A novel use of etomidate for intentional adrenal suppression to control severe hypercortisolemia in childhood.
OBJECTIVE
To describe a novel use for etomidate in critically ill children. Etomidate induction of anesthesia in children is controversial due to adrenal suppression; we review this controversy and describe a therapeutic application of this "side effect" using a continuous etomidate infusion in pediatric intensive care to deliberately suppress critically elevated endogenous cortisol.


METHODS
Case report.


METHODS
A tertiary pediatric intensive care unit.


METHODS
A 6-year-old boy with severe, life-threatening hypercortisolemia secondary to Cushing's disease.


METHODS
Admission to pediatric intensive care unit, before bilateral adrenalectomies, to facilitate etomidate infusion to reduce endogenous hypercortisolemia, as first-line treatment with metyrapone and ketoconazole had failed.


RESULTS
Continuous intravenous etomidate at 0.08 mg/kg/hr decreased serum cortisol from 1200 to 250 nmol/L within 48 hours. Once etomidate and hydrocortisone therapy provided stable serum cortisol levels, bilateral laparoscopic adrenalectomies were undertaken. A perioperative cortisol surge was seen, but to a much lower peak than expected without prior etomidate suppression.


CONCLUSIONS
The adrenal suppression caused by etomidate, so controversial in the care of the critically ill at present, can be therapeutically used for short-term control of severe hypercortisolemia in children.
Mettauer
Nicole
N
Pediatric and Neonatal Intensive Care Units, Great Ormond Street Hospital for Children, London, United Kingdom. nmettauer@bluewin.ch
Brierley
Joe
J
D000315:Adrenalectomy; D018686:Anesthetics, Intravenous / Q000627:therapeutic use*; D002648:Child; D003480:Cushing Syndrome / Q000188:drug therapy* / Q000209:etiology / Q000601:surgery; D005045:Etomidate / Q000627:therapeutic use*; D006801:Humans; D015278:Intensive Care Units, Pediatric; D008297:Male; D047748:Pituitary ACTH Hypersecretion / Q000150:complications / Q000601:surgery
D018686:Anesthetics, Intravenous; D005045:Etomidate