Monday March 26, 2007
Etomidate for intubation - yes or no?

Dr. Annane says: ICU physicians should abandon the use of etomidate! 1 Even a single dose of Etomidate for intubation can induce longer than expected (24 -36 hours) adrenal insufficiency particularly in septic patients. But dilemma for ICU physicians never ends. Either they use other agents such as midazolam, fentanyl, propofol etc and manage post-intubation hypotension shrewdly to avoid essential organs damage or add irrespectively low dose steroid along with etomidate ?
In references below, we are putting major articles in this regard from recent literature and here is a great review on said topic,

The uncertain risk of single dose Etomidate in the critically ill (reference: Hospial Pharmacy, Volume 40, number 8, 2005, page 658-661)

References: click to get abstract/article if available

1. ICU physicians should abandon the use of etomidate! -Intensive Care Med 2005, 31:325-326
2. Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. - Anaesthesia 1999, 54:861-867
3. Should We Use Etomidate as an Induction Agent for Endotracheal Intubation in Patients With Septic Shock? - A Critical Appraisal -William L. Jackson, Jr, MD, FCCP - Chest. 2005;127:1031-1038
4. Etomidate for endotracheal intubation in sepsis: acknowledging the good while accepting the bad. - Chest 2005, 127:707-709

Monday March 19, 2007
Acute hyperglycemia may lower tPA effect in stroke patients


As benefits of blood sugar control is getting more and more attention, this new study published in stroke 1 from spain is noteworthy which found that "acute" (but not chronic) hyperglycemia may lower tPA effect in stroke patients. As known from before, hyperglycemia has a deleterious effect in stroke patients by accelerating ischemic brain damage. This study showed that antifibrinolytic effect of hyperglycemia may also influence reperfusion.


Glucose level at admission was recorded in 139 consecutive stroke patients who were treated with intravenous tissue-type plasminogen activator (tPA). The existence of previous chronic hypergycemia was determined by glycosylated hemoglobin (HbA1c) and fructosamine.

• Transcranial Doppler monitoring assessed complete recanalization 2 hours after tPA bolus.
• National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and 48 hours.

Results — Patients who recanalized showed lower admission glucose levels but no differences in HbA1c or fructosamine.

Patients with an admission glucose level more than 158 mg/dL had lower recanalization rates (16% vs 36.1%) and a higher NIHSS score at 48 hours (7 vs 14.5). After adjustment for stroke etiology, age, and risk factors, the only independent predictors on admission of no recanalization were

• glucose value more than 158 mg/dL,
• proximal middle cerebral artery occlusion and
• platelet count less than 219 000/mL

Study concluded that in tPA-treated patients, the acute but not chronic hyperglycemia state may hamper the fibrinolytic process, delaying reperfusion of the ischemic penumbra. Early measures to reduce blood glucose may favor early recanalization.


Reference: Click to get abstract

1. Acute Hyperglycemia State Is Associated With Lower tPA-Induced Recanalization Rates in Stroke Patients -Stroke. 2005;36:1705