Etomidate Shortage & Alternatives

[AquaMarine78]

At risk of embarrassment (due to my profound lack of anesthetic knowledge), I am going to ask a (hopefully) simple question to the experts...

I work in a pharmacy and have been asked to compile a list of alternatives to etomidate for use in rapid sequence intubation. After reading some of the forums regarding etomidate, I am aware this drug is not favored by many of you. However, I have a fair amount of unhappy providers in urgent care and ED asking me "well what should I use instead?" It appears that this drug has become a favorite for RSI among many non-anesthesiology providers as well as some intensivists, particularly in hemodynamically unstable and septic patients.

I am CERTAINLY not an expert and often my answer is "whatever you feel most comfortable using... propofol, midazolam + fentanyl, ketamine, etc." Although I am learning, I don't know the intricacies of which agent in preferred in what situations and why (nor am I expecting you to provide this information).

I was hoping one or two of you kind souls could list a few of your favorites / alternatives (with dosage). I will review this information with our anesthesiologists for confirmation and then place a paper in the RSI kit providing this information. Even a few drugs with dosages would be appreciated, I do not expect you to list indications/contraindications, etc.

Thanks you for your help.

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[Idiopathic]

at the risk of sounding like an ass (not my intention)

Miller's Anesthesia (7th edition) Chapter 26 is an invaluable resource, although perhaps a little too technical for many, it does provide excellent background on nearly every intravenous anesthetic. Anyone administering these medications should be familiar with this information,

or, alternatively

taken from Irwin & Rippe's Intensive Care Medicine (6th edition) Chapter 1, but this is very superficial

 

[AquaMarine78]

Thank you much for the information. Very helpful. One further question - is phenylephrine frequently (or infrequently) used empirically in combination with propofol to attenuate hypotension?

I imagine this is probably avoided in cardiac patients, but would like to gain a feel for how often this is actually done in practice (during RSIs).

Thanks again, cheers.

 

[jwk]

We've nearly abandoned using etomidate even before the shortage. A few people still like it - most don't.

A little Versed and NMB of choice works well. A greatly reduced dose of propofol and NMB works well also, and has been our main alternative to etomidate.

We use phenylephrine fairly liberally if needed - we stock it in pre-filled 10cc, 50mcg/cc syringes. I've noticed a couple people mention mixing it with propofol, which I think is voodoo. Give what you need, when you need it.

 

[BobBarker]

We have been using Zima here.

 

[urge]

Brutaine also works well.

 

[cchoukal]

We have been using Zima here.

They still make that stuff? Awesome.

Agree with the others that etomidate has risks and few benefits over other carefully selected/dosed induction agents. I think it's helpful to consider the goals of induction, in general, compared to the goals of induction for RSI.

In general, we're looking for amnesia, analgesia, hypnosis, immobility, and good intubating conditions very quickly.

In the proposed ED emergent/trauma RSI, the focus is on good intubating conditions very quickly and the HOPE for amnesia. That's not to say it's okay to be cavelier with recall, but let's face it: if the the situation is dire, the goalposts change. If it's not that dire (it seldom is), there's time to be careful and make intelligent choices.

 

[BobBarker]

We have some old stock from the late 90s we have been burning through. Our pedi crew has been using it as well. They just pop in the jollyrancher of choice to make it a little more kid friendly.

 

[dhb]

Ketamine

 

[periopdoc]

dhb beat me to it.

For your non-anesthesiologist physicians, ketamine is probably the best alternative. Similar hemodynamic stability, with reasonable effectiveness. Just be sure to titrate in some midazolam with it to prevent the significant possibility of nightmares and dysphoria.

Regarding phenylephrine with propofol. Yes many do that. I think ephedrine with propofol makes more sense.

- pod

 

[OB1🤙]

Some midaz + relaxant is often all that is necessary if someone still has some semblance of mentation but on the verge of extremis. If the patient has a little reserve, I add some ketamine.

I would caution those not familiar with these scenarios that ketamine can and will bite you from time to time. We had a nonagenarian who needed reintubation after a TAVI recently, and the pulm/cc guys- after having basically the same discussion as what this thread contains with us in anesthesia- gave a bit of midaz and chased it with 1 mg/kg of ketamine. The pt was hypovolemic and had a shoddy LV to begin with and PEA resulted. The stuff is a direct myocardial depressant, and if you're living on the edge of your sympathetic reserve, it can nudge off the hemodynamic cliff. They got him back but the moral of the story is: the elderly don't need very much induction agent when they're sick. Their age alone is worth about a half MAC-awake. And while ketamine is a great drug with a favorable hemodynamic profile, it still warrants caution in people with sick hearts with little physiologic reserve.

 

[fakin' the funk]

They still make that stuff? Awesome.

Agree with the others that etomidate has risks and few benefits over other carefully selected/dosed induction agents. I think it's helpful to consider the goals of induction, in general, compared to the goals of induction for RSI.

In general, we're looking for amnesia, analgesia, hypnosis, immobility, and good intubating conditions very quickly.

In the proposed ED emergent/trauma RSI, the focus is on good intubating conditions very quickly and the HOPE for amnesia. That's not to say it's okay to be cavelier with recall, but let's face it: if the the situation is dire, the goalposts change. If it's not that dire (it seldom is), there's time to be careful and make intelligent choices.

As usual, a kickass post.

 

[fakin' the funk]

They just pop in the jollyrancher of choice to make it a little more kid friendly.

At our VA, etomidate is pretty much completely unavailable. If you need it, you gotta get a pharmacist to get it out of the main pharmacy or somesuch, i.e., it requires a lot of lead time.

In the meantime, I will follow your lead and induce with either Purple Drank or Sizzurp. All of my patients will be swervin' side to side.

 

[periopdoc]

I would caution those not familiar with these scenarios that ketamine can and will bite you from time to time... And while ketamine is a great drug with a favorable hemodynamic profile, it still warrants caution in people with sick hearts with little physiologic reserve.

Absolutely, which is why I said "similar hemodynamic stability." People tend to view Etomidate as a panacea for concerns of hypotension following induction. It isn't. In the person who is relying on maximal sympathetic tone to maintain a semblance of life, either agent will bring your pressure crashing to the ground. They are just a little less likely to do so than our typical induction agents.

Hell, I have had the situation where I intubated a patient in extremis with just a little relaxant and nothing else. Just taking away his ventilatory drive caused his pressure to crash. He didn't remember a thing.

In the above scenario. Enough midaz to hopefully make them forget is a good goal.

-pod

 

[cchoukal]

This is about the point in these posts that I usually put in a plug for the awake (well, as awake as the crashing, septic patient can be), topicalized DL. The initiation of positive pressure is going to commit enough ill will toward the hemodynamics that if you can avoid the additional insult of the induction agent, you might as well. It's not for everyone (though I've RARELY failed and had to induce), it takes an extra minute or two (I preoxygenate, sometimes with BiPap, while topicalizing and setting up), and I don't see a lot of trauma, so I'm not sure how well it works in the bloody, young airway, but for medically unstable intubations, it's the shiz.

 

[periopdoc]

- pod

 

[dhb]

Absolutely, which is why I said "similar hemodynamic stability." People tend to view Etomidate as a panacea for concerns of hypotension following induction. It isn't. In the person who is relying on maximal sympathetic tone to maintain a semblance of life, either agent will bring your pressure crashing to the ground. They are just a little less likely to do so than our typical induction agents.
-pod

 

[AquaMarine78]

Appreciate the tips guys.

Thanks...

 

[BLADEMDA]

I mix Ketamine with Propofol for trauma. No good controlled studies doing this technique but I give 0.5 mg/kg of Propofol with 0.75 mg/kg of Ketamine. Phenylephrine is always ready and available.

I think this mixture provides an excellent alternative to Etomidate.



Compared to propofol alone, "ketofol" results in less hypotension, better sedation, and enhanced patient comfort and safety

 

[MD Dreams]

Just out of curiosity, what is it about etomidate that makes it so undesirable? I wouldn't think the myoclonus would be a big issue. I understand it causes cortical suppression but is it absolute and how long does the suppression last? Thanks.

 

[pgg]

Just out of curiosity, what is it about etomidate that makes it so undesirable? I wouldn't think the myoclonus would be a big issue. I understand it causes cortical suppression but is it absolute and how long does the suppression last? Thanks.

It provokes PONV. Minor issue, and not one the ER guys really care about (or should care about) but it's one reason we don't like it.

When used on all comers, ie patients who don't really need its CV stability, the patients tend to get hypertensive during DL and intubation. Minus a style point there.

Adrenal suppression is real, though maybe not as big a deal as we make it out to be.


During our propofol shortage I used a lot of methohexital (Brevital) ... now that stuff causes some myoclonus.