Etomidate

Aka: Etomidate, Amidate

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II. Precaution

  1. Procedural Sedation with Etomidate risks respiratory depression
  2. Monitoring is critical
    1. See Procedural Sedation and Analgesia

III. Mechanism

  1. Imidazole derivative
  2. Sedation agent with minimal Analgesic effect

IV. Contraindications

  1. Hypersensitivity to Etomidate
  2. Seizure Disorder
    1. Etomidate lowers the Seizure threshold and other agents are preferred
  3. Sepsis (risk of adrenal suppression)
    1. Avoid more than single use (e.g. induction for RSI appears safe)

V. Indication

  1. Procedural Sedation
    1. Indicated for ASA Physical Status Score 2 and 3
    2. Ketamine is usually preferred over Etomidate for sedation in children
    3. Historically agent of choice in adult Conscious Sedation
    4. Consider for sedation in hypotensive adult patient
      1. Otherwise Propofol is preferred adult Sedative due to greater efficacy and less Myoclonus than Etomidate
      2. Miner (2007) Ann Emerg Med 49(1): 15-22 [PubMed]
    5. Fracture or dislocation reduction
    6. Significant Wound Debridement
    7. Rectal Foreign Body
  2. Rapid Sequence Intubation (RSI)
    1. Most hemodynamically stable agent of induction medications
    2. RSI Induction Agent of choice overall
      1. However, as of 2023, concerns that Etomidate in RSI may be associated with increased mortality (see below)
    3. Specific scenarios in which it is especially preferred
      1. Trauma
      2. Congestive Heart Failure
      3. Hemorrhagic CVA with increased Blood Pressure

VI. Preparations

  1. Etomidate 2 mg/ml in 40 mg/20 ml prefilled syringe

VII. Dosing

  1. Induction prior to intubation (induction agent)
    1. Adult: 0.2 to 0.3 mg/kg (24 mg for an 80 kg adult) over 30-60 seconds IV
    2. Child: 0.2-0.3 mg/kg IV
      1. Ketamine may be preferred in children
  2. Procedural Sedation
    1. IV: 0.15 to 0.2 mg/kg
      1. Repeat 0.05 mg/kg every 3-5 minutes as needed

VIII. Pharmacokinetics

  1. Onset: Within 1 minute of IV dose
  2. Duration: 3-5 minutes (up to 15 minutes in some cases)
  3. Metabolized by liver
    1. Effect may be prolonged in liver failure

IX. Safety

  1. Pregnancy Category C
    1. Limited data in humans (but not generally recommended in pregnancy due to animal studies)
  2. Unknown safety in Lactation
    1. However, no delay needed in Lactation

X. Adverse Effects

  1. Nausea or Vomiting on emergence from agent (>10%)
    1. Consider pre-treatment with Anti-emetic, or have one available
    2. As always with Procedural Sedation, have suction with catheter on and ready for use
  2. Myoclonus or Muscle Twitching (20-40% of cases)
    1. Typical duration 30-120 seconds
    2. Administer Etomidate slowly over 90 seconds
    3. Management
      1. Bag-valve mask
      2. Fentanyl 0.5 mcg/kg IV OR Ketamine 0.5 mg/kg IV
    4. Prevention
      1. Pre-treatment is generally not recommended
      2. Pre-treatment with Fentanyl, Midazolam or Magnesium Sulfate has been used
  3. Respiratory depression (in up to 15% of cases)
    1. More common when combined with Opioid Analgesics
    2. Responds to Supplemental Oxygen
    3. Positive Pressure Ventilation is rarely needed
  4. Adrenal suppression (impacts survival in Sepsis)
    1. Consider Ketamine as alternative in Sepsis
    2. Not Clinically Significant if used in single dose as induction agent for intubation
      1. McPhee (2013) Crit Care Med 41(3): 774-83 [PubMed]
    3. Avoid in Sepsis for any longer use than brief
      1. Cuthbertson (2009) Intensive Care Med 35(11): 1868-76 [PubMed]
      2. Jabre (2009) Lancet 374(9686): 293-300 [PubMed]
  5. Possible increased mortality in Rapid Sequence Intubation (RSI)
    1. Meta-analysis number needed to harm (NNH): 31
    2. Kotani (2023) J Crit Care 77:154317 +PMID: 37127020 [PubMed]

XI. Resources

  1. Etomidate (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=b7ed5bf8-ba75-44dc-8f81-96b4ad5766be

XII. References

  1. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
  2. Kay (2015) Crit Dec Emerg Med 29(8): 11-17
  3. Brown (2005) Am Fam Physician 71:85-90 [PubMed]
  4. Vinson (2002) Ann Emerg Med 39:592-8 [PubMed]

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