Pros and cons of etomidate--more discussion than evidence?

To evaluate the most recent publications in the long-lived debate over the use of etomidate in critically ill septic and trauma patients. Virtually without controversy is the hemodynamic stability after its use for induction of anesthesia on the one hand, and its negative effect on steroid synthesis on the other. The rating of the relative importance of both phenomena for the outcome of patients is however a highly controversial issue. We will discuss the most recent publications for two patient groups: trauma and critically ill septic patients. New meta-analyses and smaller studies have been published and might help us to weigh pros and cons in our patients. Sufficiently powered randomized controlled trials remain absent. The question whether supplemented corticosteroids after etomidate improve outcome is answered negatively by two recent studies. A single dose of etomidate supplies good intubation conditions with hemodynamic stability, but increases the risk for adrenal insufficiency. The relative importance of these characteristics for the patients' outcome remains controversial, as there is a lack of direct evidence. According to the principle 'nihil nocere', reasoning argues against its use, especially in septic patients or in those at major risk to develop septic complications (e.g. trauma patients).