Letter to the editor: Hypotension after etomidate use in sepsis.

To the Editor:

I congratulate Kim et al. for their study that tries to clarify an important issue (1). Etomidate has been used for decades, and its safety has been hotly debated recently (2-7). Etomidate has many qualities as a sedative for intubation: it does not promote respiratory or cardiovascular depression, and it does not increase intracranial pressure. It is a good option for neurological patients and has a predictable dose-response. All this virtues make it an important alternative for sedation when a procedure is needed, mainly in acutely ill patients that frequently are in unstable conditions. Nevertheless, the drug has been criticized, sometimes in a passionate way (8), due to its blockade in steroids synthesis. Although it's unquestionable that etomidate promotes adrenal suppression that is detectable even with single bolus use (9), the relevance of this laboratorial phenomena is far from elucidated. The clinical impact, if there is one, of this suppression (that can last 24 to 48 hr when the drug is used for intubation), is unknown. This is the fairest statement that can be made at this moment. Conceivably, many practitioners reserve the drug to the most unstable patients, and this fact may introduce a bias in retrospective studies. Only randomized, prospective trials will give us the answers that are urgently needed.

Etomidate is blamed for adrenal suppression, which can lately induce hypotension or even refractory shock, if untreated. Curiously, it induces less immediate post-intubation hypotension. This is the etomidate paradox.

Dear Sir:

Emergent airway establishment in decompensated shock patients does not need to be meticulously covered, and one cannot overlook etomidate's effectiveness as a RSI promoting sedative.

There is controversy surrounding whether or not etomidate has any adverse effect on mortality, however recent evidence seems to suggest that it can act as a possible risk factor for adrenal insufficiency in patients with severe sepsis.

Therefore, until there is further evidence to the contrary, we believe that although the use of etomidate should not be prohibited, we should consider the risk of adrenal insufficiency, consider preparing steroid replacements.

Also, we totally agree with the opinion that the well-designed randomized controlled study will be mandatory.