We have many meds to choose from for emergency intubations. Sometimes we use propofol works well (status epilepticus, severe hypertension), sometimes versed/fentanyl (severe pain, head injured), methohexital (if you have a time machine and are intubating in 1999), thiopental (your toxicologist needs consults) and of course ketamine is basically always the best choice (if their BP is already too high just add propofol).

Etomidate is an ok drug, decent for intubation and sometimes helpful for sedation for imaging or even for a procedure (watch out for myoclonus). But I usually point out that there is always a better option than etomidate.

This meta-analysis of only 11 studies looked at etomidate vs other agents for intubations in critically ill patients. The summary seems to support the “always a better option than etomidate statement.” See results below, how about that number needed to harm?!

Results

We included 11 randomized trials comprising 2704 patients. We found that etomidate increased mortality (319/1359 [23%] vs. 267/1345 [20%]; risk ratio (RR) = 1.16; 95% confidence interval (CI), 1.01–1.33; P = 0.03; I² = 0%; number needed to harm = 31). The probabilities of any increase and a 1% increase (NNH ≤100) in mortality were 98.1% and 92.1%, respectively.

Conclusions

This meta-analysis found a high probability that etomidate increases mortality when used as an induction agent in critically ill patients with a number needed to harm of 31.