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Medication Safety Issues
Sound-alike/look-alike issues:
Etomidate may be confused with etidronate
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
Pronunciation
(e TOM i date)
U.S. Brand Names
Generic Available
Yes
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use: Labeled Indications
Induction and maintenance of general anesthesia
Use: Unlabeled/Investigational
Sedation for diagnosis of seizure foci
Pregnancy Risk Factor
C
Contraindications
Hypersensitivity to etomidate or any component of the formulation
Warnings/Precautions
Concerns related to adverse effects:
• Adrenal steroid production: 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 4-8 hours, up to 24 hours in elderly and debilitated patients. Continuous infusion of etomidate for sedation in the ICU may increase mortality because patients may not be able to respond to stress. No increase in mortality has been identified with a single dose for induction of anesthesia. Consider exogenous corticosteroid replacement in patients undergoing severe stress.
Special populations:
• Pediatrics: Safety and efficacy have not been established in children <10 years of age.
Adverse Reactions
>10%:
Endocrine & metabolic: Adrenal suppression
Gastrointestinal: Nausea, vomiting on emergence from anesthesia
Local: Pain at injection site (30% to 80%)
Neuromuscular & skeletal: Myoclonus (33%), transient skeletal movements, uncontrolled eye movements
1% to 10%: Hiccups
<1%: Apnea, arrhythmia, bradycardia, cortisol synthesis decreased, hyper-/hypotension, hyper-/hypoventilation, laryngospasm, tachycardia
Drug Interactions
There are no known significant interactions.
Storage
Store at room temperature.
Compatibility
Y-site administration: Compatible: Alfentanil, atracurium, atropine, doxacurium, ephedrine, fentanyl, lidocaine, lorazepam, midazolam, mivacurium, morphine, pancuronium, phenylephrine, succinylcholine, sufentanil. Incompatible: Ascorbic acid, vecuronium.
Mechanism of Action
Ultrashort-acting nonbarbiturate hypnotic (benzylimidazole) used for the induction of anesthesia; chemically, it is a carboxylated imidazole which produces a rapid induction of anesthesia with minimal cardiovascular effects; produces EEG burst suppression at high doses
Pharmacodynamics/Kinetics
Onset of action: 30-60 seconds
Peak effect: 1 minute
Duration: 3-5 minutes; terminated by redistribution
Distribution: Vd: 2-4.5 L/kg
Protein binding: 76%;
Metabolism: Hepatic and plasma esterases
Half-life elimination: Terminal: 2.6 hours
Dosage
Children >10 years and Adults: I.V.: Initial: 0.2-0.6 mg/kg over 30-60 seconds for induction of anesthesia; maintenance: 5-20 mcg/kg/minute
Administration: I.V.
Administer I.V. push over 30-60 seconds. Solution is highly irritating; avoid administration into small vessels; in some cases, preadministration of lidocaine may be considered.
Monitoring Parameters
Cardiac monitoring and blood pressure required
Additional Information
Etomidate decreases cerebral metabolism and cerebral blood flow while maintaining perfusion pressure. Premedication with opioids or benzodiazepines can decrease myoclonus. Etomidate can enhance somatosensory evoked potential recordings.
Anesthesia and Critical Care Concerns/Other Considerations
Etomidate 2 mg/mL contains propylene glycol 362.6 mg/mL (35% v/v).
Clinical Pearls/Comments: In critically-ill patients, a single dose of etomidate will produce adrenal insufficiency, which may contribute to increased hospital and ICU lengths of stay and an increased number of ventilator days (Dellinger, 2008; Hildreth, 2008). During electroconvulsive therapy, etomidate prolongs seizure duration but is associated with increased postprocedure side effects (confusion, nausea, vomiting) (Ding, 2002).
Evidence-Based Information: Etomidate decreases cerebral metabolism and cerebral blood flow while maintaining perfusion pressure; can enhance somatosensory and motor-evoked potential recordings. Premedication with opioids or benzodiazepines can decrease myoclonus.
Cardiovascular Considerations
Etomidate is a relatively safe anesthetic for use in patients with stable cardiovascular disease.
Dental Health: Effects on Dental Treatment
Key adverse event(s) related to dental treatment: Hiccups.
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
None reported
Mental Health: Effects on Psychiatric Treatment
None reported
Nursing: Physical Assessment/Monitoring
Assess other medications patient may be taking for effectiveness and interactions. Assess results of laboratory tests, therapeutic effect, and adverse/toxic effects, particularly for signs of adrenal insufficiency (including hypotension, hyperkalemia). Monitor respiratory status (for conscious sedation, includes pulse oximetry), cardiovascular status, CNS status (when used for procedures monitor sedation score); cardiac monitor and blood pressure monitor required. Infusion site should be monitored closely due to potential irritation (see Administration).
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution: 2 mg/mL (10 mL, 20 mL) [contains propylene glycol 35% v/v]
References
Dellinger RP, Levy MM, Carlet JM, et al, “Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008,” Intensive Care Med, 2008, 34(1):17-60. Available at http://www.survivingsepsis.org/system/files/images/2008_20International_20SSC_20Guidelines_1_.pdf
Ding Z and White PF, “Anesthesia for Electroconvulsive Therapy,” Anesth Analg, 2002, 94(5):1351-64.
Hildreth AN, Mejia VA, Maxwell RA, et al, “Adrenal Suppression Following a Single Dose of Etomidate for Rapid Sequence Induction: A Prospective Randomized Study,” J Trauma, 2008, 65(3):573-9.
International Brand Names
Lexi-Comp.com
Last full review/revision July 2009
Content last modified July 2009
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