action were assessed using loss of righting reflex and anesthesia score assays in three or four dogs. Their pharmacokinetics were defined after single bolus administration and single bolus followed by 2-h infusion. Adrenocortical recovery times after single bolus followed by 2-h infusion of CPMM, propofol, etomidate, and vehicle were measured using an adrenocorticotropic hormone stimulation test.

RESULTS

Compared with etomidate, CPMM was half as potent as a hypnotic (ED50 approximately 0.8 mg/kg), was more rapidly metabolized, and had a shorter duration of sedative-hypnotic action. Recovery times after CPMM administration were also independent of infusion duration. After hypnotic infusion, adrenocorticotropic hormone-stimulated plasma cortisol concentrations were 4- to 27-fold higher in dogs that received CPMM versus etomidate. Adrenocortical recovery was faster in dogs after CPMM infusion versus etomidate infusion (half-time: 215 vs. 1,623 min, respectively). Adrenocortical responsiveness assessed 90 min after CPMM infusion was not significantly different from that after propofol infusion.

CONCLUSION

The studies in dogs confirm that CPMM has hypnotic and adrenocortical recovery profiles that are superior than those of etomidate, supporting the continued development of CPMM as a clinical sedative-hypnotic to be used as a single bolus and by continuous infusion to induce and maintain general anesthesia or procedural sedation.

Rapid sequence intubation medication therapies: a review in light of recent drug shortages

Rapid sequence intubation is a stepwise process developed to assist health care providers in placing emergent artificial airways for patients requiring assisted ventilation. This practice includes routine administration of sedative and neuromuscular blocking agent (NMBA) medications for patient comfort during endotracheal tube placement. Members of the multidisciplinary team should be well educated about the various medications used during this process to ensure safe medication practices in an emergent situation. Recent drug shortages have forced many health care professionals to use alternative medications with which they are less familiar. The intent of this review is to familiarize health care providers with the pharmacology and adverse effect profiles of alternative sedative and NMBA medications used in emergent airway placement in light of recent drug shortages.

Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients

When caring for critically ill children, airway management remains a primary determinant of the eventual outcome. Airway control with endotracheal intubation is frequently necessary. Rapid sequence intubation (RSI) is generally used in emergency airway management to protect the airway from passive regurgitation of gastric contents. Along with a rapid acting neuromuscular blocking agent, sedation is an essential element of RSI. A significant safety concern regarding sedatives is the risk of hypotension and cardiovascular collapse, especially in critically ill patients or those with pre-existing comorbid conditions. Ketamine and etomidate, both of which provide effective sedation with limited effects on hemodynamic function, have become increasingly popular as induction agents for RSI. However, experience and clinical investigations have raised safety concerns associated with both etomidate and ketamine. Using a pro-con debate style, the following manuscript discusses the use of ketamine versus etomidate in RSI.

Advantages and disadvantages of etomidate use for intubation of patients with sepsis

Etomidate is a potent imidazole hypnotic used widely in single doses in the rapid sequence intubation of critically ill patients with sepsis due to its presumed hemodynamic safety, fast onset, and short duration of action. However, the literature is conflicting regarding the hemodynamic advantages of etomidate over other induction agents, and its safety in this population is a matter of strong debate in the critical care community as the drug is associated with suppression of adrenal steroidogenesis, which can last up to 72 hours after a single dose, primarily through potent inhibition of the 11β-hydroxylase enzyme. However, the clinical impact of this adrenal suppressive effect is not certain. The use of continuous-infusion etomidate in critically ill patients was abandoned more than 20 years ago due to reports of increased mortality. Nevertheless, mortality data of single-dose etomidate are still controversial, with no strong evidence of benefit over other agents and a tendency toward harm (keeping in mind the limitations of the available literature). Proponents of single-dose etomidate use in patients with sepsis suggest that the increased mortality associated with etomidate is merely a reflection of the patients' severity of illness and not related to the drug itself, whereas others believe that the drug causes true harm and increases mortality in this population. In view of the lack of a clear clinical advantage of etomidate over other agents used in rapid sequence intubation, it would be prudent to favor other agents until further conclusive evidence of etomidate safety is available in critically ill patients with sepsis.

Corticosteroid after etomidate in critically ill patients: a randomized controlled trial

OBJECTIVE

To investigate the effects of moderate-dose hydrocortisone on hemodynamic status in critically ill patients throughout the period of etomidate-related adrenal insufficiency.

DESIGN

: Randomized, controlled, double-blind trial (NCT00862381).

SETTING

University hospital emergency department and three intensive care units.

INTERVENTIONS

After single-dose etomidate (H0) for facilitating endotracheal intubation, patients without septic shock were randomly allocated at H6 to receive a 42-hr continuous infusion of either hydrocortisone at 200 mg/day (HC group; n = 49) or saline serum (control group; n = 50).

MEASUREMENTS AND MAIN RESULTS

After completion of a corticotrophin stimulation test, serum cortisol and 11β-deoxycortisol concentrations were subsequently assayed at H6, H12, H24, and H48. Forty-eight patients were analyzed in the HC group and 49 patients in the control group. Before treatment, the diagnostic criteria for etomidate-related adrenal insufficiency were fulfilled in 41 of 45 (91%) and 38 of 45 (84%) patients in the HC and control groups, respectively. The proportion of patients with a cardiovascular Sequential Organ Failure Assessment score of 3 or 4 declined comparably over time in both HC and control groups: 65% vs. 67% at H6, 65% vs. 69% at H12, 44% vs. 54% at H24, and 34% vs. 45% at H48, respectively. Required doses of norepinephrine decreased at a significantly higher rate in the HC group compared with the control group in patients treated with norepinephrine at H6. No intergroup differences were found regarding the duration of mechanical ventilation, intensive care unit length of stay, or 28-day mortality.

CONCLUSION

These findings suggest that critically ill patients without septic shock do not benefit from moderate-dose hydrocortisone administered to overcome etomidate-related adrenal insufficiency.

Differential effects of etomidate and its pyrrole analogue carboetomidate on the adrenocortical and cytokine responses to endotoxemia

OBJECTIVE

We developed a novel pyrrole analog of etomidate, (R)-ethyl 1-(1-phenylethyl)-1H-pyrrole-2-carboxylate (carboetomidate), which retains etomidate's desirable anesthetic and hemodynamic properties but lacks its potent inhibitory affect on adrenocorticotropic hormone-stimulated steroid synthesis. The objective of this study was to test the hypothesis that in contrast to etomidate, carboetomidate neither suppresses the adrenocortical response to endotoxemia nor enhances the accompanying production of proinflammatory cytokines.

DESIGN

Animal study.

SETTING

University research laboratory.

SUBJECTS

Male Sprague-Dawley rats.

INTERVENTIONS

For both single and multiple anesthetic dose studies, rats were injected with Escherichia coli lipopolysaccharide immediately followed by a hypnotic dose of etomidate, carboetomidate, or vehicle alone (dimethyl sulfoxide) as a control. For single-dose studies, no additional anesthetic (or vehicle) was administered. For multiple anesthetic dose studies, additional doses of anesthetic (or vehicle) were administered every 15 mins for a total of eight anesthetic (or vehicle) doses.

MEASUREMENTS AND MAIN RESULTS

Plasma adrenocorticotropic hormone, corticosterone, and cytokine concentrations were measured before lipopolysaccharide administration and intermittently throughout the 5-hr experiment. In single anesthetic dose studies, plasma adrenocorticotropic hormone and cytokine concentrations were not different at any time point among the etomidate, carboetomidate, and vehicle groups, whereas plasma corticosterone concentrations were briefly (60-120 mins) reduced in the etomidate group. In multiple anesthetic dose studies, plasma corticosterone concentrations were persistently lower and peak plasma interleukin-1β and interleukin-6 concentrations were higher in the etomidate group vs. the carboetomidate and control groups. Peak plasma interleukin-10 concentrations were similarly elevated in the etomidate and carboetomidate groups vs. the control group.

CONCLUSIONS

Compared with etomidate, carboetomidate produces less suppression of adrenocortical function and smaller increases in proinflammatory cytokine production in an endotoxemia model of sepsis. These findings suggest that carboetomidate could be a useful alternative to etomidate for maintaining anesthesia for a prolonged period of time in patients with sepsis.

Integrating outcome benefit into anesthetic design: the promise of steroids and statins

Steroids and statins may facilitate the integration of anesthetic design with clinical outcome. Although steroids clearly benefit adult cardiac surgical patents, the evidence is weaker in pediatric cardiac surgery. Current large randomized trials of steroids likely will determine the future role of steroids in adult cardiac surgery. In the intensive care unit, steroid therapy is indicated in septic shock that is refractory to fluid and pressor therapy. Recent data, however, indicate that liberal steroid therapy for sepsis may have adverse outcome consequences. A 2nd concern in the intensive care unit is acute adrenal suppression secondary to bolus etomidate therapy because it may be deleterious in patients with septic shock. Possible clinical solutions include alternative induction agents, concomitant steroid therapy, and recent etomidate derivatives. Statins also reduce mortality and atrial fibrillation after cardiac surgery. Furthermore, they slow the progression of rheumatic valvular stenosis, an important consideration in the developing world. Statins also may reduce delirium, stroke, and acute renal injury after cardiac surgery, but further randomized trials are required before definitive recommendations can be formulated. Statins are essential in vascular surgery because they reduce mortality, myocardial ischemia, and acute renal injury. As a result, they have been recommended highly for outcome enhancement in recent perioperative guidelines. Although they may improve survival in sepsis, further investigation is indicated to define their therapeutic role.