title: Increased risk of adrenal insufficiency following etomidate exposure in critically injured patients.
abstract: 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.
  
  
  METHODS
  Retrospective registry study.
  
  
  METHODS
  Academic level I trauma center.
  
  
  METHODS
  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.
  
  
  METHODS
  Cosyntropin stimulation testing, in which response was defined as an increase of 9 mug/dL (248 nmol/L) or more in cortisol level.
  
  
  METHODS
  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%] vs 28 [52%]), and etomidate exposure (59 [71%] vs 28 [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.
authors.affiliation: Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S, 404 Medical Arts Bldg, Nashville, TN 37212, USA. bryan.cotton@vanderbilt.edu
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Oscar D
authors.initials: OD
authors.lastname: Guillamondegui
authors.forename: Sloan B
authors.initials: SB
authors.lastname: Fleming
authors.forename: Robert O
authors.initials: RO
authors.lastname: Carpenter
authors.forename: Shivani H
authors.initials: SH
authors.lastname: Patel
authors.forename: John A
authors.initials: JA
authors.lastname: Morris
authors.forename: Patrick G
authors.initials: PG
authors.lastname: Arbogast
mesh_terms: D018806:APACHE; D000046:Academic Medical Centers; D000293:Adolescent; D000309:Adrenal Insufficiency / Q000139:chemically induced* / Q000401:mortality* / Q000503:physiopathology; D000328:Adult; D000368:Aged; D003366:Cosyntropin; D005045:Etomidate / Q000009:adverse effects* / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006993:Hypnotics and Sedatives / Q000009:adverse effects / Q000627:therapeutic use; D015601:Injury Severity Score; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D016012:Poisson Distribution; D011336:Probability; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D014193:Trauma Centers
chemical_list: D006993:Hypnotics and Sedatives; D003366:Cosyntropin; D005045:Etomidate