Etomidate for rapid sequence induction in patients with major trauma

The use of etomidate for inducing emergency anesthesia is controversial. Although it is known for its circulatory neutrality, it promotes the occurrence of adrenal insufficiency. Thus its use is not recommended in the S3 Guideline on Treatment of Patients with Severe and Multiple Injuries by the German Trauma Society. The guidelines of the Eastern Association for the Surgery of Trauma and the Advanced Trauma Life SupportA (R) manual do not rule out its use. Both guidelines are based on comparative evidence shown in this review: Clear evidence for harmful effects could not be supplied. There is consensus on the lack of significant studies hitherto for a concluding judgment. We carried out a structured literature search in PubmedA (R) for current studies that had not been published at the time the guideline was completed and identified 14 studies (four systematic reviews/meta-analyses, one non-systematic review, three randomized controlled trials, three cohort studies, and three post hoc analyses), which are summarized in the following. None of the current studies is able to clarify the benefits and risks of a one-time bolus dose of etomidate for inducing emergency anesthesia in trauma patients with regards to survival, complications, and course of treatment. In conclusion, despite new evidence, it is still unclear which of the original controversial recommendations should be adhered to in day-to-day practice. As long as there is an alternative medication that the provider knows how to handle carefully, the use of etomidate should be restricted to controlled clinical trials. In this case, an etomidate-induced adrenal insufficiency should be considered.