Etomidate-- I think this needs its own thread

[Noyac]

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Probably not a good idea. Ketamine carries that risk of direct myocardial depression so in someone with maxed out catecholamine secretion who likely doesnt have much sympathetic reserve to rely on, I could see them doing poorly. Some versed should work nicely.

So are you saying that ketamine is going to have a worse effect in these pts?

In my experience, once they are "maxed" out all the induction agents are similiar within reason. You still can't give 200 mg of propofol to these pts and expect to have any vitals worth a crap. But Ketamine in an effective dose is just as good as etomidate or propofol or STP. It all depends on the amount and the situation.

 

[pgg]

The other problem with Etomidate is that it is a weak hypnotic and it causes frequent myoclonic activity if no muscle relaxant is given.

Off the thread's topic, but I've been using a ton of methohexital lately because of the propofol shortage. God do those patients wiggle and hiccup and twitch if you don't give muscle relaxant. I'd never realized it was so bad in that regard since the only time I ever used it as a resident was for ECTs, and they got succ.

 

[Planktonmd]

Off the thread's topic, but I've been using a ton of methohexital lately because of the propofol shortage. God do those patients wiggle and hiccup and twitch if you don't give muscle relaxant. I'd never realized it was so bad in that regard since the only time I ever used it as a resident was for ECTs, and they got succ.

And that's why Methohexital is preferred for ECT's, it does not suppress the brain's electrical activity as well as the other induction agents.

 

[Idiopathic]

So are you saying that ketamine is going to have a worse effect in these pts?

In my experience, once they are "maxed" out all the induction agents are similiar within reason. You still can't give 200 mg of propofol to these pts and expect to have any vitals worth a crap. But Ketamine in an effective dose is just as good as etomidate or propofol or STP. It all depends on the amount and the situation.

mainly just that none of the induction agents are good, but some people have a perception that ketamine is better because of the indirect sympathetic stimulation but many overlook the direct myocardial depressant effect which can be as bad as/worse than what is seen with other agents in the right situation.

 

[Hamhock]

mainly just that none of the induction agents are good, but some people have a perception that ketamine is better because of the indirect sympathetic stimulation but many overlook the direct myocardial depressant effect which can be as bad as/worse than what is seen with other agents in the right situation.

Can you please direct me to a source to read more about this?

...the way ketamine is 'indirectly' sympathetic stimulating and the 'cardiac depressent effects'

Although people are using ketamine all around me (and I will ask them too), I haven't used it as much and am not as familiar with it as with others.

Thanks, HH

 

[Hernandez]

The other problem with Etomidate is that it is a weak hypnotic and it causes frequent myoclonic activity if no muscle relaxant is given.

I've got a pitt cc traned attending whowears the treatment for etomidTe massager spasm is more etomisate as underdosing is a frequent cause, I can't find that in literature, you guys know?

 

[pgg]

And that's why Methohexital is preferred for ECT's, it does not suppress the brain's electrical activity as well as the other induction agents.

Right, I've just been surprised at how much movement they consistently have. It's much much worse than the myoclonus from other agents. With LMAs, at least 1/2 the time I end up giving some muscle relaxant to get rid of the hiccups to allow me to get some gas on.

 

[Idiopathic]

Can you please direct me to a source to read more about this?

...the way ketamine is 'indirectly' sympathetic stimulating and the 'cardiac depressent effects'

Although people are using ketamine all around me (and I will ask them too), I haven't used it as much and am not as familiar with it as with others.

Thanks, HH

Baby Miller is a start

 

[Idiopathic]

I've got a pitt cc traned attending whowears the treatment for etomidTe massager spasm is more etomisate as underdosing is a frequent cause, I can't find that in literature, you guys know?

ive never heard of any of those drugs you mention 😉

 

[Idiopathic]

while underdosing could certainly be a reason why you might have masseter spasm )i assume you are referring to jaw tightness making it difficult to get a blade in the mouth) the true treatment would be something like succinylcholine or rocuronium i would think.

i think the point can be made that sedation-only intubations are very difficult and should probably not be routinely performed.

 

[Hernandez]

ive never heard of any of those drugs you mention 😉

Damn iPhone and gorilla fingers don't mix. I didn't realize how bad that post was

 

[PianoGirl04]

Interesting discussion. I started out as an ER resident, and we used etomidate for all our intubations due to fear of propofol-induced hypotension in hypovolemic trauma patients or crashing septic patients. As a new CA-1 starting out in the midst of a propofol shortage, I find myself using etomidate a lot for routine cases. I wonder if we're doing our patients a disservice, or if it's generally OK for your basic CA-1 cases.

Either way, I find it slightly surreal that our chief resident has to draw up 10cc syringes of propofol and dole them out to each resident like food or gasoline rations. We basically get 20cc for the whole day. Sometimes we have a little bit of propofol but not enough for induction, and we combine it with a small dose of etomidate to make "propidate."

 

[Mman]

Interesting discussion. I started out as an ER resident, and we used etomidate for all our intubations due to fear of propofol-induced hypotension in hypovolemic trauma patients or crashing septic patients. As a new CA-1 starting out in the midst of a propofol shortage, I find myself using etomidate a lot for routine cases. I wonder if we're doing our patients a disservice, or if it's generally OK for your basic CA-1 cases.

Either way, I find it slightly surreal that our chief resident has to draw up 10cc syringes of propofol and dole them out to each resident like food or gasoline rations. We basically get 20cc for the whole day. Sometimes we have a little bit of propofol but not enough for induction, and we combine it with a small dose of etomidate to make "propidate."

Ever consider just turning on the sevo and letting them breathe themselves down after a decent dose of midaz and fent?

Etomidate blows for many reasons, but with routine use you will assuredly see more puking in the PACU.

 

[cchoukal]

I've been using etomidate almost exclusively for the past 3-4 weeks due to the propofol shortage (we're also out of succ and running out of phenylephrine, for what it's worth). I combine it with sevo and that seems to have gotten rid of the shakes and wiggles I was seeing without the sevo (maybe I was underdosing the etomidate, as well). Although my N is not enormous (probably 30 or 40 patients int he last few weeks), and my patients are veterans, I haven't seen much nausea. Less, in fact, than when I was a resident at a different institution.

 

[Mman]

Although my N is not enormous (probably 30 or 40 patients int he last few weeks), and my patients are veterans, I haven't seen much nausea. Less, in fact, than when I was a resident at a different institution.

I'm assuming the baseline PONV risk of an older, male, smoker (aka a veteran) is sufficiently low that even a reasonable increase in relative risk is not a very big absolute increase.

Patients at higher risk are definitely more likely to vomit in the PACU after etomidate compared to propofol.

 

[Arch Guillotti]

Sometimes we have a little bit of propofol but not enough for induction, and we combine it with a small dose of etomidate to make "propidate."

This seems silly and there seem to be a number of alternatives to this practice.

 

[lushmd]

As a new CA-1 starting out in the midst of a propofol shortage, I find myself using etomidate a lot for routine cases. I wonder if we're doing our patients a disservice, or if it's generally OK for your basic CA-1 cases.

I don't quite understand the question about etomidate being generally OK for basic CA-1 cases.

Either way, I find it slightly surreal that our chief resident has to draw up 10cc syringes of propofol and dole them out to each resident like food or gasoline rations.

Sounds like a crappy gig.

We basically get 20cc for the whole day. Sometimes we have a little bit of propofol but not enough for induction, and we combine it with a small dose of etomidate to make "propidate."

As you know, 20cc of propofol isn't going to take you very far. Mixing propofol and etomidate can work quite nicely in certain patients (I'll occasionally use a combination of lidocaine, propofol, and etomidate). As others have indicated, this is far from your only option though.

 

[PianoGirl04]

Ever consider just turning on the sevo and letting them breathe themselves down after a decent dose of midaz and fent?

Etomidate blows for many reasons, but with routine use you will assuredly see more puking in the PACU.

We have been breathing them down a bit...push a shortage-sized dose of propofol, then turn on the sevo while you're ventilating them. Haven't tried fent/midaz with this, but thanks for the suggestion!

Lushmd, to clarify my question, what I mean is that most of the cases we see as CA-1s are generally healthy people for routine elective surgeries rather than sick ICU players. What I'm wondering is whether the adrenal suppression caused by a single dose of etomidate in this population is clinically significant.

 

[dbiddy808]

People who are induced with etomidate are usually much sicker to begin with, so they are therefore more likely to die. As far as I know, there are no real studies (randomized, double-blinded) comparing its use in sick patients.

 

[ASA6]

We have been breathing them down a bit...push a shortage-sized dose of propofol, then turn on the sevo while you're ventilating them. Haven't tried fent/midaz with this, but thanks for the suggestion!

Lushmd, to clarify my question, what I mean is that most of the cases we see as CA-1s are generally healthy people for routine elective surgeries rather than sick ICU players. What I'm wondering is whether the adrenal suppression caused by a single dose of etomidate in this population is clinically significant.

An attending at my program does a prop/sevo induction for every case (im a ca-1). We push about 3 cc of propofol, then turn on the sevo. occasionally we will give another 2-3 cc of prop. I kind of like it, very smooth induction. Its his standard induction, but a great way to save your propofol!

 

[Idiopathic]

People who are induced with etomidate are usually much sicker to begin with, so they are therefore more likely to die. As far as I know, there are no real studies (randomized, double-blinded) comparing its use in sick patients.

pure presumption

 

[Idiopathic]

An attending at my program does a prop/sevo induction for every case (im a ca-1). We push about 3 cc of propofol, then turn on the sevo. occasionally we will give another 2-3 cc of prop. I kind of like it, very smooth induction. Its his standard induction, but a great way to save your propofol!

why even push any propofol? im gonna start doing one breath inductions.

 

[ASA6]

why even push any propofol? im gonna start doing one breath inductions.

good point. I suppose we could just do a complete mask induction. Would you do your 1 breath induction with a nitro/sevo combination? OR just prime the circuit with sevo? Do you see more hemodynamic stability in the OR after a 1 breath mask induction?

 

[Idiopathic]

yes, i do it like a peds induction, except i prime the circuit first, have them take three breaths, exhale all the way out, place the mask on, have them inhale deeply and hold it, sometimes they end up taking three breaths to go to sleep, and i think the literature says they get a little more hypotension than a gentle propofol induction (i.e. not 2/kg bolus) but i may be making that up. ive done less than ten and never had a problem.

i rarely do this though, may start with some of the new residents.