How would you induce?

[Planktonmd]

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There is good evidence that one dose induction using Etomidate significantly increases mortality in crtically ill patients:
http://ccforum.com/content/10/4/161

 

[Jeff05]

why would you ever use etomidate in kids? it burns A LOT and makes them puke. propofol is the way to go.

 

[pgg]

why would you ever use etomidate in kids? it burns A LOT and makes them puke. propofol is the way to go.

Propofol stings too, but thiopental doesn't. I use STP for almost all of my pediatric IV inductions. Archaic but useful drug.

I'd guess the ER used etomidate for the induction in that case because that's all the ER ever uses for any induction in anyone. 🙂

As for the ER using etomidate for sedation ... there was a long contentious thread (aren't they all) in here a while ago about this. Some places apparently have credentialing policies where using propofol for sedation requires the anesthesiology department to be involved. Some ERs get around that by using "their" drug, etomidate. Also, it's harder to hurt someone right away (hemodynamically speaking) with etomidate than propofol. I've never seen an ER doc push phenylephrine or ephedrine; they use pressors the way the ICU uses pressors: call up the pharmacy and start a drip when it gets there. Not so great if you've just bottomed someone out with propofol. I can see why the ER likes etomidate ... it's a safe stable drug for the next 30 minutes, and the adrenal suppression (if it happens) will be handled down the road by someone else.

 

[Stitch]

Propofol stings too, but thiopental doesn't. I use STP for almost all of my pediatric IV inductions. Archaic but useful drug.

I'd guess the ER used etomidate for the induction in that case because that's all the ER ever uses for any induction in anyone. 🙂

As for the ER using etomidate for sedation ... there was a long contentious thread (aren't they all) in here a while ago about this. Some places apparently have credentialing policies where using propofol for sedation requires the anesthesiology department to be involved. Some ERs get around that by using "their" drug, etomidate. Also, it's harder to hurt someone right away (hemodynamically speaking) with etomidate than propofol. I've never seen an ER doc push phenylephrine or ephedrine; they use pressors the way the ICU uses pressors: call up the pharmacy and start a drip when it gets there. Not so great if you've just bottomed someone out with propofol. I can see why the ER likes etomidate ... it's a safe stable drug for the next 30 minutes, and the adrenal suppression (if it happens) will be handled down the road by someone else.

That about sums it up, and we are pretty hooked on etomidate in general. Propofol is anesthesia's territory and etomidate is stable on the vitals. We may be dealing with the unknown, especially in an RSI situation. Some people will use a nice dose of versed as an RSI drug, but if the kid is particularly irritable or their pressures are low, it won't work.

As for short procedures like CT, etomidate is quick, lasts just long enough to scan the kid, and then they're fine. For other procedures like fracture reductions or abscess I&D we mainly use ketamine.

Plankton, thanks for the link, that's helpful.