Tuesday, January 6, 2009

Etomidate in sepsis??

Ya know, I do some sedation on a regular basis, for dislocation or fracture reductions, cardioversions, intubations, etc.etc. One of my favorites besides propofol, is etomidate and versed. However, for a long time, we have been cautioned against using etomidate in any patient with suspected infection, such as elderly patient with respiratory distress that could be secondary to pneumonia or sepsis. This warning has been based on an older study that showed increased mortality in patients with sepsis who had also recieved etomidate, this is thought to be due cortisol production suppression and a blunting of the ACTH response. Etomidate does cause both of these effects, however, this is a transient effect. Per Ron Walls, MD, "there has been no credible study that goes against using etomidate in septic shock and...the greatest service we can do to our patients is to conduct the large, high quality trials needed to base our clinical practice on truly robust evidence."

Source: Ron Walls, MD; Annals of Emergency Medicine 2008;52(1):13-14

For myself, until this is sorted out, I will continue to use propofol in adult patients who are considerd possibly septic, and ketamine in children.

FWIW, before anyone asks, YES, at our instituion, the PA's can perform the sedation, as long as the attending is aware of what you are doing. Some attendings like to be present, others only want to know if there is a problem.


Anonymous said...

Why are many PAs more humble than NPs?

physasst said...

Hehe. Likely due to our training. PA's are trained, and consistently reminded that we are DEPENDENT providers, we need a physician to practice. We cannot be completely independent. We may see some patients independently, but there is some oversight, even if it is just a physician visiting once a month to review charts. NP's have a different goal. Completely independent practice, independent of any physician oversight. To me, this is dangerous. I feel that if you want completely independent practice, go to medical school.
That's my hunch at least.

SLP said...

physasst, I am really enjoying your blog, and your participation at the PA Forum. Keep writing!

I am set to begin PA school next January, and I just don't understand all the hoopla about this degree creep thing. PA's are designed to work in concert with physicians, and a Dsc behind your name will not make a difference when it comes to doing your job well. If the NP's want to practice independently, I say let them have at it. I have no interest in following in their footsteps. Competence has absolutely nothing to do with credentials, hence the fact that there are still top notch PA programs that are offering certificates and Bachelor degrees. I think a lot of people are put off by the word "dependent," as if this somehow equates to incompetence. That is not the case. I strongly believe in the partnership between physicians and PA's, as I think it makes for good medicine! I agree, if one wants to practice independently, the only option to do so should be medical school.