Rapid sequence induction in the emergency department: induction drug and outcome of patients admitted to the intensive care unit

Abstract

Objectives: Etomidate is used widely for rapid sequence induction (RSI) of anaesthesia in the emergency department (ED) as a result of its relative cardiovascular stability. There is concern over possible adrenal suppression and also that outcomes could be worse than in patients given other induction drugs. This possible association has not been studied in ED patients undergoing RSI.

Methods: 525 consecutive patients who underwent RSI in the ED and were subsequently admitted to an intensive care unit (ICU) were reviewed. The following information was retrieved from the records: induction drug use; incidence of hypotension and vasopressor administration at induction; acute physiology and chronic health evaluation (APACHE) II severity of illness and predicted mortality; and ICU and hospital outcome. The choice of induction drug was not controlled but was at the discretion of the attending clinicians.

Results: The numbers of patients given an induction drug were 184 etomidate, 306 thiopental and 35 propofol. Patients given etomidate were older and sicker than those given thiopental or propofol. Mortality appeared greater with etomidate but there was no difference when outcome was related to pre-existing risk. Age, APACHE II score and presenting diagnosis were independent predictors of hospital mortality, but etomidate use was not.

Conclusion: Induction drug was not related to patient outcome in this cohort of patients. The risks of developing hypotension and receiving a vasopressor at induction were greatest with propofol. Emergency physicians should choose an induction drug based on individual patient circumstances, rather than being solely concerned about adrenal suppression.