Etomidate vs. Propofol

[Hamhock]

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-. The fact is that the current literature is all about Propofol and is down on etomidate. Don't use Propofol to treat insomnia though.

I really don't want to derail this thread (sorry, OP), but I am so curious about what you mean, docB, about "down on etomidate". Do simply mean that most sedation work has been with Propofol recently? Or, has there been some new research cautioning about the use of etomidate?

Maybe a quick answer and then folks can return to the previously scheduled thread...sorry for the interruption

HH

 

[docB]

This is a good question and deserves its own thread.

I was referring to the Miner paper. I've seen docs moving from etomidate to Propofol locally and I'm hearing nursing push back about etomidate because etomidate is "actually an induction agent and not a sedative." I don't really agree with that because I think that Propofol could be said to be the same thing and all the studies done before Propofol became the new darling showed that etomidate was safe in the ED as well.

 

[southerndoc]

I use both. If it's a dislocation and it's quick, I'll use propofol. If it's a fracture reduction and I'm going to need to hold it in place while the tech splints, then I use etomidate since it lasts a little longer.

The reason I don't use propofol for fracture reductions is because I have to push the propofol by state regulations. I can't hold the reduced fracture in place while pushing propofol at the same time.

 

[Octagonecology]

Regarding SouthernDoc's comment about only him being able to "push" the propofol....

When I was a critical care medic doing intra-facility flights we would frequently txp. folks who were under via Propofol drip post intubation, 3rd degree w/ pacing, etc. The ER nurse would always hand me a few 10cc boluses of Prop in case the pt. became light en route...and this was done obviously w/ the ER doc (and I assume) receiving physicians knowledge. If they started bucking the tube or thrashing I would always put them back down w/ 10 cc's.

This was the norm amongst the transport crews and ER's although as Southern Doc points out...the only one's w/ the authority to "push" propofol was the ER Doc or Anesthesiologist depending on procedure, etc. I live in FL.

Was this malpractice on my part, the part of the docs or a combination of both or what? I am unsure of the exact laws in FL but it was well known that it was kind of wrong but had to be done anyway....

Southern...how do you handle this when you turf someone out on Prop?

 

[DoctorMedic]

Doing MICU txp we were never allowed to transport propofal, usually had to use Versed or the like to keep em down. This was in Hudson Valley NY, but every region in NY has different protocols so I'm not sure about other areas.

 

[southerndoc]

Southern...how do you handle this when you turf someone out on Prop?

Not sure what you mean. If you're talking about anesthesiology allowing us to use propofol, a lot has to do with the fact that the same group I am contracted with is also the same group that provides anesthesia coverage to our health system. We provide emergency, anesthesia, and hospitalist services (hospitalists in my health system aren't part of my group).

 

[Stitch]

We've pretty much stopped using etomidate due to concerns about adrenal suppression, even after single doses. Previously we'd be using etomidate a lot Our PICU feels it's never warrented. I've been using a lot more ketamine for procedures and intubations, but I don't think that's a viable solution in adults, at least not alone.

Anyone using dexmedetomidine?

 

[Rendar5]

We've pretty much stopped using etomidate due to concerns about adrenal suppression, even after single doses. Previously we'd be using etomidate a lot Our PICU feels it's never warrented. I've been using a lot more ketamine for procedures and intubations, but I don't think that's a viable solution in adults, at least not alone.

Anyone using dexmedetomidine?

I've heard a lot about the studies and was shown them during recent state conferences and during the airway course in my program's orientation lectures. The data showing worse outcomes for etomidate awhile back was retrospective and didn't really control enough for confounders. More recent stuff that's controlled compared ketamine to etomidate which showed equivalent safety profiles. The point of the paper at the time was to show that ketamine was an effective alternative to etomidate because of worry over etomidate's risks. But showing equal safety profiles kind of also shows etomidate to be a perfectly safe drug. The little bit of adrenal suppression that it causes didn't lead to worse outcomes. Also, was shown a paper that basically said that giving steroids to offset the expectd adrenal suppression had no effect on outcomes.

 

[Aloha Kid]

Tough anterior shoulder dislocation the other night. Tried everything. Etomidate just didn't seem to do the trick. Used propofol and it popped right back. Not sure if it was the myoclonus or if it just didn't sedate the guy enough. I'll be using propofol a lot more.

 

[DrQuinn]

I was a big "etomidator" in residency, but having been out three years now (holy crap has it been that long?!) I have really switched to propofol only. Far easier to use, less myoclonus, and less scrutiny.

Q

 

[roja]

Tough anterior shoulder dislocation the other night. Tried everything. Etomidate just didn't seem to do the trick. Used propofol and it popped right back. Not sure if it was the myoclonus or if it just didn't sedate the guy enough. I'll be using propofol a lot more.

I love propofol. I tend to use it for short procedures, as noted above.

*as an aside, occasional with a 'tough' shoulder dislocation, the humerus can actually end up wrapped around the neck and will be unable to be reduced in a closed fashion.*

 

[bulgethetwine]

I use both. If it's a dislocation and it's quick, I'll use propofol. If it's a fracture reduction and I'm going to need to hold it in place while the tech splints, then I use etomidate since it lasts a little longer.

The reason I don't use propofol for fracture reductions is because I have to push the propofol by state regulations. I can't hold the reduced fracture in place while pushing propofol at the same time.

I'm actually the opposite. I use etomidate if its quick and I'm almost guaranteed to only need a one shot. Like simple shoulder dislocation. It's actually more of a hassle with propofol for me if its such a simple short term requirement as I invariably start at 20-40 mg then have to titrate in 10-20 mg boluses to get 'em right. 8-12 etomidate pretty much always does the trick. I use fentanyl simultaneously, too.

If I think it might need re-dosing (like trying to put in a hip) then I use prop so I don't have to be under scrutiny for etomidate re-dosing as a supposed cause of adrenal suppression. Yes, I know the cynics will point out that even a single dose can supposedly cause suppression, but in an otherwise healthy person, I think it's unlikely to cause any problems, and agree with the comments above that the equivalency studies have actually shown it to be pretty safe.

Also, using propofol and titrating for sedation is even more comfortable if you're carrying a stick of phynylepherine in your pocket and can control any hypotension.

Using some ketafol, too, see Messenger's paper out of Canada.

I don't use precedex in the ER. I think it's got great utility as an agent in the longer term setting - easy on, off, great alpha agonism for the ETOHers, and you can extubate people on it. But haven't tried it for conscious sedation at all.

 

[takotsubo]

How do you guys use propofol for procedural sedation?

I had a ankle fx/dislocation the other day in a ~80kg 30 something old male and I started with 2mg of dilaudid about 10-15 minutes before, then I had the nurse start with 60mg of Propofol then give 20mg aliquots. I went up to 200mg total and the guy was barely sedated.

What was I doing wrong? Do you guys give bigger increments? I know young people eat up propofol real easily but this guy was unreal.

I ended up using Versed and Fentanyl when we had to reduce it AGAIN because the first time wasnt that good.

 

[tkim]

How do you guys use propofol for procedural sedation?

I had a ankle fx/dislocation the other day in a ~80kg 30 something old male and I started with 2mg of dilaudid about 10-15 minutes before, then I had the nurse start with 60mg of Propofol then give 20mg aliquots. I went up to 200mg total and the guy was barely sedated.

What was I doing wrong? Do you guys give bigger increments? I know young people eat up propofol real easily but this guy was unreal.

I ended up using Versed and Fentanyl when we had to reduce it AGAIN because the first time wasnt that good.

With young people, I usually give 1 mg/kg, push it FAST, and give big aliquots.

 

[KYTNOH]

I use 0.1-0.15mg/kg of etomidate for fairly quick procedures (about 5 minutes) like chest tube placement, tri/bi mal reductions, and occasionally hips or shoulders if we think they'll be easy. I use propofol for longer procedures or multiple procedures like difficult hips, bilateral ankle fractures, complex laceration closures in kids, etc. I generally use propofol and ketamine interchangeably in kids with the one exception being for long procedures or multiple procedures that will take 15-30 minutes.

As for dosing propofol, I give 1mg/kg to start with and see where they are. If they need more I give roughly 0.5mg/kg aliquots until they are sedated and then I slowly infuse the propofol as a continual "drip" making sure to watch their end tidal CO2 and BP. I infuse it at around 5mg/minute or so but will titrate up or down depending on how deep they need to be.

 

[BKN]

With young people, I usually give 1 mg/kg, push it FAST, and give big aliquots.

😱 Do not like, hope you are trolling.

hypotension, apnea

 

[Arch Guillotti]

😱 Do not like, hope you are trolling.

hypotension, apnea

I don't think that 1 mg/kg of propofol for a young person is all that much.

 

[tkim]

😱 Do not like, hope you are trolling.

hypotension, apnea

Not at all. Younger people, especially ones who are not 'naive', will suck up all that propofol and ask for more. Older people I'll give .5 mg/kg and follow with light 'touches'.

 

[Arch Guillotti]

Not at all. Younger people, especially ones who are not 'naive', will suck up all that propofol and ask for more. Older people I'll give .5 mg/kg and follow with light 'touches'.

For an induction in the OR in a young person, we will give 200 mg of propofol and sometimes more. I realize that goals in the OR and ED are different but my experience is that the young folks drink it up and tolerate it well most of the time.

 

[KYTNOH]

I had an alcoholic with an upper GI bleed (no varices) who we ended up intubating for the EGD in the ER. I RSI'ed him with succs and etomidate and then we put him on a propofol drip with several 0.5-1.0 mg/kg boluses of propofol given. He would not stay down. We ended up giving him versed as well. After the 20-30 minute EGD we had given him a total of 850mg of propofol, 30 mg of etomidate, and 5 mg of versed. We never truly had him as sedated as I would have liked, but it got the job done. We extubated him within 15 minutes of the procedure being completed. I've never seen any adults metabolize propofol that quickly, but I have seen several kids compete with that metabolism rate when adjusted for their weight.

 

[Hamhock]

put him on a propofol drip with several 0.5-1.0 mg/kg boluses of propofol given. He would not stay down. We ended up giving him versed as well. After the 20-30 minute EGD we had given him a total of 850mg of propofol, 30 mg of etomidate, and 5 mg of versed. We never truly had him as sedated

but no analgesia? (ie fentanyl)

HH

 

[KYTNOH]

If I remember correctly we used a pretreatment dose of fentanyl prior to the RSI since it wasn't an emergent airway.

 

[EMRAGE]

Propofol: 40 / 40 or 20 / 20 / 20 and so on... for the average sized adult. That is my standard. Start low and go slow. There's no hurry. The best sedation is the safe sedation.

I don't use Etomidate. I've seen bruxism occur one too many times, so from a safety perspective, I stay clear of that one unless I'm using it for rapid induction and plan to hose the trachea. Not saying anyone is wrong....

RAGE

 

[southerndoc]

The best sedation is the safe sedation.

That's a saying worth repeating.

 

[Hernandez]

We've pretty much stopped using etomidate due to concerns about adrenal suppression, even after single doses. Previously we'd be using etomidate a lot Our PICU feels it's never warrented. I've been using a lot more ketamine for procedures and intubations, but I don't think that's a viable solution in adults, at least not alone.

Anyone using dexmedetomidine?

http://chestjournal.chestpubs.org/content/138/6/1327.abstract

 

[The White Coat Investor]

I start with 40 in an old lady with a hip dislocation and then 20 as needed, not anticipating hitting 100 total. (last one took 60 total)

I start with 60 in a normal, younger person, then 20s as needed, anticipating using 200 or less.

I start with 80 in a 25 year old 200+ lb weightlifter, and anticipate needing more than the 200 the nurses usually bring me for a sedation.

Kids I start with 0.5 mg/kg, and am occasionally surprised when the total dose goes over 2 mg/kg.

If there is anything I've learned about etomidate and propofol is that people have variable responses to them. You absolutely have to be set up and prepared for hypotension and/or apnea. If you've never bagged a patient you sedated on propofol you haven't done enough of them. I probably have to use verbal stim +/- a chin lift on 50% of them, and bag probably 1 out of 20. The reason we use propofol is we need deep, not moderate sedation. Shoulders, hips, fractures etc are all better under deep sedation. And it's very easy to slip from deep sedation to apnea. It isn't that I don't think emergency docs are very well trained to do brief, deep sedations. They are. But you must respect the drugs. I stay at the bedside until the patient is talking to me, and at least 5 minutes after the last dose.

 

[WilcoWorld]

My simple guidelines for sedation (in order of importance):

1) Don't start until you have airway management tools (O2, suction, BVM, ETT, etc) in the room.

2) Start with doses on the low-end. It's easy to put more drugs in the bloodstream, but it's really hard to get them out.

3) Don't use opiates to sedate drug users, and think twice about using bezos or your doses will be through the roof.

 

[EMRAGE]

If there is anything I've learned about etomidate and propofol is that people have variable responses to them. You absolutely have to be set up and prepared for hypotension and/or apnea. If you've never bagged a patient you sedated on propofol you haven't done enough of them. I probably have to use verbal stim +/- a chin lift on 50% of them, and bag probably 1 out of 20.

Couldn't agree more.

In addition to the essential tools listed above, always use capnography. Plan and prepare. Expect the worse possible outcome and be prepared for it. Complications aren't wrong, not being prepared and handling the complication is.

RAGE

 

[ORL10]

If we are talking about intubation of patients during RSI adrenal suppression from etomidate should make you weary in septic patients. Especially in patients who are hypotensive, not responding to fluid boluses and your expected clinical course is for decompensation. It is definitely true that etomidate causes adrenal suppression with even just one bolus dose, but what is the clinical significance has yet to be elucidated.

There are only two papers that I know that have actually addressed this one out of france and one out of chicago. Both showed non-statistically significant increases in mortality (around 6%) in those who were randomized to etomidate instead of versed. I am not sure there have been any studies on the relevance of this in non-septic patients.


as for procedural sedation ketofol works fantastic, and precedex (totally off market) seems promising. We have used it in our ICU's for patients in DT's but are limited by cost, and the duration (48hrs) we can use it because of the hospital policies. we dont have access in the ed

 

[EMRAGE]

I've not been to impressed with the Etomidate / Septic pt data. Honestly, when I have a septic pt, I always check the cortisol level and treat with decadron if it is low. The important part is your definition of low.

Each of my ICU attending have a different threshold. I've drawn my own assumption that a cortisol level < 17 is most likely low... so I give decadron. This allows the ICU attendings to do a stim test if they feel the need, but honestly, they never do the test. They are pretty satisfied with the baseline level and just begin treatment with hydrocortisone. I'm pretty sure this is not standard practice everywhere, but it seems to work in our institution.

RAGE

 

[takotsubo]

I've not been to impressed with the Etomidate / Septic pt data. Honestly, when I have a septic pt, I always check the cortisol level and treat with decadron if it is low. The important part is your definition of low.

Each of my ICU attending have a different threshold. I've drawn my own assumption that a cortisol level < 17 is most likely low... so I give decadron. This allows the ICU attendings to do a stim test if they feel the need, but honestly, they never do the test. They are pretty satisfied with the baseline level and just begin treatment with hydrocortisone. I'm pretty sure this is not standard practice everywhere, but it seems to work in our institution.

RAGE

I have never ordered a cortisol level in the ED. Anyone else doing this? I have considered roids if pt is not improving after fluids and pressors.

 

[Stitch]

I have never ordered a cortisol level in the ED. Anyone else doing this? I have considered roids if pt is not improving after fluids and pressors.

I haven't either. If I use etomidate, then I usually call the unit and ask if they want me to give steroids then send them up.

 

[EMRAGE]

I haven't either. If I use etomidate, then I usually call the unit and ask if they want me to give steroids then send them up.

My only question would be, when they say yes, give steroids, what do they want you to give: Decadron, Solumedrol, or Hydrocortisone.

Order a cortisol. You might be surprised what they do.... you might be surprised what you do.

RAGE

 

[Stitch]

My only question would be, when they say yes, give steroids, what do they want you to give: Decadron, Solumedrol, or Hydrocortisone.

Order a cortisol. You might be surprised what they do.... you might be surprised what you do.

RAGE

Hydrocortisone, generally.

Seems like it would take a while to get back. What do you do in the meantime? And if you're handing off care to the intensivists, how will it change what you do? If the unit wants it and it helps them manage the patient, I'm all for it.

 

[tkim]

Hydrocortisone, generally.

Seems like it would take a while to get back. What do you do in the meantime? And if you're handing off care to the intensivists, how will it change what you do? If the unit wants it and it helps them manage the patient, I'm all for it.

If the unit wants me to order a cortisol level that they can check on later, fine. Unless the patient is going to be boarded for a long time, I'm not sure of what benefit it will be for me or the patient during their brief (hopefully) stay in the ED.

 

[EMRAGE]

Hydrocortisone, generally.

Seems like it would take a while to get back. What do you do in the meantime? And if you're handing off care to the intensivists, how will it change what you do? If the unit wants it and it helps them manage the patient, I'm all for it.

I find it interesting they would want you to begin Hydrocortisone therapy without any laboratory evidence of adrenal insufficiency... it would be based on a hypotension (presumed sepsis) and just your utilization of Etomidate at that point. Adrenal insufficiency is treated with a relatively prolonged course of hydrocortisone, 100 mg TID for 10- 14 days I believe. Seem like a hap-hazard way to begin someone on a prolonged course of steroids.

With no cortisol or stim test data, I thought the best answer to give would've been Decadron. Like I mentioned earlier, you can give 10 mg IV Decadron and it will have no effects on the stim test if they choose to do one later.

Our cortisol comes back pretty fast. Usually before the pt has gone to the unit for sure.

If the unit wants me to order a cortisol level that they can check on later, fine. Unless the patient is going to be boarded for a long time, I'm not sure of what benefit it will be for me or the patient during their brief (hopefully) stay in the ED.

I generally agree, but you'd be surprised how quickly an adrenal insufficient pt will correct there hypotension with a dose of steroid, but again, I agree the impact of ED steroid administration is mild and we have many other things we could perfect before worrying with cortisol and steroid treatment (i.e. early goal directed therapy)

I really think of adrenal insufficiency in the really elderly patients and those who may have a chronic medical problem requiring steroids, which they may or may not be taking.

I appreciate the discussion from all

RAGE

 

[corpsmanUP]

Back to the sedation stuff. I find that with reasonably young and healthy people, for a quick procedure, it just pays to give the 1mg/kg of propofol and get it done. I used to be really timid and give 20-40mg at a time, but I found myself wanting to rebolus soon and eventually the doses would start stacking. That's when you get the apnea and have to bag them with white knuckles. In elderly, I generally do about .5mg/kg. I would say that for most quick reductions or procedures it is a one time dose and done!