Septic Patients Present with a Variety of Symptoms - Essay Example

Introduction Mccormick (2006, p discusses that septic patients present with a variety of symptoms which are normal bodily responses to the infectious agent. He also points out that these responses usually include inflammation, coagulation, organ dysfunction, organ hypoxia, decreased respiratory rate, and hypotension. The management of the severely septic patient initially involves resuscitation through adequate assessment of patient’s airway, breathing, and circulation (Mccormick, 2006, p. 1). In instances where the patient already manifests with respiratory failure, rapid-sequence intubation has to be initiated. Rapid sequence intubation is the preferred method of intubation in the emergency and trauma units because it carries a decreased risk of patient aspiration and vomiting (Lafferty & Kunkarni, 2008). To facilitate induction, anaesthetic agents like etomidate or midazolam are used. However, practitioners and experts acknowledge that anaesthesia use for intubation and ventilation is hazardous and poorly tolerated in critically ill patients (Mccormick, 2006, p. 1). Mccormick (2006, p. 1) recommends that a trained anaesthetist should be present when this procedure is undertaken. Hypotension is one of the adverse effects that can manifest after induction, hence, the needed presence of the anaesthetist at this stage of the procedure. However, literature on the use of etomidate as an induction agent has been rendered controversial. Bridgewater (n.d, p. 2) claims that this controversy mainly stems from the fact that etomidate actually causes adrenal suppression. Other studies have yet to substantially prove or disprove the merits of etomidate use in septic patients. Hence, this study is now being undertaken in order to assess the current researches on this subject in the hope of coming up with an academic and evidence-based resolution to this controversy. Methods Data was gathered for this paper in different databases through electronic and library catalogue searches. The MEDLINE electronic database was assessed through the Google search engine. Catalogue searches included ‘anaesthesia etomidate’ and ‘septic patients etomidate’. Index searches of books included the following keywords: ‘etomidate’ and ‘septic patients’. Electronic searches through the Google search engine used the words ‘etomidate induction septic patients’. In order to further specify searches, the words ‘etomidate mortality risk’ and ‘rapid sequence intubation’ were added in. Websites for the Cochrane Library and the National Library of Medicine were also searched using the above keywords. The articles and journal studies were reviewed and those which were deemed relevant were included for further evaluation for this paper. Studies which were considered relevant included those which discussed the use of etomidate on septic patients during rapid sequence intubation (RSI). Other journals and articles were assessed in more or less the same manner as explained above. Journals which were searched included the Annals of Emergency Medicine, PubMed Central, Western Journal of Emergency Medicine, Journal or Accident and Emergency Medicine, and the British Journal of Anaesthesia. Experts on the topic at hand were consulted for input and suggestions on possible directions and expectations of research. Results There are various studies which discussed the controversy surrounding the induction of etomidate in septic patients during rapid sequence intubation . A study published in the Critical Care website assessed the effects of etomidate on septic patients; adverse effects which sometimes include possible adrenal suppression and cardiovascular depression (Zausig, 2009, R144). The study revealed a possible relationship between the dose of the etomidate and the depression of cardiac functions. The study also revealed that induction agents that were tested registered a dose dependent depression of cardiac functions (Zausig, 2009, R144). Propofol registered the highest impact on cardiac functions with ketamine and etomidate showing the least amount of impact on cardiac functions. Nevertheless, these tested drugs which included ketamine, midazolam, etomidate, propofol, and methohexitone all presented direct impact on cardiac functions of a septic patient’s heart (Zausig, 2009, R144). In another paper, Jabre, et.al., (2009, p. 293) assessed the use of etomidate on septic patients because of its potential for causing reversible adrenal insufficiency and consequently causing the patient’s death. There were 655 patients from 12 emergency departments and 65 ICUs in France who were included in this study. About 234 of the patients were grouped in the etomidate group, and 235 in the ketamine group. The study revealed that as far as the Sequential Organ Failure Assessment (SOFA) was concerned, there was no significant difference between the two groups. However, the study revealed that there was a significant difference between the etomidate group and the ketamine group when considering the percentage of patients who registered with adrenal insufficiency. Considering such results, the study recommended that during rapid sequence intubation for septic patients, ketamine should be used instead of etomidate. In a study published with the Western Journal of Emergency Medicine, researchers sought to assess the in-house mortality between septic patients who were given etomidate and those who were given other induction agents for intubation (Tekwani, et.al., 2008, p. 195). The paper was conducted via a retrospective chart review of intubated septic patients in the hospital setting; the in-hospital mortality rate of each group was assessed. The paper revealed that there were 181 septic patients who were intubated within the study period of the research. About 135 of these were given etomidate, and 46 were given alternative induction agents. In patients given alternative induction agents, there was a mortality rate of 39.1% and for patients given etomidate, there was a 46.7% mortality rate. Although non-statistically significant, the study found a 7.6% absolute increase in mortality in patients who were given etomidate (Tekwani, et.al., 2008, p. 195). In a retrospective study by Ray and McKeown (2007), they assessed the effect of etomidate use in patients who were seriously ill. This study was conducted because of its adrenal suppression effects on patients. The charts of 159 septic patients admitted in the ICU were reviewed in order to assess the relationship between induction agent and the clinical outcome, which included vasopressor, inotrope, and steroid therapy use. The chart review revealed that the hospital mortality for inclusive patients was 65%. There were 74 patients given induction agents, 25 of these given etomidate. There was less vasopressor therapy needed when etomidate was used and there was no evidence found which established that clinical outcome or therapy was affected by the use of etomidate. Their study was also able to reveal that the use of etomidate caused less cardiovascular depression as compared to other induction agents for septic patients. Researchers concluded that studies assessing etomidate use should consider all issues and concerns, and not just the possibility of adrenal suppression in the patient. They also point out that concerns on adrenal suppression may not prove important upon the issuance of steroid supplements (Ray & McKeown, 2007). A prospective observational study by Choi, et.al., (2004, p. 700-702) attempted to compare the haemodynamic effect of using low dose midazolam and etomidate as induction agents in trauma departments’ RSI. Haemodynamic data before and after intubation were recorded for purposes of comparison. The study revealed a 10% increase in mean systolic blood pressure in the midazolam group with the etomidate group registering to significant changes. About 19% of the patients given midazolam had low blood pressure and only about 3% of etomidate patients experienced hypotension. As a result, this study concluded that etomidate was more likely to cause hypotension as compared to midazolam, therefore, etomidate should be the preferred induction agent during RSI In yet another study, Kim, et.al., (2006) compared the incidence of adrenal insufficiency and mortality between the septic shock patients who received etomidate and those who were given midazolam. A total of 65 patients were included in this study. The study revealed that hospital mortality rates were at 36% in the group given etomidate and 50% in the group given midazolam. The results however, were not statistically significant. Adrenal insufficiency however was significantly higher in the etomidate group as compared to the midazolam group. The study went on to conclude that physicians treating patients with septic shock should be made aware that etomidate can cause adrenal insufficiency; and that they should use corticosteroids whenever they administer etomidate to their patients (Kim, et.al., 2006). A study by Payen, et.al., (2008) was done in order to assess if etomidate should still be used. They discussed that etomidate functions to block cortisol synthesis by inhibiting 11 beta hydroxylase which consequently leads to primary adrenal insufficiency. This study criticizes other studies for not measuring serum accumulation of 11 beta-deoxycortisol and low serum secretion of cortisol in order to assess adrenal impairment of etomidate. Nevertheless, studies in critically ill patients without sepsis have revealed that the administration of etomidate causes adrenal inhibition. There have been uncertainties raised on the actual mortality and morbidity impact of etomidate to patients with sepsis. However, the study was able to establish that in patients who have arterial hypotension after severe traumatic brain injury, etomidate helped to improve their condition and helped facilitate tracheal intubation (Paven, 2008, p. 915). A study by Ching, et.al. (2009, p. 201) attempted to assess the use of etomidate and rocurorium in the emergency airway management of children and adolescents with critical illnesses. The study established various advantages in the use of both drugs for the study group. The study was able again to affirm that etomidate does suppress adrenal function; rocurorium, on the other hand, produced favourable intubating effects without causing serious complications . The available evidence that this study was able to establish revealed a favourable safety endorsement on the use of etomidate and rocurorium in rapid sequence intubation; however, the study also emphasizes the need to come up with more prospective studies on etomidate use in paediatric patients. A retrospective study by Sokolove, et.al., (2000, p. 18) published in the Pediatric Emergency Care Journal sought to establish whether paediatric patients who were given etomidate for RSI in the emergency department developed clinically important hypotension or adrenal insufficiency. The researchers were able to find no clinically important adrenocorticoid suppression; and they found low incidence of clinically important hypotension when etomidate was used for children during RSI. This study recommended that a prospective version of the study be undertaken in order to further evaluate the use of etomidate in the paediatric population (2000, p. 21). A case study by Grabarczyk, et.al. (2009) assessed the case of an 85 year-old male admitted to the Emergency Department complaining of chest pain. He had a history of essential hypertension, right bundle block, colon carcinoma and GERD. The study was able to reveal that the use of etomidate as an anaesthetic induction agent caused postoperative adrenal suppression. However, the immediate administration of hydrocortisone to the patient was able to resolve the issue of the patient’s hypotension when it was identified as a possible danger in the administration of etomidate. The study recommended to other practitioners that there is a need for them to be vigilant and alert in the administration of etomidate in both septic and non-septic patients. A prospective study by Hildreth, et.al., (2009, p. 573) as seen in the Journal of Trauma attempted to study the effect of one dose of etomidate for RSI on adrenal function and its consequent significance during and after resuscitation in trauma patients. Subjects were given different induction agents which included etomidate and fentanyl + midazolam. Baseline levels for cortisol were established before the administration of the induction agents. The study revealed lower serum cortisol levels in the etomidate group as compared to the fentanyl and midazolam group. The etomidate group also required longer ICU length of stay, more ventilator days, and consequently longer hospital stay. The study concluded that etomidate caused adrenal insufficiency and longer hospital stay as compared to groups given fentanyl + midazolam. They also recommend more studies to be undertaken in order to assess the safety profile of etomidate use for critically ill patients (Hildreth, 2009, p. 573-579). A study by Fengler (2008, p. 229) published in the American Journal of Emergency Medicine assessed if etomidate should be used for rapid sequence intubation in critically ill septic patients. A literature review of studies on paediatric and adult intensive care indicated an association between a single induction dose of etomidate in critically ill septic patients and sustained suppression of the adrenal functions leading to an increase in mortality risk (Fengler, 2008, p. 229). This study also revealed that it is difficult for the authors to assess that the increase in mortality would be offset by concomitant corticosteroid administration. It also showed that the resuscitation of septic patients with fluids, antibiotics, and vasopressors indicated lower mortality rates, consequently giving an opportunity for the use of alternative agents previously discouraged because of concerns of hemodynamic collapse during intubation. The researcher recommended a prospective randomized trial in septic patients of etomidate induction against the use of alternative induction agents in order to assess differences in mortality (Fengler, 2008, p. 229). A prospective study by Schenarts, et.al., (2001, p. 1) aimed to assess adrenocortical function after intravenous etomidate use in ED patients who required RSI. Patients were given either midazolam or etomidate during the RSI. The study was able to establish that there was a normal response in the control group, while the etomidate group registered registered with adrenocortical dysfunction. Cortisol levels remained within normal levels during the dysfunction, and the adrenal dysfunction was able to resolve itself within 12 hours after the administration of single-bolus dose of etomidate (Schenarts, et.al., 2001, p. 1-7). A study by Cotton, et.al., (2008, p. 62) as seen in the Archives of Surgery sought to identify the risk factors involved in patients who may later develop adrenal insufficiency after etomidate induction. The study was done in an Academic level I trauma centre covering all trauma patients in the ICU who underwent cosyntropin stimulation testing for adrenal insufficiency. 137 patients were eventually included in this study. It revealed that the rates of sepsis, mechanical ventilation and mortality were similar for the two groups; however incidents for hemorrhagic shock on admission, and requirement of vasopressor support against etomidate exposure were significantly higher in the nonresponder group (Cotton, et.al., 2008, p. 62). The study also revealed that the risk of adrenal insufficiency remained after controlling variables of age and revised trauma score. This study concluded that etomidate is considered a modifiable risk factor in the development of adrenal insufficiency in critically injured patients. There is also a need to re-evaluate the use of etomidate for procedural sedation and rapid-sequence intubation in critically injured patients (Cotton, et.al., 2008, p. 62). A study by Zed, et.al., (2006, p. 378) as published in the Academic Emergency Journal was conducted in order to assess the intubating conditions and hemodynamic effects of etomidate in patients undergoing rapid sequence intubation in the emergency department. The authors observed patients who were given RSI over a 42-month period in a tertiary hospital. The study was able to reveal that etomidate was used in the induction of RSI in 522 patients. It also revealed that etomidate provides appropriate intubating conditions in a mixed group of patients undergoing RSI in the emergency department. Although etomidate proved to be effective in maintaining hemodynamic stability, authors recommend that this must be weighed against adverse effects which relate to adrenal suppression (Zed, et.al., 2006, p. 378). Vinclair and his colleagues sought to determine the incidence and duration of adrenal inhibition induced by a single dose of etomidate in critically ill patients. This study covered three ICUs in a university hospital. There were 40 critically ill patients without sepsis who received a single dose of etomidate for facilitating ET intubation. The study concluded that a single bolus infusion of etomidate led to a wide adrenal inhibition in seriously ill patients. However, this change was reversible within 48 hours after the administration of the drug. The study also concluded that the use of steroids for 48 hours after administration of etomidate in ICU patients without septic shock should also be considered by practitioners and physicians (Vinclair, et.al., 2008, p. 714). A study review on the use of etomidate in septic patients revealed that ketamine and etomidate are recommended choices as induction agents during emergency intubation. They point out that no convincing evidence, as yet, has been presented to support the allegations that etomidate should be avoided in patients with septic shock. They recommend that prospective studies on the issue should first be presented in order to prove or disprove the above allegations. And pending such prospective studies, the practitioners should still use ketamine or etomidate as induction agents because they are the agents least likely to induce or worsen hypotension (Walls & Osborn, p. 4). Summary of Results The studies above revealed that the mortality rate in the use of etomidate for septic patients undergoing RSI ranges from 36% to 65%. This covers three studies which were able to reveal mortality rates in the course of their research. All but one of the studies presented were able to establish that all septic patients given etomidate during RSI later exhibited with adrenal suppression or insufficiency. About 50% of the studies presented above emphasized that the adrenal suppression created by etomidate is reversible and can be remedied through the administration of corticosteroids. About 38% of the studies presented above pointed out that etomidate brings about favourable benefits for the septic patients during RSI like decreased incidents of arterial hypotension, decreased vasopressor use, and hemodynamic stability. These benefits must be weighed against the established risk of adrenal insufficiency which is very much reversible and manageable. Five out of the 16 studies presented above recommend that more prospective studies on the use of etomidate for septic patients during RSI should be conducted in order to accurately assess the controversy based on firm and repeatable results. About 50% of the studies presented above recommend the use of etomidate for septic patients undergoing RSI. Some of these studies argue that there is no sufficient evidence proving that etomidate causes more harm than good to the patient. Until such studies are presented, 50% of the studies recommend that etomidate still be used, and precautionary measures like corticosteroids be prepared to counter adrenal insufficiency. Discussion Principle Results This study mainly establishes that the use of etomidate in septic patients increases mortality risk. However, such risks are reversible and modifiable when proper precautions are taken by physicians. Adrenal insufficiency caused by etomidate which consequently increases the risk for mortality can be prevented through the administration of corticosteroids. The benefits of using etomidate, when weighed against its modifiable risk, makes etomidate still the recommended drug of choice for septic patients undergoing RSI. Strengths and Weaknesses of the Search This study was able to focus on a specific, evidence, and issue-based search in order to establish a thorough and comprehensive assessment of the issue at hand. The search used a variety of search engines and catalogue searches in order to establish a diverse data gathering process. The use of more specific words in the search engines directed this research into more detailed and explicit studies discussing this issue. An evaluation of the references used by the papers already cited for this review also provided a convenient and accessible manner of conducting this research. Through hand searches of journal in libraries and indexes, a rich and detailed literature review was made possible. Such hand searches also allowed this researcher to undergo the process of sifting through and choosing the most appropriate papers for this review. The authors or researchers of the papers which were included in this review mostly had backgrounds in emergency medicine and critical care. Some of them are anaesthetists who were mostly fielded in critical care and trauma hospitals. The results of some of these studies were not agreed upon by other practitioners who also presented their own studies in the hope of offering a more objective assessment of the controversy. Strengths and Weaknesses of the Papers There were 6 prospective researches, 7 retrospective, and 3 literature reviews included in this paper. Most of the papers are retrospective, therefore the conditions of the research are unpredictable and not well-controlled. The prospective method is still very much superior to the retrospective approach, however, ethical boundaries in research can be dangerously breached in this topic if more prospective studies would be done. The risks to patient safety and mortality in a prospective study cannot be ignored. However, a retrospective study design offers benefits which cannot be found in a prospective study. Retrospective studies can be used to measure incidence rates (Hulley, p. 99). And in this paper, incidence rates related to mortality in the use of etomidate for septic patients were assessed and established by retrospective studies. Most of the studies were observational with subjects observed for possible reactions to etomidate. In these studies, there was no attempt to issue treatment or to control the subjects. Through these observational studies, it was possible to assess for hidden biases. These hidden biases helped distinguish and identify patterns in studies included in this research. This review used the data presented by the previous studies in order to assess the issue on etomidate use. Some of the studies used had a limited population, and the rest had larger populations. The rest of the studies were also literature reviews, hence, the information from these reviews were already secondary sources. Differences in the results for each paper were mostly on population, alternative induction agents used, and methods of research. Some of the researches consisted of chart reviews; others were more comprehensive and in-depth assessments of septic patients. The medical centres and physicians involved in the care of the patients included in this paper were also different from each other. They all had their areas of specialization and care which impacted on the expertise of the physicians fielded in these hospitals and on the quality of care rendered to each patient. These centres employed various procedures and protocols which often affected the treatment choices for each patient. Some institutions also have choice drugs to administer to their patients, and these choices often differed from other hospitals. Again, these differences affect the consistency of this paper. Patients included in this study came in under a variety of conditions which were not included in some of the papers assessed in this review. Some patients came in under septic conditions only and others came in with co-morbid conditions which made them more vulnerable to the adverse effects of etomidate. Some of the studies used in this review presented overall figures on mortality and adrenal insufficiencies, however, they did not present other adverse effects which may arise from factors unique to each patient and each induction agent used. The individual characteristics and history of the patients were not assessed comprehensively in the studies used in this review. Statistical assessment of the studies cited in this review was made based on percentages. Due to the diverse population of each study used, only a rough range could be effectively used in order to determine overall mortality rates. A rough average or median was used in order to determine the overall trend of studies discussing this issue or controversy. Most of the studies cited in this review compared the use of etomidate and other induction agents. The basis of comparison mostly related to mortality rates and to adverse effects like adrenal insufficiency, cardiovascular depression, arterial hypotension, and hemodynamic stability. The results of such comparison however do not unequivocally settle the present controversy. Implications for Practice in the UK The results unearthed in the studies cited in this review imply that Emergency Physicians and Anaesthetists involved in the RSI of septic patients need to be vigilant about the use of etomidate. The choice of using etomidate as an induction agent should be made consciously and carefully by the medical practitioner. It is already established by studies cited above that etomidate does cause adrenal sufficiency; this fact is already acknowledged by various practitioners and experts in the medical field. Whether or not such adrenal insufficiency would now lead to the patient’s death is entirely dependent on the precautions taken by the physician. The results of this review also imply that this issue presents with contrasting results. Where some practitioners make light of the controversy and still highly recommend the use of etomidate, other practitioners are wary of the risks involved in its use. And yet, none of the studies can firmly offer definitive proof relating increased patient mortality rate with etomidate use. Practitioners remain confused and unsure about the prudent and medically relevant decision to make about etomidate use in septic patients. Future Research Considering the present confusion on the current issue of etomidate use, this review implies that prospective studies on the topic need to be undertaken. Prospective studies would help come up with a more accurate evaluation of the issue. Prospective studies would also potentially avoid the pitfalls of retrospective research. Future studies on etomidate use in trauma centres across a larger area also have to be undertaken in order to establish more consistent results. This review also implies that future research needs to focus on individual characteristics of each patient which may affect mortality rates. This would help establish whether or not mortality rates can be credited to etomidate induction or other co-morbid factors. Conclusion This review was not able to unequivocally settle the issue being raised. Three studies were able to present mortality rates related to etomidate use. However, other studies were able to effectively question the veracity of these studies and mortality rates. And yet, all practitioners do accept the fact that etomidate leads to adrenal suppression or insufficiency. Adrenal insufficiency is considered a dangerous medical condition which, if not remedied, can lead to patient mortality. This is the very point that detractors of etomidate use emphasize; however, proponents of etomidate use point out that adrenal insufficiency can be remedied through the administration of corticosteroids. They stress that the benefits of etomidate use should not be set aside over its modifiable risks. Based on this review, I personally agree that this issue is being blown out of proportion. With the proper vigilance of the medical team, it is possible to secure the best induction agent (etomidate) for the patient, and still avoid its pitfalls. Works Cited Bridgewater, J., (n.d) Etomidate: Single dose adrenal suppression, Clinical Departments, viewed 14 September 2009 from http://clinicaldepartments.musc.edu/anesthesia/intranet/education/resident%20research/files/Joel%20Bridgewater.pdf Ching, K. & Baum, C., March 2009, Newer Agents for Rapid Sequence Intubation: Etomidate and Rocurorium, Pediatric Emergency Care, volume 25, number 3, pp. 201-211 Choi, Y., Wong, T., & Lau, C., November 2004, Midazolam is more likely to cause hypotension than etomidate in emergency department rapid sequence intubation, Emergency Medicine Journal, volume 21, number 6, pp. 700-702 Cotton, B., Guillamondegui, O., Fleming, S., Carpenter, R., Patel, S., Morris, J., Arbogast, P., January 2008, Increased risk of adrenal insufficiency following etomidate exposure in critically injured patients, Archives of Surgery, volume 143, number 1, pp. 62-67 Fengler, B., February 2008, Should etomidate be used for rapid-sequence intubation induction in critically ill septic patients?, American Journal of Emergency Medicine, volume, 26, number 2, pp. 229-232 Grabarczyk, J., Papadimos, T., Almasri, M., Chiricolo, A., & Snyder, L., 2009, A presumptive case of adrenal insufficiency following a single dose of etomidate for induction of anesthesia in a cardiac surgery patient, The Internet Journal of Anesthesiology, volume 21, number 1 Hildreth, A., Mejia, V., Maxwell, R., Smith, P., Dart, B., & Barker, D., August 2009, Adrenal suppression following a single dose of etomidate for rapid sequence induction: a prospective randomized study, Journal of Trauma, volume 65, number 3, pp. 573-579 Hulley, S., 2007, Designing clinical research, Pennsylvania: Lippincott Williams & Wilkins Jabre, P., Combes, X., Lapostelle, F., Dhaouadi, M., Ricard-Hibon, A., Bertrand, L., et.al., 25 July 2009, Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial, The Lancet, volume 374, pp. 293-300 Kim, T., Rhee, J., Kim, K., Cha, W., Suh, G., & Jung, S., December 2008, Etomidate should be used carefully for emergent endotracheal intubation in patients with septic shock, Journal of Korean Medical Science, volume 23, number 6, pp. 988-991. Lafferty, K., & Kulkarni, R., 27 October 2008, Tracheal intubation, rapid sequence intubation, eMedicine Medscape, viewed 13 September 2009 from http://emedicine.medscape.com/article/80222-overview Mccormick, B., 10 June 2006, Management of Sepsis: Overview, Anaesthesia UK, viewed 14 September 2009 from http://www.frca.co.uk/article.aspx?articleid=100484 Payen, J., Vinclair, M., Broux, C., Faure, P., & Chabre, O., November 2008, Should etomidate still be used?, Annales francaises danesthesie et de reanimation, volume 27, number 11, pp. 915-919 Ray, D. & McKeown, D., 16 May 2007, Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock, Critical Care, volume 7, number 3, R56. Schenarts, C., Burton, J. & Riker, R., January 2001, Adrenocortical dysfunction following etomidate induction in emergency department patients, Academy of Emergency Medicine, volume 8, number 1, pp. 1-7. Sokolove, P., Price, D., & Okada, P., February 2000, The safety of etomidate for emergency rapid sequence intubation of pediatric patients, Pediatric Emergency Care, volume 16, number 1, pp. 18-21. Tekwani, M., Karis, L., Watts, H., Chan, C., Nanini, S., Rzechula, K., & Kulstad, E., 9 November 2008, The Effect of Single-Bolus Etomidate on Septic Patient Mortality: A Retrospective Review, Western Journal of Emergency Medicine, volume 9, number 4, pp. 195-200 Vinclair, M., Broux, C., Faure, P., Genty, C., Jacquot, C., Chabre, O., & Payen, J., April 2008, Duration of adrenal inhibition following a single dose of etomidate in critically ill patients, Intensive Care Medicine, volume 34, number 11, pp. 2117-2118 Walls, R. & Murphy, M., 1 July 2008, Continue to Use Etomidate for Intubation of Patients With Septic Shock, American College of Emergency Physicians, volume 52, number 1 Zausig, Y., Busse, H., Lunz, D., Sinner, B., Zink, W., & Graf, B., 8 September 2009, Cardiac Effects of Induction Agents in the Septic Rat Heart, Critical Care, volume 13, R144. Zed, P., Riyad, A., Harrison, D., 2006, Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: An observational cohort study, Academic Emergency Medicine, volume, 13, number 4, pp. 378-383 Read More