Logo

Log In Sign Up |  An official publication of: American College of Emergency Physicians
Navigation
  • Home
  • Multimedia
    • Podcasts
    • Videos
  • Clinical
    • Airway Managment
    • Case Reports
    • Critical Care
    • Guidelines
    • Imaging & Ultrasound
    • Pain & Palliative Care
    • Pediatrics
    • Resuscitation
    • Trauma & Injury
  • Resource Centers
    • mTBI Resource Center
  • Career
    • Practice Management
      • Benchmarking
      • Reimbursement & Coding
      • Care Team
      • Legal
      • Operations
      • Quality & Safety
    • Awards
    • Certification
    • Compensation
    • Early Career
    • Education
    • Leadership
    • Profiles
    • Retirement
    • Work-Life Balance
  • Columns
    • ACEP4U
    • Airway
    • Benchmarking
    • Brief19
    • By the Numbers
    • Coding Wizard
    • EM Cases
    • End of the Rainbow
    • Equity Equation
    • FACEPs in the Crowd
    • Forensic Facts
    • From the College
    • Images in EM
    • Kids Korner
    • Medicolegal Mind
    • Opinion
      • Break Room
      • New Spin
      • Pro-Con
    • Pearls From EM Literature
    • Policy Rx
    • Practice Changers
    • Problem Solvers
    • Residency Spotlight
    • Resident Voice
    • Skeptics’ Guide to Emergency Medicine
    • Sound Advice
    • Special OPs
    • Toxicology Q&A
    • WorldTravelERs
  • Resources
    • ACEP.org
    • ACEP Knowledge Quiz
    • Issue Archives
    • CME Now
    • Annual Scientific Assembly
      • ACEP14
      • ACEP15
      • ACEP16
      • ACEP17
      • ACEP18
      • ACEP19
    • Annals of Emergency Medicine
    • JACEP Open
    • Emergency Medicine Foundation
  • About
    • Our Mission
    • Medical Editor in Chief
    • Editorial Advisory Board
    • Awards
    • Authors
    • Article Submission
    • Contact Us
    • Advertise
    • Subscribe
    • Privacy Policy
    • Copyright Information

Should You Etomidate Me?

By Ken Milne, MD | on August 25, 2023 | 0 Comment
Skeptics' Guide to EM
  • Tweet
  • Click to email a link to a friend (Opens in new window) Email
Print-Friendly Version

Case

A critically ill patient presents to the emergency department (ED) requiring an emergent, definitive airway. While preparing to perform the endotracheal intubation with video laryngoscopy, you remember a randomized controlled trial (RCT) recently suggesting etomidate could increase mortality if used as the induction agent.

You Might Also Like
  • Videolaryngoscope Helps Residents Learn Neonatal Endotracheal Intubation
  • How To Prevent Peri-intubation Deaths with Careful Medication Choice
  • Traumacology Tips
Explore This Issue
ACEP Now: Vol 42 – No 08 – August 2023

Background

Etomidate has been a popular induction agent for critically ill patients for more than a decade. This is due to its being hemodynamically neutral and its fast onset of action. However, a 2012 systematic review and meta-analysis (SRMA) reported that etomidate was associated with adrenal insufficiency and increased mortality in septic patients.1

There have been multiple randomized trials studying the effect of etomidate as an induction agent on adrenal function and mortality. These studies have reported mixed results—with some finding a statistically significant increase in mortality. A recent, single-center, randomized trial compared etomidate versus ketamine in adult patients requiring emergency endotracheal intubation.2 The primary outcome was all-cause mortality at seven days and showed an eight percent absolute increase for patients allocated to the etomidate group. This outcome was no longer statistically different at 28 days. There were multiple issues with this trial including a lack of masking and potential selection bias.

A new SRMA was published in 2021 that reported an associated increase in adrenal suppression and mortality with etomidate. However, this review combined high-level studies (five randomized controlled trials) with low-level studies (nine post hoc and 15 retrospective studies).3

Clinical Question

Will using etomidate as an induction agent in critically ill adult patients cause an increase in mortality?

Reference: Kotani, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77:154317.

Population: Critically ill adult patients requiring emergency endotracheal intubation

  • Exclusions: Pediatric patients less than or equal to 15 years old, etomidate as an infusion, non-randomized trials, systematic reviews, commentaries or editorials, literature reviews, studies not addressing the review question
  • Intervention: Etomidate
  • Comparison: Any other induction agent
  • Outcomes:
    • Primary Outcome: Mortality at the main time point defined by trial authors
    • Secondary Outcome: Adrenal insufficiency

Authors’ Conclusions

“This meta-analysis found a high probability that etomidate increases mortality when used as an induction agent in critically ill patients with a number needed to harm [NNH] of 31.”

Results

Eleven randomized trials were included in this study (n=2,704 patients). Etomidate was compared in four studies to ketamine, in four studies to midazolam, in one study to thiopental, in one study to ketamine with midazolam, and in one study to ketamine with propofol.

Pages: 1 2 3 | Single Page

Topics: AirwayClinicalCritical Careetomidateinduction agentsIntubation

Related

  • Push-Dose Pressors in the Emergency Department

    June 29, 2025 - 1 Comment
  • Case Report: When Syncope Gets Hairy

    June 17, 2025 - 0 Comment
  • New Clinical Policy for Adult Patients with Acute Carbon Monoxide Poisoning

    May 7, 2025 - 0 Comment

Current Issue

ACEP Now: July 2025

Download PDF

Read More

No Responses to “Should You Etomidate Me?”

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *


*
*

Wiley
  • Home
  • About Us
  • Contact Us
  • Privacy
  • Terms of Use
  • Advertise
  • Cookie Preferences
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 2333-2603