Etomidate and mortality in cirrhotic patients with septic shock

This is a nested-cohort study within a randomized double blind placebo controlled study evaluating the use of low dose hydrocortisone in cirrhotic septic patients. Cirrhotic septic patients ≥ 18 years were included in the study. Patients who received etomidate prior to intubation were compared to those who did not receive etomidate for all cause 28-day mortality as a primary outcome.Sixty two intubated patients out of the 75 patients randomized in the initial trial were eligible for this study. Twenty three of the 62 intubated patients received etomidate dose prior to intubation. Etomidate use was not associated with all cause 28-day mortality or hospital mortality but was associated with significantly higher ICU mortality (91% vs. 64% for etomidate and controls groups, respectively; p = 0.02). Etomidate patients who received subsequent doses of hydrocortisone required lower doses of vasopressors and had more vasopressor-free days but no improvement in mortality.In this group of septic cirrhotic patients with very high mortality, etomidate increased ICU mortality. Subsequent use of hydrocortisone appears to have no benefit beyond decreasing vasopressor requirements. The lowest mortality was observed in patients who did not receive etomidate but received hydrocortisone.Hypoxemia, hypotension, volume depletion are commonly present in septic shock patients and induction of anesthesia may cause cardiovascular collapse. This effect is thought to be least with etomidate making it the favored agent to use for rapid-sequence intubation (RSI) of patients who have or are at risk of hemodynamic collapse increasing its use in the critical care setting [1-4]. However, etomidate use is not without risks as it has been shown to suppress the adrenal function through the inhibition of 11 β-hydroxylase enzyme that converts 11 β-deoxycortisol into cortisol in the adrenal gland leading to a state of relative adrenal insufficiency that may persist for up to 72 hours [5-10]. What remains