Increased risk of adrenal insufficiency following etomidate exposure in critically injured patients

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. Intervention: Cosyntropin stimulation testing, in which response was defined as an increase of 9 mu g/dL (248 nmol/L) or more in cortisol level. Main Outcome Measure: 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%] vs28 [52%]), andetomidateexposure (59 [71%] vs28 [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.