Etomidate vs. Versed Peds Procedural Sed

[bulgethetwine]

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Article in Annals this month:

Etomidate Versus Midazolam for Procedural Sedation in Pediatric Outpatients: A Randomized Controlled Trial
Liddo, et al.,
Ann Emerg Med 2006;48:433-440.

In brief, a randomized, double-blind study of 100 kids in an orthopedic clinic based trial who were sedated for displaced extremity fractures.

All got 1 mcg/kg fentanyl plus either 0.2 mg/kg etomidate or 0.1 mg/kg medazolam.

Etomidate had significantly quicker induction and recovery time, both had a similar side effect of desaturation (around 10% in both groups).

The "cost" of the quicker onset and recovery time was increased pain at injection site (46 vs. 12% in the etomidate group) and myoclonus occurred in 20% of the etomidate group but none with the versed.

There were limitations, too, like the fact that once a kid gets myoclonus, the person recording recovery time isn't really blinded anymore... but putting aside this and other limitations of the paper, my question is this:

If a kid has myoclonus, is this gonna prevent me from getting an MRI or CT which might be the reason I sedated the little chigger in the first place?? Or is it likely to be so transient that it won't matter?

For the record, the authors rightly pointed out that it would still be nice to see a large series to better establish the safety profile of etomidate as well as a randomized trial comparing relative efficacy and safety of etomidate, propofol, and ketamine.

 

[MasterintuBater]

I love etomidate. But the one thing I generally don't use it for is dislocation or fracture reductions....because of the myoclonus thing. For most other things, etomidate rocks. Just my anecdotal .02

 

[bulgethetwine]

Article in Annals this month:

Etomidate Versus Midazolam for Procedural Sedation in Pediatric Outpatients: A Randomized Controlled Trial
Liddo, et al.,
Ann Emerg Med 2006;48:433-440.

In brief, a randomized, double-blind study of 100 kids in an orthopedic clinic based trial who were sedated for displaced extremity fractures.

All got 1 mcg/kg fentanyl plus either 0.2 mg/kg etomidate or 0.1 mg/kg medazolam.

Etomidate had significantly quicker induction and recovery time, both had a similar side effect of desaturation (around 10% in both groups).

The "cost" of the quicker onset and recovery time was increased pain at injection site (46 vs. 12% in the etomidate group) and myoclonus occurred in 20% of the etomidate group but none with the versed.

There were limitations, too, like the fact that once a kid gets myoclonus, the person recording recovery time isn't really blinded anymore... but putting aside this and other limitations of the paper, my question is this:

If a kid has myoclonus, is this gonna prevent me from getting an MRI or CT which might be the reason I sedated the little chigger in the first place?? Or is it likely to be so transient that it won't matter?

For the record, the authors rightly pointed out that it would still be nice to see a large series to better establish the safety profile of etomidate as well as a randomized trial comparing relative efficacy and safety of etomidate, propofol, and ketamine.

Plenty of posts trying to divine the "best EM program" and "Do I have a chance as an osteopath" but no comments on an actual issue? I'm taking my football and going home 😉

 

[mikecwru]

I like etomidate; I use it for reductions frequently despite the myoclonus issue.

You wouldnt want etomidate for an MRI since it's so short acting. For cts on little kids, I usually brutaine/papoose and that's fine.

mike

Article in Annals this month:

Etomidate Versus Midazolam for Procedural Sedation in Pediatric Outpatients: A Randomized Controlled Trial
Liddo, et al.,
Ann Emerg Med 2006;48:433-440.

In brief, a randomized, double-blind study of 100 kids in an orthopedic clinic based trial who were sedated for displaced extremity fractures.

All got 1 mcg/kg fentanyl plus either 0.2 mg/kg etomidate or 0.1 mg/kg medazolam.

Etomidate had significantly quicker induction and recovery time, both had a similar side effect of desaturation (around 10% in both groups).

The "cost" of the quicker onset and recovery time was increased pain at injection site (46 vs. 12% in the etomidate group) and myoclonus occurred in 20% of the etomidate group but none with the versed.

There were limitations, too, like the fact that once a kid gets myoclonus, the person recording recovery time isn't really blinded anymore... but putting aside this and other limitations of the paper, my question is this:

If a kid has myoclonus, is this gonna prevent me from getting an MRI or CT which might be the reason I sedated the little chigger in the first place?? Or is it likely to be so transient that it won't matter?

For the record, the authors rightly pointed out that it would still be nice to see a large series to better establish the safety profile of etomidate as well as a randomized trial comparing relative efficacy and safety of etomidate, propofol, and ketamine.

 

[docB]

I routinely use etomidate for reductions despite the myoclonus. In kids for CT I usually use versed. If they need a little more I give some morphine.

In my neck of the woods ther's this policy that drives me nuts. I like PO and IM versed. My hospitals demand that any time a kid is given sedation they have an IV. I feel it's overkill.

 

[Jeff698]

I typically only use etomidate for my RSIs. My goto deep sedation agent is propofol for adults. I use ketamine for kids. I've been very happy with the results of propofol. I love that stuff.

An issue I've seen raised recently, however, was with etomidate and RSI in sepsis patients. We know if can cause adrenal suppresion when given over time as an infusion but it isn't clear that this occurs with a single dose (~20-ish mg) for intubation. Now some folks are questioning even a single dose in septic patients.

Is anyone not using it for RSI because of this concern? If not, would a single dose of etomidate with a single bolus of decadron allieve your concerns?

Take care,
Jeff

 

[Big Z]

Anyone else out there using ketophol? 50/50 mix of propofol and ketamine, works great for reductions/painful procedures.

 

[DrQuinn]

I typically only use etomidate for my RSIs. My goto deep sedation agent is propofol for adults. I use ketamine for kids. I've been very happy with the results of propofol. I love that stuff.

An issue I've seen raised recently, however, was with etomidate and RSI in sepsis patients. We know if can cause adrenal suppresion when given over time as an infusion but it isn't clear that this occurs with a single dose (~20-ish mg) for intubation. Now some folks are questioning even a single dose in septic patients.

Is anyone not using it for RSI because of this concern? If not, would a single dose of etomidate with a single bolus of decadron allieve your concerns?

Take care,
Jeff

Bah. I would just give some Dex. If they really are adrenally suppressed, they'll need to be on roids for most of their ICU care anyways....

Q

 

[EMT2RN2MD]

If etomidate + sepsis = hyperkalemia, hyponatremia, and hypotension, would a balanced steroid such as Solucortef be a better option than Dex. which has little mineralocorticoid activity?

 

[bulgethetwine]

I like etomidate; I use it for reductions frequently despite the myoclonus issue.

You wouldnt want etomidate for an MRI since it's so short acting. For cts on little kids, I usually brutaine/papoose and that's fine.

mike

Seriously? I mean, head imaging in particular... I'm failing ot see how brutaine and papoose is applicable ? They need to be STILL, no?

 

[mikecwru]

Seriously? I mean, head imaging in particular... I'm failing ot see how brutaine and papoose is applicable ? They need to be STILL, no?

Yeah, I haven't had any problems interpreting the images. The medics are good at papoosing and the techs are fairly good at getting the images done. This usually gets you through the few seconds you need for a scan.

mike

 

[ERMudPhud]

Its true with a good papoose you should be able to get any images you want. Otherwise I use Ketamine for everything in kids. Way safer and easier than anything else. I'd be hard pressed to come up with anything that I would use etomidate or versed for. If my kids needed a procedure you'd have to do a lot of convincing to get me to agree to anything other than special K

 

[Daiphon]

If etomidate + sepsis = hyperkalemia, hyponatremia, and hypotension, would a balanced steroid such as Solucortef be a better option than Dex. which has little mineralocorticoid activity?

true... but the ICU peeps like the cosyntropin test to see if there's truly adrenal insufficiency. solucortef will mess with this test; but decadron doesn't. per my friend, Mr. UTDOL:

" [in acute adrenal crisis]... Neither hydrocortisone (cortisol) nor cortisone (which is converted to cortisol by the liver) is given because both are measured in cortisol radioimmunoassays. Dexamethasone, which is not measured in these assays, is the glucocorticoid of choice in these patients."

That's why. d=)
-t

 

[EMT2RN2MD]

You're right. I was ASS-U-MEing that the potential hypoadrenal crisis would be iatrogenic. (etomidate+sepsis) I wasn't thinking that it could very well have a different etiology, just exacerbated by the etomidate admin. Thanks Diaphon!