Etomidate

Question 1

Etomidate

Dose for Induction for General Anesthesia in Adults

Answer 1

IV: Initial:

0.3 mg/kg

Range: 0.2 to 0.6 mg/kg over 30 to 60 seconds for induction of anesthesia.

Question 2

Etomidate

Dose for Procedural Sedation

Answer 2

IV: Initial:

0.1 to 0.2 mg/kg, followed by 0.05 mg/kg every 3 to 5 minutes as needed

Question 3

Etomidate

Dose for Cushing Syndrome

Answer 3

IV: Initial:

0.04 to 0.05 mg/kg/hour (usually equates to ~2.5 to 3 mg/hour).

Titrate to serum cortisol of 18 to 29 mcg/dL (500 to 800 nmol/L) in a physiologically stressed patient or 5.5 to 11 mcg/dL (150 to 300 nmol/L) in a non-physiologically stressed patient.

For complete blockade, titrate infusion rate to achieve a cortisol level <5.5 mcg/dL (<150 nmol/L).

Hydrocortisone IV is required if complete blockade desired rather than partial blockade (‘block and replace’)

Question 4

Etomidate

Are there renal impairment adjustments?

Answer 4

Dosing: Renal Impairment:

Adult
There are no dosage adjustments provided in the manufacturer’s labeling; use with caution, risk of toxicity is greater in patients with renal impairment.

Question 5

Etomidate

Are there hepatic impairment dosing adjustments / considerations?

Answer 5

There are no dosage adjustments provided in the manufacturer’s labeling.

Hepatic function impairment:
Vd and elimination half-life increase 2-fold in patients with cirrhosis compared with healthy subjects.

Question 6

Etomidate

Dose for Induction for General Anesthesia in Infants

Answer 6

IV: 0.2 to 0.3 mg/kg/dose as a single dose; dosing based on a prospective

Observational trial and two pharmacokinetic studies (Kay 1976; Lin 2012; Su 2015)

Question 7

Etomidate

Dose for Induction for General Anesthesia in Children <10

Answer 7

IV:

0.2 to 0.3 mg/kg/dose as a single dose (Coté 2013; Du 2015; Kay 1976)

Question 8

Etomidate

Dose for Induction for General Anesthesia in Children >10 and Adolescents

Answer 8

Usual dose: IV:

0.3 mg/kg/dose as a single dose; range: 0.2 to 0.6 mg/kg/dose

Question 9

Etomidate

Procedural Sedation Dose for >6 mo, children, adolescents

Answer 9

Infants ≥6 months, Children, and Adolescents
IV: Usual initial dose: 0.2 mg/kg/dose prior to procedure

(reported range: 0.1 to 0.4 mg/kg/dose); repeat doses may be needed depending on patient response and duration of the procedure; repeat doses vary in the literature and

Range from 0.1 to 0.2 mg/kg/dose

Reported total dose ranged from 0.3 to 0.6 mg/kg/procedure

Question 10

Does Etomidate have analgesic properties?

Answer 10

Etomidate does not have analgesic properties

Question 11

Etomidate RSI dose

1. Weight based?
2. Max dose?

Infants, Children, Adolescents

Answer 11

Children, and Adolescents

IV, Intraosseous: 0.2 to 0.4 mg/kg/dose as a single dose

Maximum dose: 20 mg/dose

Question 12

Can you administer Etomidate with Lidocaine?

Answer 12

Solution is highly irritating; avoid administration into small vessels; in some cases, preadministration of lidocaine may be considered.

Question 13

What is the most common side effect for Central nervous system for Etomidate?

Answer 13

Central nervous system: Myoclonus (33%)

Myoclonus refers to a quick, involuntary muscle jerk.

Question 14

What is the most common side effect for Endocrine for Etomidate?

Answer 14

Adrenal suppression

Question 15

What is the most common side effect for GI for Etomidate?

Answer 15

Nausea, vomiting (on emergence from anesthesia)

10% get Hiccups

Question 16

What is the most common side effect for MSK for Etomidate?

Answer 16

Musculoskeletal disease (transient skeletal movements)

Question 17

What is the most common side effect for Ophthalmological for Etomidate?

Answer 17

Ophthalmic: Nystagmus

Question 18

What enzyme does Etomidate inhibit?

Answer 18

Etomidate inhibits 11-B-hydroxylase, an enzyme important in adrenal steroid production.

A single induction dose blocks the normal stress-induced increase in adrenal cortisol production for 6 to 8 hours, up to 24 hours in elderly and debilitated patients.

Question 19

Are there concerns for single dose induction for adrenal suppression?

Answer 19

No increase in mortality has been identified with a single dose for induction of anesthesia (McPhee 2013).

Question 20

What special population and pathology do you have to consider with Etomidate?

Answer 20

• Elderly: May induce cardiac depression in elderly patients, especially those with hypertension; may require lower doses.

Question 21

Does Etomidate Cross the Placenta?

Answer 21

Etomidate crosses the placenta (Esener 1992; Gregory 1991).

Question 22

Is Etomidate used for induction for Caesarian deliveries?

Answer 22

Use of etomidate for induction of anesthesia prior to cesarean delivery has been described (Downing 1979; Houlton 1978; Regaert 1984). However, other agents may be more commonly used

Question 23

Is Etomidate Present in Breast Milk?

Answer 23

Etomidate is present in breast milk (Esener 1992).

Following use of etomidate as an induction agent in 40 women undergoing cesarean delivery, etomidate was present in the colostrum at both 30 minutes and 2 hours after maternal injection

Etomidrate was not present in breast milk 4 hours after the maternal dose (Esener 1992).

Question 24

Does the Etomidate Manufacturer recommend using Etomidate in a breast feeding patient?

Answer 24

The manufacturer recommends that caution be exercised when administering etomidate to breastfeeding females; however, use is considered acceptable (Dalal 2014).

Question 25

Etomidate

Mechanism of Action

Answer 25

Ultra-short-acting nonbarbiturate general anesthetic (benzylimidazole) used for rapid induction of anesthesia with minimal cardiovascular effects

Question 26

Etomidate

Effects on neuromonitoring?

Answer 26

Produces EEG burst suppression at high doses.

Question 27

Etomidate

Onset of Action

Answer 27

30-60 seconds

Question 28

Etomidate

Peak Effect

Answer 28

1 minute

Question 29

Etomidate

Duration

Answer 29

Duration:

Dose dependent:
2 to 3 minutes (0.15 mg/kg dose);
3 to 5 minutes (0.3 mg/kg dose)

Rapid recovery is due to rapid redistribution

Question 30

Etomidate

Volume of Distribution

Answer 30

2 to 4.5 L/kg

Question 31

Etomidate

Protein Binding

Answer 31

Protein binding:

76%; decreased protein binding resulting in an increased percentage of “free” etomidate in patients with renal failure or hepatic cirrhosis

Question 32

Etomidate

Metabolism

Answer 32

Hepatic and plasma esterases

Question 33

Etomidate

Half Life

Answer 33

2.6 to 3.5 hours

Question 34

Etomidate

Time to peak effect?

Answer 34

Serum = 7 minutes

Question 35

Etomidate

Excretion

Answer 35

Urine ~75%

80% as metabolite; 2% as unchanged drug

Question 36

Etomidate

Are there geriatric dosing adjustments / considerations?

Answer 36

Vd
Total clearance
Plasma protein binding are decreased in elderly patients