Dose of steroids after Etomidate?

[neuroride]

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Anybody use a single dose of solumedrol after induction with Etomidate for fear of adrenocortical suppression?

I hadn't heard this done after only one dose. Had a pulmonologist tell me that he does every time he does an induction with Etomidate.

Also, this patient was in the ICU with ARDS.

 

[militarymd]

ARDS network has recommendations on steroids in ARDS....along with SCCM's recommendations on supraphysiologic doeses of steroids for critically ill patients.

I would not have given it for the etomidate, but then I wouldn' have used etomidate.....but then this patient will likely receive some steroids at some point during his hospital course...

so....doesn't matter.

 

[coprolalia]

[sarcasm]

Everyone should know that the only good use for etomidate is "conscious" sedation in the ED.

[/sarcasm]

🙄

-copro

 

[coprolalia]

I would not have given it for the etomidate, but then I wouldn' have used etomidate.....

👍

Exactly.

-copro

 

[Noyac]

Yep, never use etomidate.

 

[leviathan]

Why not just use propofol?

 

[Planktonmd]

Why not just use propofol?

Your profile says you are a medical student so I am assuming that you don't know the history behind using Etomidate in hemodynamically unstable patients.
As you know almost all the medications we use for induction of GA exacerbate hypotension by a negative inotropic effect on the heart and vasodilatation.
Etomidate is an exception to this rule because it can actually induce anesthesia with minimal effect on hemodynamics if the volume status is not horrible.
This is why Etomidate became popular for induction in critically ill patients and trauma patients.
The problem is that Etomidate causes adrenal suppression and recently there has been some data suggesting that even one dose of Etomidate can increase the mortality in septic patients, so, many people started abandoning Etomidate but it continues to be widely used for lack of alternative and because people are so used to it.

 

[leviathan]

Your profile says you are a medical student so I am assuming that you don't know the history behind using Etomidate in hemodynamically unstable patients.
As you know almost all the medications we use for induction of GA exacerbate hypotension by a negative inotropic effect on the heart and vasodilatation.
Etomidate is an exception to this rule because it can actually induce anesthesia with minimal effect on hemodynamics if the volume status is not horrible.

I am somewhat familiar with the hemodynamics of etomidate/other GAs as I did a few courses in anaesthesiology back when I was an RT student. I just thought propofol is generally a better option unless you are concerned about the hemodynamic status of the patient.

 

[coprolalia]

I am somewhat familiar with the hemodynamics of etomidate/other GAs as I did a few courses in anaesthesiology back when I was an RT student. I just thought propofol is generally a better option unless you are concerned about the hemodynamic status of the patient.

Yes. Correct.

But, I think the problem is more the relative overdoses people give of induction agents. Often, you can get the patient amnestic (which is the goal here) with half the dose frequently used, this especially includes etomidate.

People that still like to use etomidate, at least the ones I know, still give WAY too much in my opinion.

Point is, in the trauma patient - especially the head injured one - I don't knee-jerk grab etomidate. I find that thiopental works just fine, provided you don't (again) overdose it. And, you probably get the best "bang-for-your-buck" on neuro protection as well with thiopental, not that etomidate is necessarily bad in that regard. Likewise, I've not had a problem with crashing a trauma patient's hemodynamics with thiopental because I give about 1/4th the dose you normally would. Trust me, they ain't gonna remember **** (especially if they bonked their head) provided you keep 'em adequately anesthetized after you get the tube in.

Just my $0.02.

-copro

 

[Noyac]

Yes. Correct.

But, I think the problem is more the relative overdoses people give of induction agents. Often, you can get the patient amnestic (which is the goal here) with half the dose frequently used, this especially includes etomidate.

People that still like to use etomidate, at least the ones I know, still give WAY too much in my opinion.

Point is, in the trauma patient - especially the head injured one - I don't knee-jerk grab etomidate. I find that thiopental works just fine, provided you don't (again) overdose it. And, you probably get the best "bang-for-your-buck" on neuro protection as well with thiopental, not that etomidate is necessarily bad in that regard. Likewise, I've not had a problem with crashing a trauma patient's hemodynamics with thiopental because I give about 1/4th the dose you normally would. Trust me, they ain't gonna remember **** (especially if they bonked their head) provided you keep 'em adequately anesthetized after you get the tube in.

Just my $0.02.

-copro

I haven't seen thiopental since residency.👍

 

[seinfeld]

I hate when non anesthesia people are talking about how they had to use etomidate blah, blah blah, all i think to myself it that except for some better stability in BP at the time of induction it side effect profile is horrible.

I agree with previous posts about the doses of propfol often used. When was finishing my CA-3 year i would push my own drugs and i would find attendings always amazed at how little it took to put the patient to sleep. My approach to an unstable patient for intubation is a little midazolam and a little propofol.

 

[Mista Suprane]

i have an attending that uses propofol for these cases, but in a lower dose (so like 1mg/kg as opposed to 2mg/kg), and then also pushes ketamine 1mg/kg to add to the induction but also to theoretically counteract the hypotension that you might see with propofol only. i suppose you could even mix them in one syringe.

i've only worked with him a few times, but it seemed to me that there was very little variation in BP. of course maybe that was just because he was telling me that's what it would do. 🙂

anyone else use this technique or something similar?

 

[Noyac]

i have an attending that uses propofol for these cases, but in a lower dose (so like 1mg/kg as opposed to 2mg/kg), and then also pushes ketamine 1mg/kg to add to the induction but also to theoretically counteract the hypotension that you might see with propofol only. i suppose you could even mix them in one syringe.

i've only worked with him a few times, but it seemed to me that there was very little variation in BP. of course maybe that was just because he was telling me that's what it would do. 🙂

anyone else use this technique or something similar?

Mix 100-200 mcg neo in the propofol.

 

[militarymd]

Mix 100-200 mcg neo in the propofol.

I do the same thing

 

[neuroride]

Thanks for the replies guys. Etomidate for someone with hypotension is my first idea as I am only an anesthesia intern.

We do all of the emergent intubations for the hospital at night and I am not totally comfortable yet to use smaller doses of propofol. Most of my intubations have been patients in decompensated shock with crappy access or just not enough fluids on board.

Propofol is great but at this point for me I am still gun-shy of totally bottoming out somone's pressure during an induction even with lower dosing.

 

[dfk]

i have an attending that uses propofol for these cases, but in a lower dose (so like 1mg/kg as opposed to 2mg/kg), and then also pushes ketamine 1mg/kg to add to the induction but also to theoretically counteract the hypotension that you might see with propofol only. i suppose you could even mix them in one syringe.

i've only worked with him a few times, but it seemed to me that there was very little variation in BP. of course maybe that was just because he was telling me that's what it would do. 🙂

anyone else use this technique or something similar?

20mg of ketamine in 200mg of prop works well for induction.

 

[Noyac]

20mg of ketamine in 200mg of prop works well for induction.

Thats not enough.

Are you giving the whole dose?

 

[dfk]

Thats not enough.

Are you giving the whole dose?

not if i'm not using whole syringe.
haven't done it too much, so still playing with the numbers.
from what i've done thus far though, it has worked alright.

what do you think would be a more "appropriate" ketamine dose then?

 

[Noyac]

not if i'm not using whole syringe.
haven't done it too much, so still playing with the numbers.
from what i've done thus far though, it has worked alright.

what do you think would be a more "appropriate" ketamine dose then?

Well instead of giving you the answer lets see if you already know it. How much have you used ketamine? Sedation or GA?

You say you are not giving the whole syringe, so how much you gonna give? How much ketamine is that gonna add up to?

BTW, I get your sarcasm.

 

[dfk]

Well instead of giving you the answer lets see if you already know it. How much have you used ketamine? Sedation or GA?

You say you are not giving the whole syringe, so how much you gonna give? How much ketamine is that gonna add up to?

BTW, I get your sarcasm.

actually, there wasn't any sarcasm there.
but, if you want some, i'm sure i can muster some for you.

ketamine works out to 1 mg/ml in my concoction.
so, however many mils of prop i give, that will
also be how many mgs of ketamine.
i'm not using it for maintenance.
just to help offset the prop side effects.

i'm by no means a pro with ketamine, just looking
to use it more is all.

i hope this clears up any cloudy offerings you might have received.

 

[Noyac]

actually, there wasn't any sarcasm there.
but, if you want some, i'm sure i can muster some for you.

ketamine works out to 1 mg/ml in my concoction.
so, however many mils of prop i give, that will
also be how many mgs of ketamine.
i'm not using it for maintenance.
just to help offset the prop side effects.

i'm by no means a pro with ketamine, just looking
to use it more is all.

i hope this clears up any cloudy offerings you might have received.

Ok fine.

Heres' how I would do it. I don't use ketamine to "offset" the propofol effects. I use phenylephrine for this as described above. If I were wanting to decrease my propofol induction dose with some added K then I would make the K conc more like 2-3mg/cc of propofol. I'd then give 5-10 cc's depending on the pt of this mixture. I think your 1mg/cc conc is too small.

 

[SleepIsGood]

Ok fine.

Heres' how I would do it. I don't use ketamine to "offset" the propofol effects. I use phenylephrine for this as described above. If I were wanting to decrease my propofol induction dose with some added K then I would make the K conc more like 2-3mg/cc of propofol. I'd then give 5-10 cc's depending on the pt of this mixture. I think your 1mg/cc conc is too small.

Never used Ketamine for induction with propofol....I think you would use 1mg per 10 mg of propofol for "Ketafol" (when you are doing sedation). So I would have to agree with Noy here in that maybe 1 mg/ml of propofol may be too low.

Dude why are you guys putting neo into propofol to offset the side effects? Seems like too much work and extra $$ spent. As someone stated earlier, why not just give 1/2 the dose of propofol or just 'titrate' to effect. That way you can save on the Neo vial? I'm just looking at it fiscally, just seems like lots of $$ if you look at how many pts a day one operates on.🙄

 

[militarymd]

Never used Ketamine for induction with propofol....I think you would use 1mg per 10 mg of propofol for "Ketafol" (when you are doing sedation). So I would have to agree with Noy here in that maybe 1 mg/ml of propofol may be too low.

Dude why are you guys putting neo into propofol to offset the side effects? Seems like too much work and extra $$ spent. As someone stated earlier, why not just give 1/2 the dose of propofol or just 'titrate' to effect. That way you can save on the Neo vial? I'm just looking at it fiscally, just seems like lots of $$ if you look at how many pts a day one operates on.🙄

I won't flame ya...because I know you're a resident, and you still have to get a few more under your belt...but some patients just need it.


I have had one patient literally arrest after 10 mg (that's right 1 cc) of propofol.......some patients are pretty sick...and depending on the circumstances, they can "look" OK until you give something...

I know what some will say...why not just use "brutane"...but the dude who arrested with 10 mg of propofol looked pretty good before I gave the 10 mg.....and it wasn't to put him to sleep....it was just to sedate him a little as we moved him onto the OR table.....pre 10 mg vitals...hr 120...bp 110/70...or something like that...had palpable pulses...with a leaking AAA..

10 mg....and pulses went away...

 

[Noyac]

Dude why are you guys putting neo into propofol to offset the side effects? Seems like too much work and extra $$ spent. As someone stated earlier, why not just give 1/2 the dose of propofol or just 'titrate' to effect. That way you can save on the Neo vial? I'm just looking at it fiscally, just seems like lots of $$ if you look at how many pts a day one operates on.🙄

I wasn't clear enough. I put 100-200 mcg of neo in the 1/2 dose of propofol. Its not so I can get all 20 cc of propofol in the pt. Its so I don't get the drop in BP with the smaller dose.

 

[jennyboo]

why not just give 1/2 the dose of propofol or just 'titrate' to effect. That way you can save on the Neo vial?

Nuh-uh, these aren't the patients you want to save a few cents on by not cracking the phenylephrine.

These are the patients for whom you hook up the pressors and even consider starting them before your induction, and happily waste the drug if you never end up using them.

You can use half the dose of propofol, wait a little longer and save $ on phenylephrine or ephedrine if they're 20 years old and having a knee scope.... But say, in shock with bad CAD and poor EF and severe AS and maybe some dead gut -- not worth a few cents IMO.

 

[Noyac]

Nuh-uh, these aren't the patients you want to save a few cents on by not cracking the phenylephrine.

These are the patients for whom you hook up the pressors and even consider starting them before your induction, and happily waste the drug if you never end up using them.

You can use half the dose of propofol, wait a little longer and save $ on phenylephrine or ephedrine if they're 20 years old and having a knee scope.... But say, in shock with bad CAD and poor EF and severe AS -- not worth a few cents IMO.

Well said jenny. Someone is moving along just fine in residency (I think your still a resident). 👍

 

[SleepIsGood]

Nuh-uh, these aren't the patients you want to save a few cents on by not cracking the phenylephrine.

These are the patients for whom you hook up the pressors and even consider starting them before your induction, and happily waste the drug if you never end up using them.

You can use half the dose of propofol, wait a little longer and save $ on phenylephrine or ephedrine if they're 20 years old and having a knee scope.... But say, in shock with bad CAD and poor EF and severe AS and maybe some dead gut -- not worth a few cents IMO.

Ok ok...in really sick pts that's a totally different story. In a young healthy 20yo, I just don't see the point.👍

 

[ZA_Gasman]

If I may add my 2c worth as well.... I find that ketamine isn't that good in the patient who is in extremis, as they are pretty much maximally SNS stimulated anyway. On the odd occasion we've used Ketamine in these situations it hasn't been any better than Etomidate or a judicious dose of Propofol.

If a patient is gonna crash on induction, they'll do it with just about any induction agent. That is why I agree with Jennyboo. Pressors/Inotropes on before induction, and then an appropriate dose of whatever poison you like. (with the exception of Etomidate😛)

 

[Planktonmd]

Ok ok...in really sick pts that's a totally different story. In a young healthy 20yo, I just don't see the point.👍

The discussion was about an alternative to using Etomidate, and you wouldn't use Etomidate in a young healthy 20 Y/O would you?

 

[Noyac]

If I may add my 2c worth as well.... I find that ketamine isn't that good in the patient who is in extremis, as they are pretty much maximally SNS stimulated anyway.

Yep👍