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Etomidat zur „rapid sequence induction“ bei schwerem Trauma

Etomidate for rapid sequence induction in patients with major trauma

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Zusammenfassung

Das Anästhetikum Etomidat ist zur Einleitung einer Notfallnarkose umstritten. Obwohl es wegen seiner Kreislaufneutralität geschätzt wird, begünstigt es die Entstehung einer Nebenniereninsuffizienz. Der Gebrauch wird daher in der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung der Deutschen Gesellschaft für Unfallchirurgie nicht empfohlen. Die Leitlinien der Eastern Association for the Surgery of Trauma und des Advanced Trauma Life Support® schließen den Gebrauch hingegen nicht aus. Beide Leitlinien basieren auf vergleichbarer Evidenz, die in der hier vorgenommenen Rückschau dargestellt wird. Ein klarer Nachweis von schädlichen Effekten konnte demnach bisher nicht erbracht werden. Es besteht jedoch Konsens darüber, dass aussagekräftige Studien für eine abschließende Beurteilung bisher fehlen.

Wir führten daher in Pubmed® eine strukturierte Literatursuche nach neuen Studien durch, die bei Fertigstellung der o. g. Leitlinien noch nicht verfügbar waren und identifizierten 14 Studien (4 systematische Reviews/Metaanalysen, 1 systematisches Review, 3 randomisierte kontrollierte Studien, 3 Kohortenstudien und 3 Post-hoc-Analysen), die in diesem Artikel zusammengefasst dargestellt werden. Jedoch kann auch keine dieser aktuellen Studien Nutzen und Risiken einer einmaligen Bolusgabe von Etomidat zur Einleitung einer Notfallnarkose bei Traumapatienten mit ausreichend guter Aussagekraft im Hinblick auf Überleben, Komplikationen und Behandlungsverlauf aufklären. Zusammenfassend bleibt trotz neuer Evidenz weiterhin unklar, welche der beiden widersprüchlichen Empfehlungen für die tägliche Praxis beachtet werden sollte. Etomidat sollte bei Verfügbarkeit alternativer Medikamente, deren Anwendung sicher beherrscht wird, nur im Rahmen von kontrollierten Studien eingesetzt werden. Auf eine etomidatinduzierte Nebenniereninsuffizienz ist dann zu achten.

Abstract

The use of etomidate for inducing emergency anesthesia is controversial. Although it is known for its circulatory neutrality, it promotes the occurrence of adrenal insufficiency. Thus its use is not recommended in the S3 Guideline on Treatment of Patients with Severe and Multiple Injuries by the German Trauma Society. The guidelines of the Eastern Association for the Surgery of Trauma and the Advanced Trauma Life Support® manual do not rule out its use. Both guidelines are based on comparative evidence shown in this review: Clear evidence for harmful effects could not be supplied. There is consensus on the lack of significant studies hitherto for a concluding judgment. We carried out a structured literature search in Pubmed® for current studies that had not been published at the time the guideline was completed and identified 14 studies (four systematic reviews/meta-analyses, one non-systematic review, three randomized controlled trials, three cohort studies, and three post hoc analyses), which are summarized in the following. None of the current studies is able to clarify the benefits and risks of a one-time bolus dose of etomidate for inducing emergency anesthesia in trauma patients with regards to survival, complications, and course of treatment. In conclusion, despite new evidence, it is still unclear which of the original controversial recommendations should be adhered to in day-to-day practice. As long as there is an alternative medication that the provider knows how to handle carefully, the use of etomidate should be restricted to controlled clinical trials. In this case, an etomidate-induced adrenal insufficiency should be considered.

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Danksagung

Die Autoren danken Frau Carolin Braun für die Assistenz bei der Erstellung des Manuskripts.

Einhaltung ethischer Richtlinien

Interessenkonflikt. H. Trentzsch, M. Münzberg, J. Luxen, B. Urban und S. Prückner geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag enthält keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Institut für Notfallmedizin und Medizinmanagement (I N M), Campus Innenstadt, Klinikum der Universität München, Schillerstr. 53, 80336, München, Deutschland

    H. Trentzsch, J. Luxen, B. Urban & S. Prückner

  2. BG-Unfallklinik Ludwigshafen, Ludwigshafen, Deutschland

    M. Münzberg

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  1. H. Trentzsch
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  2. M. Münzberg
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Correspondence to H. Trentzsch.

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Trentzsch, H., Münzberg, M., Luxen, J. et al. Etomidat zur „rapid sequence induction“ bei schwerem Trauma. Notfall Rettungsmed 17, 521–535 (2014). https://doi.org/10.1007/s10049-014-1899-7

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