Etomidate increases susceptibility to pneumonia in trauma patients

• Published in: Intensive care medicine Vol. 38; no. 10; pp. 1673 - 1682
• Main Authors: Asehnoune, Karim, Mahe, Pierre Joachim, Seguin, Philippe, Jaber, Samir, Jung, Boris, Guitton, Christophe, Chatel-Josse, Nolwen, Subileau, Aurelie, Tellier, Anne Charlotte, Masson, Françoise, Renard, Benoit, Malledant, Yannick, Lejus, Corinne, Volteau, Christelle, Sébille, Véronique, Roquilly, Antoine
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer-Verlag 01-10-2012; Springer; Springer Nature B.V; Springer Verlag
• Subjects: ACTH; Adolescent; Adrenal Insufficiency; Adrenal Insufficiency - chemically induced; Adrenal Insufficiency - drug therapy; Adrenal Insufficiency - etiology; Adult; Aged; Analysis; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthesiology; Anesthetics, Intravenous; Anesthetics, Intravenous - administration & dosage; Anesthetics, Intravenous - adverse effects; Bacterial pneumonia; Biological and medical sciences; Child; Child, Preschool; Clinical trials; corticoids; Cosyntropin; Critical care; Critical Care Medicine; Cross Infection; Cross Infection - chemically induced; Cross Infection - drug therapy; Deltas; Double-Blind Method; Emergency and intensive care: injuries, diseases due to physical agents. Diving. Drowning. Disaster medicine; Emergency Medicine; Etomidate; Etomidate - administration & dosage; Etomidate - adverse effects; Female; Hospitals; Human health and pathology; Humans; Hydrocortisone; Hydrocortisone - adverse effects; Hydrocortisone - therapeutic use; Hépatology and Gastroenterology; Intensive; Intensive care; Intensive care medicine; Life Sciences; Male; Medical research; Medical sciences; Medicine; Medicine & Public Health; Medicine, Experimental; Middle Aged; Mortality; Original; Pain Medicine; Pediatrics; Pneumology/Respiratory System; Pneumonia; Pneumonia, Bacterial; Pneumonia, Bacterial - chemically induced; Pneumonia, Bacterial - drug therapy; Respiration, Artificial; Risk Factors; Sensitivity; Steroids; Ventilation; Ventilators; Wounds and Injuries; Wounds and Injuries - complications; Wounds and Injuries - drug therapy; Young Adult; France; Adrenal insufficiency; Hydrocortisone; Trauma; Bacterial pneumonia; Etomidate; Endocrinopathy; Human; Corticosteroid; Imidazole derivatives; Lung disease; Intensive care; Steroid hormone; Respiratory disease; Antiinflammatory agent; Glucocorticoid; General anesthetic; Adrenal hormone; Adrenal gland diseases; Resuscitation
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-012-2619-8

Purpose
To investigate the impact of etomidate on the rate of hospital-acquired pneumonia (HAP) in trauma patients and the effects of hydrocortisone in etomidate-treated patients.
Methods
This was a sub-study of the HYPOLYTE multi-centre, randomized, double-blind, placebo-controlled trial of hydrocortisone in trauma patients (NCT00563303). Inclusion criterion was trauma patient with mechanical ventilation (MV) of ≥48 h. The use of etomidate was prospectively collected. Endpoints were the results of the cosyntropin test and rate of HAP on day 28 of follow-up.
Results
Of the 149 patients enrolled in the study, 95 (64 %) received etomidate within 36 h prior to inclusion. 79 (83 %) of 95 patients receiving etomidate and 34 of the 54 (63 %) not receiving etomidate had corticosteroid insufficiency (
p
 = 0.006). The administration of etomidate did not alter basal cortisolemia (
p
 = 0.73), but it did decrease the delta of cortisolemia at 60 min (
p
 = 0.007). There was a correlation between time from etomidate injection to inclusion in the study and sensitivity to corticotropin (
R
2
 = 0.19;
p
 = 0.001). Forty-nine (51.6 %) patients with etomidate and 16 (29.6 %) patients without etomidate developed HAP by day 28 (
p
 = 0.009). Etomidate was associated with HAP on day 28 in the multivariate analysis (hazard ratio 2.48; 95 % confidence interval 1.19–5.18;
p
 = 0.016). Duration of MV with or without etomidate was not significantly different (
p
 = 0.278). Among etomidate-exposed patients, 18 (40 %) treated with hydrocortisone developed HAP compared with 31 (62 %) treated with placebo (
p
 = 0.032). Etomidate-exposed patients treated with hydrocortisone had fewer ventilator days (
p
 < 0.001).
Conclusions
Among the patients enrolled in the study, etomidate did not alter basal cortisolemia, but it did decrease reactivity to corticotropin. We suggest that in trauma patients, etomidate is an independent risk factor for HAP and that the administration of hydrocortisone should be considered after etomidate use.