A novel use of etomidate for intentional adrenal suppression to control severe hypercortisolemia in childhood*

OBJECTIVE: To describe a novel use for etomidate in critically ill children. Etomidate induction of anesthesia in children is controversial due to adrenal suppression; we review this controversy and describe a therapeutic application of this "side effect" using a continuous etomidate infusion in pediatric intensive care to deliberately suppress critically elevated endogenous cortisol. DESIGN: Case report. SETTING: A tertiary pediatric intensive care unit. PATIENT: A 6-year-old boy with severe, life-threatening hypercortisolemia secondary to Cushing's disease. INTERVENTIONS: Admission to pediatric intensive care unit, before bilateral adrenalectomies, to facilitate etomidate infusion to reduce endogenous hypercortisolemia, as first-line treatment with metyrapone and ketoconazole had failed. MEASUREMENT AND MAIN RESULTS: Continuous intravenous etomidate at 0.08 mg/kg/hr decreased serum cortisol from 1200 to 250 nmol/L within 48 hours. Once etomidate and hydrocortisone therapy provided stable serum cortisol levels, bilateral laparoscopic adrenalectomies were undertaken. A perioperative cortisol surge was seen, but to a much lower peak than expected without prior etomidate suppression. CONCLUSIONS: The adrenal suppression caused by etomidate, so controversial in the care of the critically ill at present, can be therapeutically used for short-term control of severe hypercortisolemia in children.