<unk>  suppresses corticosteroid synthesis in the adrenal cortex by reversibly inhibiting 11β-hydroxylase, an enzyme important in adrenal steroid production; it leads to primary adrenal suppression. Using a continuous<unk>  infusion for sedation of critically ill trauma patients in intensive care units has been associated with increased mortality due to adrenal suppression. Continuous intravenous administration of<unk>  leads to adrenocortical dysfunction. The mortality of patients exposed to a continuous infusion of<unk>  for more than 5 days increased from 25% to 44%, mainly due to infectious causes such as pneumonia. Because of<unk> -induced adrenal suppression, its use for patients with sepsis is controversial. Cortisol levels have been reported to be suppressed up to 72 hours after a single bolus of<unk>  in this population at risk for adrenal insufficiency. For this reason, many authors have suggested that<unk>  should never be used for critically ill patients with septic shock because it could increase mortality. However, other authors continue to defend<unk> 's use for septic patients because of<unk> 's safe hemodynamic profile and lack of clear evidence of harm. A study by Jabre et al. showed that a single dose of<unk>  used for Rapid Sequence Induction prior to endrotracheal intubation has no effect on mortality compared to ketamine even though<unk>  did cause transient adrenal suppression. In addition, a recent meta-analysis done by Hohl could not conclude that<unk>  increased mortality. The authors of this meta-analysis concluded more studies were needed because of lack of statistical power to conclude definitively about the effect of<unk>  on mortality. Thus, Hohl suggests a burden to prove<unk>  is safe for use in septic patients, and more research is needed before it is used. Other authors advise giving a prophylactic dose of steroids (e.g. hydrocortisone) if<unk>  is used, but only one small prospective controlled study in patients undergoing colorectal surgery has verified the safety of giving stress dose corticosteroids to all patients receiving<unk> . In a retrospective review of almost 32,000 people,<unk> , when used for the induction of anaesthesia, was associated 2.5-fold increase in the risk of dying compared with those given propofol. People given<unk>  also had significantly greater odds of having cardiovascular morbidity and significantly longer hospital stay. These results, especially given the large size of study, strongly suggest that, at the very least, clinicians should use<unk>  judiciously. However, given this is a retrospective study, it is clearly misinterpreting how<unk>  is typically used:<unk>  is a drug that is reserved for sicker patients whom may not tolerate the more severe hemodynamic liability (towards lower mean pressures) and, thus the bias of this retrospective study is inconclusive, at best. In people with traumatic brain injury,<unk>  use is associated with a blunting of an ACTH stimulation test. The clinical impact of this effect has yet to be determined. In addition, concurrent use of<unk>  with opioids and/or benzodiazepines, is hypothesized to exacerbate<unk> -related adrenal insufficiency. However, only retrospective evidence of this effect exists and prospective studies are needed to measure the clinical impact of this interaction.<unk>  is associated with a high incidence of burning on injection, postoperative nausea and vomiting, and superficial thrombophlebitis (with rates higher than propofol).
Etomidate
Metharbital
Sevoflurane
Esketamine
Remifentanil
Ketamine
Propofol
Methoxyflurane