ISR chez le traumatisé: Etomidate toujours pas convaincant

Pre-hospital emergent intubation in trauma patients: the influence of etomidate on mortality, morbidity and healthcare resource utilization.

Gäßler M  et AL. Scand J Trauma Resusc Emerg Med. 2019 Jun 7;27(1):61. doi: 10.1186/s13049-019-0637-z.

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Cette publication revient sur le débat qui porte sur l'emploi de l'étomidate pour l'intubation préhospitalière. Son emploi est remis en cause par certains, notamment à cause de ses effets dépresseurs cortico-surrénaliens tout particulièrement en cas de sepsis. Les auteurs,  si ils ne rapportent pas d'effets délétères sur la mortalité, mettent en évidence une durée d'hospitalisation et de ventialtion plus longue dans le groupe ETO. Plusieurs informations méritent une lecture critique de ce travail. Le premier est la présence dans le groupe non-ETO de thiopental, responsable de nombreux décès lors de l'attaque de pearl harbour (1). La seconde est l'augmentation significative de défaillance cardio-vasculaire dan le groupe non-ETO. On peut se poser la question de l'impact du thiopental dans ce groupe. Le propofol peut également être à l'origine d'une instabilité hémodynamique et nécessite un vrai apprentissage. La quatrième réflexion porte sur le niveau de qualification, qui n'est pas précisé, des personnels réalisant ces intubations.

Ce document ne permet pa de remettre en question la recommandation d'emploi de la Kétamine pour l'ISR dans le cadre de la mise en condition de survie du blessé de guerre (2).

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 BACKGROUND:

Due to its favorable hemodynamic characteristics and by providing good intubation conditions etomidate is often used for induction of general anesthesia in trauma patients. It has been linked to temporary adrenal cortical dysfunction. The clinical relevance of this finding after a single-dose is still lacking appropriate evidence.

METHODS:

This retrospective multi-centre study is based on merged data from a German Helicopter Emergency Medical Service (HEMS) database and a large trauma patient registry. All trauma patients who were intubated prior to hospital admission with a documented Injury Severity Score ≥ 9 between 2008 and 2012 were eligible for analysis. The primary endpoint was hospital mortality. Other outcome measures were organ failures, sepsis, length of ventilation, as well as length of stay in hospital and ICU.

RESULTS:

One thousand six hundred ninety seven patients were enrolled into the study. Seven hundred sixty two patients received etomidate and 935 patients received other induction agents. The in-hospital mortality was similar in both groups (18.9% versus 18.2%; p = 0.71). Incidences of organ failures and sepsis were not increased in the etomidate group. However, health care resource utilization parameters were prolonged (after adjusting: + 1.3 days for ICU length of stay, p = 0.062; + 0.8 days for length of ventilation, p = 0.15; + 2,7 days for hospital length of stay, p = 0.034). A multivariable logistic regression analysis did not identify etomidate as an independent predictor of hospital mortality (OR: 1.10, 95% CI: 0.77-1.57; p = 0.60).

CONCLUSIONS:

This is the largest trial investigating outcome data for trauma patients who had received a single-dose of etomidate for induction of anesthesia. The use of etomidate did not affect mortality. The influence on morbidity and health care resource utilization remains unclear.