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Increased Risk of Adrenal Insufficiency Following Etomidate Exposure in Critically Injured Patients
Bryan A. Cotton, MD;
Oscar D. Guillamondegui, MD;
Sloan B. Fleming, PharmD;
Robert O. Carpenter, MD;
Shivani H. Patel, PharmD;
John A. Morris Jr, MD;
Patrick G. Arbogast, PhD
Arch Surg. 2008;143(1):62-67.
Background Timely diagnosis and treatment of adrenal insufficiency (AI) dramatically reduces mortality in trauma patients. We sought to identify risk factors and populations with a high risk of developing AI.
Design Retrospective registry study.
Setting Academic level I trauma center.
Patients All trauma patients in the intensive care unit who underwent cosyntropin stimulation testing (CST) for presumed AI from January 1, 2002, through December 31, 2004.
Interventions Cosyntropin stimulation testing, in which response was defined as an increase of 9 µg/dL (248 nmol/L) or more in cortisol level.
Main Outcome Measures Risk factors for developing AI in critically ill trauma patients.
Results In 137 patients, CST was performed; 83 (60.6%) were nonresponders and 54 (39.4%) were responders. Age, sex, race, trauma mechanism, Injury Severity Score, and Revised Trauma Score were not statistically different between the groups. Rates of sepsis/septic shock, mechanical ventilation, and mortality were also similar between the 2 groups. However, rates of hemorrhagic shock on admission (45 [54%] vs 16 [30%]), requirement of vasopressor support (65 [78%] vs 28 [52%]), and etomidate exposure (59 [71%] vs 28 [52%]) were all significantly higher in the nonresponder group (P < .01). The increased risk of AI remained after controlling for potential confounding covariates (age, mechanism, Injury Severity Score, and Revised Trauma Score).
Conclusions Exposure to etomidate is a modifiable risk factor for the development of AI in this sample of critically injured patients. The use of etomidate for procedural sedation and rapid-sequence intubation in this patient population should be reevaluated.
Author Affiliations: Division of Trauma and Surgical Critical Care, Department of Surgery (Drs Cotton, Guillamondegui, Carpenter, and Morris), and Departments of Clinical Pharmacology (Drs Fleming and Patel) and Biostatistics (Dr Arbogast), Vanderbilt University Medical Center, Nashville, Tennessee.
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