Etomidate in sepsis: understanding the dilemma

David J. Gagnon, David B. Seder


Etomidate is the most commonly utilized induction agent for rapid sequence intubation in emergency departments in the United States (1). Favorable characteristics include reliably good intubating conditions, a rapid onset and offset of activity, non-renal elimination, and maintenance of the cardiorespiratory drive (2). Unfortunately, etomidate causes relative adrenal insufficiency in up to 90% of patients after a single dose (3). Serious safety concerns first surfaced in the early 1980’s when continuous infusions were associated with increased mortality in trauma patients (4,5). Since then, there has been considerable uncertainty regarding its role for rapid sequence intubation, especially in septic patients who may depend on their adrenal reserves for survival during the acute phase of illness (6,7). Understanding the history of this controversy, and reviewing the most recent research into etomidate use in sepsis may help clinicians decide whether or not to use the drug in routine clinical practice.